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High-intensity Resistance Training in Post-Acute Care Produces Better Outcomes<p></p><p>Results of a study by researchers from the University of Colorado Anschutz Medical Campus show that high-intensity rehabilitation training for older patients in skilled nursing facilities can safely and effectively accelerate improvements in their function, enabling them to return home sooner. The study was published in <em>Physical Therapy</em>, October 2020.<br></p><p>Skilled nursing facilities provide medical and rehabilitation services to individuals post-hospitalization to help facilitate the transition to home or the next level of care. However, research has shown the trajectory of functional recovery following hospitalization and skilled nursing stay care is generally poor, with fewer than 25 percent of patients returning to pre-hospitalization levels of function. </p><h2>How the Study Worked</h2><p>“Our study identified an impactful opportunity to improve the way we care for patients in skilled nursing facilities,” said lead author Allison Gustavson, PT, DPT, PhD, at the CU Anschutz Medical Campus. “Our findings demonstrate that high-intensity resistance training is safe, effective, and preferable in caring for medically complex older adults in skilled nursing facilities.”<br></p><p>The study split 103 participants into two nonrandomized independent groups—usual care and high-intensity care—within a single skilled nursing facility. For both groups, physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge.</p><h2>Results of the Study</h2><p>For the high-intensity training group, the physical therapists used the i-STRONGER program (Intensive Therapeutic Rehabilitation for Older Skilled Nursing Home Residents).<br></p><p>The patients participating in the high-intensity program benefited by increasing their functional independence, as evidenced by a significant and clinically meaningful increase in their walking speed from evaluation to discharge by&#160;0.13 meters/second&#160;more than the usual care group. This is a critical outcome for this patient population, as improvements in walking speed greater than 0.1 meters/second are associated with reduced mortality.<br></p><p>Also, the patients’ stay at the skilled nursing facility was reduced by 3.5 days.</p><h2>Implications for Future Rehab Approaches</h2><p>Based on their findings, the researchers advocate the need to increase the intensity of rehabilitation provided to patients with medically complex conditions to promote greater value and patient experience within post-acute care. <br></p><p>“Our study shows that the quality of rehabilitation compared to the quantity drives better outcomes,” said Principal Investigator Jennifer Stevens-Lapsley, MPT, PhD, FAPTA. “These findings provide a timely solution to address rehabilitation value in the context of recent post-acute care changes by policymakers who are looking to raise the bar on the quality and efficiency of post-acute care services,” she said.<br></p><p>“We are eager to support the transition to this safer and more effective high-intensity care approach,” said Stevens-Lapsley, a professor and director of the Rehabilitation Science PhD Program at the CU Anschutz Medical Campus.<br></p><p>“We are encouraged by the results that accelerated the improvement in patient function, created positive patient and clinician experience, and resulted in less time needed for care in the skilled nursing facility,” she said.<br></p><p><img src="/Topics/Special-Features/PublishingImages/2021/1021/LaurenHinrichs.jpg" alt="Lauren Hinrichs" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;170px;height&#58;216px;" />The University of Colorado has partnered with the American Health Care Association to offer a CEU-credited High-intensity Resistance training program. For those interested in learning more about the research or training or for implementation support, contact Lauren Hinrichs or visit <a href="http&#58;//www.movement4everyone.org/" target="_blank">www.movement4everyone.org</a> for more information. <br><br><em>Lauren Hinrichs, PT, DPT, OCS, board-certified in orthopedics, is a Rehabilitation Science PhD student with the Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine. She can be reached at </em><a href="mailto&#58;lauren.hinrichs@CUAnschutz.edu" target="_blank"><em>lauren.hinrichs@CUAnschutz.edu</em></a><em>.</em><br></p>2021-10-01T04:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2021/1021/SF_intensity.jpg" style="BORDER&#58;0px solid;" />Clinical;DietLauren HinrichsResearchers advocate the need to increase the intensity of rehabilitation provided to post-acute patients to promote greater value and patient satisfaction.
