| Detecting and Treating Dementia Early | <