Taking the Mystery Out of Seizures in Older Adults<p>Epilepsy and seizures are more common in the nursing home than in any other population. In fact, epilepsy is the third-most common neurological disorder affecting older adults. “Seizures often cause panic,” says Ilo Leppik, MD, FANN, professor of pharmacy and neurology and director of the Epilepsy Research and Education Program at the University of Minnesota. <br></p><p>“Because they can be scary and staff are unsure how to handle them, they often send patients out to the emergency room [ER].”<br></p><p>It is time to take the mystery out of epilepsy by developing and promoting protocols and a streamlined approach to treating this condition, he says, especially new-onset seizures.<br></p><p>The good news, Leppik says, is that there seems to be a growing interest in the issue. He is currently working on a survey/study to gain insights into how facilities approach managing a first seizure in nursing home residents. In the meantime, much clinical knowledge and evidence are available to help ensure the best possible care for people who have epilepsy or experience a seizure.</p><h2>Why Epilepsy? Why Now?</h2><p>According to the Centers for Disease Control and Prevention (CDC), about 3 million adults in the United States aged 18 or older have active epilepsy, and about a million of these are 55 or older. The growing incidence of epilepsy in the elderly is linked to the increased prevalence of stroke, dementia, and brain tumors. The Cardiovascular Health Study confirmed that patients with a history of stroke have a higher risk of developing epilepsy. <br></p><p>“The number of people who develop epilepsy in the nursing home is about 12 times higher than in the community at large, and about 1.6 percent of residents develop epilepsy every year,” Leppik says. Individuals age 60 and older also are about twice as likely to develop a first unprovoked seizure than younger people, and they are more likely to have subsequent seizures in the first year after the initial event.</p><h2>Sometimes Secretive Nature of Seizures</h2><p>People often think of seizures as involving convulsions. However, in fact, seizures can be much more subtle, particularly in older people. For instance, they may exhibit brief episodes of memory problems, confusion, falls, or dizziness. A resident may stare into space; wander; be unable talk, answer questions, or respond to instructions; or exhibit a chewing motion with the mouth. These may last a few minutes or hours. If staff aren’t trained to recognize these behaviors as signs of a seizure, a patient’s epilepsy may go undiagnosed and untreated. <br></p><p>There are three main categories of seizures&#58; generalized-onset, focal-onset, and unknown-onset. Generalized-onset seizures affect both sides of the brain, or neurons on both sides simultaneously. For these types of seizures, symptoms may include sustained rhythmical jerking movements, muscles becoming limp or weak, muscles getting tense or rigid, brief muscle twitching, or epileptic spasms where the body flexes and extends repeatedly. People also may experience absence seizures, which are staring spells. <br></p><p>Focal-onset seizures can start in one area or group of neurons in one part of the brain. Focal-onset aware seizures happen when the person is awake and aware during the seizure. This used to be called a simple partial seizure.<br></p><p>Focal-onset impaired awareness, which used to be called a complex partial seizure, is when the person is confused or their awareness is affected in some way during the seizure. Symptoms may include jerking, limp or weak muscles, tense or rigid muscles, brief muscle twitching, and repeated movements such as clapping or rubbing hands, lipsmacking or chewing, or running. Patients also may exhibit changes in sensation, emotions, thinking or cognition, gastrointestinal sensations, waves of heat or cold, goosebumps, or a racing heart. <br></p><p>If an unknown-onset seizure of this type isn’t witnessed by anyone, it may be diagnosed later as a focal or generalized seizure. </p><h2>Education Needed</h2><p>When people think of epileptic seizures, they often imagine what used to be called Grand Mal seizures. These are convulsions and can be very alarming for staff, Leppik says. People begin to jerk around and might lose control of their bladder or bowels. These types of seizures are easy to recognize, but when staff don’t know how to handle them, they may send patients to the hospital when they could be managed onsite. <br></p><p>“The first thing we need to do is educate everyone on what to do in terms of first aid for convulsive seizures,” Leppik says. “We have cards in our clinic we hand out to people with this information. In addition, every facility should have a protocol in place.” He suggests that videos and other materials can be helpful as well. <br></p><p>Seizures with more subtle signs are easy to miss or misinterpret. Sometimes practitioners and other team members need to be detectives and ask a lot of questions to determine if someone is indeed having seizures.<br></p><p><img src="/Topics/Special-Features/PublishingImages/2021/1021/RebeccaO%27Dwyer.jpg" alt="Rebecca O'Dwyer" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;165px;height&#58;210px;" />For example, Rebecca O’Dwyer, MD, assistant professor in the Department of Neurological Sciences at Rush Medical College, had an older patient who was excitedly looking forward to a family celebration. On the day of the event, his family reported that he “wasn’t quite himself, and he wasn’t excited.” They brought him to see O’Dwyer because he had no memory of the day and insisted he hadn’t been at the event.<br></p><p>“When we took a deeper history, we discovered he had days where he would just stare into space,” she recalls. It turns out that he was having seizures, but no one realized it. “The nice thing about seizures in the elderly is that when you get them under control, [the resident’s] cognition often improves,” says O’Dwyer, which was what happened with this patient.</p><h2>Hold Off on Hospitalization</h2><p>“We’ve found that many facilities don’t have a protocol for seizures, and staff often don’t know what to do when one occurs. As a result, they often send patients to the hospital or ER,” Leppik says, which is disruptive, costly, and often unnecessary. “Most patients recover in a few minutes, so the seizure is often over by the time the ambulance arrives.” <br></p><p>This situation can be avoided by having a seizure protocol that all staff are trained to follow, Leppik says. This would detail what to do to keep the patient safe and comfortable, what medications (if any) to use, and when it might be appropriate to send them to the ER. “A uniform plan will prevent confusion and give staff the confidence to care for patients who experience a seizure,” he suggests.<br></p><p>O’Dwyer adds, “Keeping the patient safe and comfortable can do more good than calling 911. Staff having appropriate training can give them the confidence to handle seizures safely and avoid unnecessary transfers to the hospital or ER.” <br></p><p>This means making sure they know what not to do as well as what to do.<br></p><p>For instance, O’Dwyer notes that people used to put something in a seizing person’s mouth to keep them from biting their tongue. “You don’t want to put anything in their mouth. They could bite you. Just get them flat, preferably on their side on the floor. Don’t try to stop their arms and legs from convulsing. Make sure there is nothing in their hands.” It can seem like a seizure goes on forever, O’Dwyer says, but in reality, it usually is only a few minutes. <br></p><p>If this is the person’s first seizure, O’Dwyer says, “Look for common triggers for when the patient is back to baseline.” These could include fever, stress, or lack of sleep. Often a further workup is necessary to determine what’s happening with the patient. A follow-up with a neurologist is important, but not immediately necessary. <br></p><p>However, O’Dwyer says, “Try to figure out why the patient had a seizure and follow up. If someone has an established diagnosis of epilepsy, their seizures will likely look similar every time. And this is important to know as well.” If the person becomes limp on one side, one side of the face droops, or doesn’t come back to baseline within 30 minutes, then consider that the patient has had a stroke and that an emergent evaluation will be necessary, she says.</p><h2>Meds or No Meds?</h2><p>Jumping right to pharmacologic treatment may not be the best intervention for long term care residents. All antiseizure drugs have significant drug interactions that may cause cognitive side effects. “We need more research to determine if it is appropriate to treat seizures with medications after the first seizure,” says Leppik. It may be advisable to monitor the person to see if they have additional seizures, realizing this could be an isolated event and not a condition requiring lifelong treatment. In fact, many older adults don’t experience another seizure episode after the first one.<br></p><p>Candidates for antiseizure medication therapy include those with recurrent seizures, an onset of epilepsy, or a clear predisposition for seizures. When medication is determined to be appropriate, it is recommended to start low and go slow with one antiseizure drug. </p><h2>Learning More for Better Care</h2><p>“We really need to get a current level of understanding and practice. Then we can develop resources for education programs based on what we find. We can’t develop these until we know what the level of knowledge and treatment is for facilities and practitioners,” says Leppik.<br></p><p>At that point, consistent information, clinical evidence, and best practices can be shared to improve seizure and epilepsy care and maximize quality of life for residents and confidence and peace of mind for staff. <br></p>2021-10-01T04:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2021/1021/1021_CF3.jpg" style="BORDER&#58;0px solid;" />Management;ClinicalJoanne KaldyStaff need to be aware that seizures may present simply as confusion or an inability to respond to questions and may last a few minutes or hours.
Pandemic Takes its Toll on Sleep<p>During the pandemic, sleep was in short order for many people. In one survey, 56 percent of U.S. adults said they have experienced more sleep disturbances—ranging from problems falling or staying asleep to having disturbing dreams or nightmares—in the past year and a half. In fact, this has been so common, the phenomenon has been given a name—COVID-somnia. <br></p><p>Pandemic-related sleep issues haven’t discriminated. Young and old people alike report some sleep-related problem. Long term and post-acute care centers not only need to identify and address sleep disturbances in their residents but in their staff as well. </p><h2>Wide Awake, Not Dreaming</h2><p>Numerous factors have contributed to the widespread sleep disruptions. “Stress, anxiety, changes in schedules, and increased caffeine or alcohol consumption can all contribute to sleep problems,” says Steven Buslovich, MD, MS, CMD, a New York-based geriatrician and president of Patient Pattern. At the same time, chronic pain, thyroid disease, dementia, and other medical issues can cause sleep disruptions. <br></p><p><img src="/Monthly-Issue/2021/September/PublishingImages/Buslovich.jpg" alt="Steven Buslovich, MD, MS, CMD" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;160px;height&#58;200px;" />Numerous prescription medications can cause insomnia, says Robin Fine, RPH, a consultant with Forum Extended Care Services. These include selective serotonin reuptake inhibitors (antidepressants), dopamine agonists, psychostimulants and amphetamines, anticonvulsants, steroids, beta agonists, and theophylline. <br></p><p>It is important not to make assumptions about what is causing someone’s sleep issues or that they are normal or not worth addressing. “We have to determine what is causing the problem,” Fine stresses. “Once we identify the root cause, we can begin to address it with targeted interventions.”<br></p><p>Getting to the bottom of a resident’s sleep disturbances or even getting the person to admit or realize he has a problem can be a challenge. “We need to make asking about sleep a regular part of our interactions with residents,” suggests Buslovich. This doesn’t just means asking how he is sleeping. Instead, it calls for a deeper dive and inquiring if he is falling asleep quickly, if he wakes up in the middle of the night, if he experiences early morning wakening with the ability to return back to sleep, or if he is sleeping later than usual. <br></p><p>By identifying and addressing sleep problems early, it is possible to prevent falls, behavioral issues, and other problems that can result due to lack of sleep.<br></p><p>“We don’t generally focus on sleep as a quality measure, but looking at sleep patterns and sleep disturbances can give you insights into other things that are going on, such as depression or untreated pain. All of these tend to manifest at night. Inquiring about sleep is a gateway question to discovering other issues,” Buslovich notes. <br></p><p>Lea Watson, MD, a Colorado-based geriatric psychiatrist, says, “[Certified nurse assistants] can walk down the hall at night and peek into residents’ rooms to see if they are asleep. However, we need other, more accurate means to assess sleep, such as the use of wearable devices.”</p><h2>Treating COVID-somnia</h2><p>Instead of starting with medications, says Watson, it is important to consider nonpharmacologic solutions. For instance, environment interventions such as reducing noise, light, and room temperature can help. Aromatherapy and white noise or sound machines are other options.<br></p><p><img src="/Monthly-Issue/2021/September/PublishingImages/LeaWatson.jpg" alt="Lea Watson, MD" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;160px;height&#58;200px;" />Good sleep hygiene—getting up and going to bed on a regular schedule, limiting caffeine intake to the morning hours, and getting some exercise during the day—also can make a difference. “When I get calls about patients having problems sleeping, they often aren’t doing these things,” Watson says. “It’s important not to assume that people know about sleep hygiene.”<br></p><p>For instance, some people may think that wine or other alcoholic beverage before bed will help them relax and go to sleep when, in fact, it may result in disrupted sleep.<br></p><p>Don’t underestimate the power of sunshine and light on sleep. “Natural sunlight in the morning can help reset your circadian rhythm, the body’s 24-hour clock that coordinates lots of processes, including sleep,” Watson says.</p><h2>Positive Actions</h2><p>Exercise is key to good sleep, and this has been challenging during lockdowns and quarantines. “Re-entry phenomenon is a huge issue. Our residents are so used to having their activity restricted. We need to rebuild their trust and confidence to get out do things they want to do,” Watson says. “We’ve seen a drop in enthusiasm about activities, and we have to find ways to build this back up.”<br></p><p>Patients or families may be tempted to use over-the-counter sleep aids, but no decision should be made without consulting a physician, pharmacist, or other clinician. “These products aren’t without side effects and actually may not be as effective as changing behaviors and employing nonpharmacologic interventions,” says Watson.<br></p><p>As more family come in for visits, Fine says, “They will want to bring in foods and take residents out for meals and social events. It is important to remind them about the impact of caffeine, alcohol, sugar, eating heavy meals before bedtime, and other things on sleep.”<br></p><p>At the same time, she suggests, remind family to reach out to the physician, pharmacist, or other practitioner if their loved one isn’t sleeping well, instead of bringing in over-the-counter products, herbals, or other prescriptives.<br></p><p>Prescription drugs should be a last result and not a first-line treatment, Watson says. “Many approved hypnotics on the market have a limited evidence base for outcomes. And there is a huge myth that sleeping pills are robustly helpful, but this too is based on limited data, and they have serious side effects.”<br></p><p>When prescription drugs are necessary, she says, “I don’t put anyone on long-term use of sleep medicines. They always should be scheduled and not be given PRN. This reinforces the positive loop of having to demonstrate the need for the meds regularly over time.”<br></p><p>Fine agrees&#58; “You can’t just throw medication at the problem. You have to do a root-cause analysis. If you find that a resident is on a medication, such as a beta-blocker for cardiac issues that can’t be changed, you have to look at other ways to improve sleep quality.” </p><h2>When Sleeplessness Slams Staff</h2><p>Team members may feel tired or have trouble sleeping, but they also may just shrug it off or be hesitant to admit it. “Despite increased attention to this issue, there is still a lack of awareness,” says Buslovich. At the same time, he says, “Sleep deprivation is common in this field, but that doesn’t mean it’s okay or that we can’t help people get better sleep.” <br></p><p>Watson concurs and says, “This is absolutely a real problem. People are homeschooling their children and going to work. They’re overburdened and overworked, and they’re not doing normal self-care.” However, people aren’t likely to report their lack of sleep. <br></p><p>“There is a misplaced idea that lack of sleep says you’re working hard. Frontline staff are sleep-deprived but don’t think to report it,” she says, which is because they often don’t identify insomnia as a chief complaint.<br>When people aren’t sleeping well, particularly because of stress or anxiety, it can be tempting to self-medicate with over-the-counter medications, illicit substances, and/or alcohol. It is important to encourage staff to take positive, safe, and healthy approaches to better sleep.<br></p><p>“We may not be able to improve quantity of sleep, but we can help people get better quality of sleep,” says Buslovich. It is important to encourage staff to pursue exercise, healthy eating, and mental and physical rejuvenation and give them opportunities via efforts such as a lunchtime walking group and onsite yoga classes, easy access to healthy snacks, and mindfulness meditation training. </p><h2>Willing Watchfulness </h2><p>Jea Theis, MSW, LCSW, LIMHP, of Omaha Therapy and Arts Collaborative, stresses, “Anything we consume can contribute to our distress, which can impact our sleep. For instance, feeding ourselves a steady diet of TV news or other media increases stress and anxiety. We call it secondary trauma exposure, and we need to limit our consumption of these things.”<br></p><p>Providing staff with links to free downloads of music, movies, and books may encourage them to turn off the news and pursue more positive, uplifting diversions. <br></p><p>It can be challenging, but promoting a work-life balance is important, Theis says. Sending and receiving after-hours work-related emails or texts can increase stress and make it harder for people to relax and clear their minds. It may help to encourage managers and team leaders to think twice before sending a late-night message to a colleague or employee and consider&#58; Is this urgent or can it wait until morning?<br></p><p>Moving forward, says Theis, “Be alert. Any time you see a shift in behavior or mood—such as irritability, anger, increased confusion, or lack of focus—in a resident or staff member, that is telling you something. And it may be saying that sleep quality isn’t good. It is important to check in with people, particularly when you see these signs.”<br></p><p>At the same time, she suggests, have integrative therapies readily available, everything from pet therapy and yoga to aromatherapy and mindfulness. “People need things that help them feel good and that bring their bodies to a safer, calmer place,” she says. <br></p><p>On a broader level, it’s about connections, Theis says. “If we just ask people about sleep, we are missing the bigger picture. We need to talk about healthy ways to live, improve their quality of life, and ultimately get quality sleep.” <br></p>2021-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/September/PublishingImages/0921_CF3.jpg" style="BORDER&#58;0px solid;" />COVID-19;ClinicalJoanne KaldyIn one survey, 56 percent of U.S. adults said they have experienced more sleep disturbances—ranging from problems falling or staying asleep to having disturbing dreams or nightmares—in the past year and a half.
Sense of Smell Loss Due to COVID May Present Problems for Some People<p>Early in the pandemic, anosmia—loss of smell—became a common sign of COVID-19 infection. There have been questions about how long this loss of olfactory function lasts. However, a new study published in <em>JAMA Network Open</em> suggests complete recovery is likely at one year, if not sooner.<br></p><p>Over the course of a year, researchers in France followed a cohort of patients who had COVID-related acute loss of smell. At four months, 23 of 51 patients reported full recovery of olfactory function, while 27 reported partial recovery. Only one person still reported total anosmia. At one year, everyone had recovered, although two patients reported that they still had limited olfactory function. <br></p><p>The authors concluded, “Persistent COVID-19-related anosmia has an excellent prognosis with nearly complete recover at one year. As clinicians manage an increasing number of people with post-COVID syndrome, data on long-term outcomes are needed for informed prognostication and counseling.”<br></p><p>This study is promising for COVID survivors in long term care. As Steven Buslovich, MD, CMD, MSHCPM, a New York-based physician and medical director, says, “Weight loss in institutionalized adults is a frailty deficit that contributes to risk for morbidity and decline. It is important to evaluate the etiology of weight loss, nutritional status, adequacy of nutritional support, and one's ability to absorb nutritional intake, recognizing that anosmia may be persistent as part of post-COVID phenomenon.” <br></p><p>Karl Steinberg, MD, CMD, president of AMDA – The Society for Post-Acute and Long-Term Care Medicine, says, “The good news is that even though loss of smell can last a long time, it eventually returns. The bad news is that for some of our residents, it can contribute to a failure-to-thrive clinical picture, since smell is such an important part of the enjoyment of food, appetite, and taste. For some residents—especially those where other factors like isolation due to visiting restrictions have been such a problem—a year may be too long to wait.” <br></p><p>It is important to consider strategies to encourage residents to eat, even when they have anosmia or a diminished sense of smell. Steinberg suggests, “Encouraging people to eat foods with stronger flavors, like spicy food and salty food, and different textures can be a strategy to make food more interesting and appealing for some residents, even though it may go against what we usually recommend.”<br></p><p>At the same time, Buslovich says, “Those who experience anosmia may respond favorably to temperature and texture, as those senses remain preserved.”</p>2021-07-08T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/LossOfSmell.jpg" style="BORDER&#58;0px solid;" />COVID-19;ClinicalJoanne KaldyEarly in the pandemic, anosmia became a common sign of COVID-19 infection. There have been questions about how long this loss of olfactory function lasts. However, a new study suggests complete recovery is likely at one year, if not sooner.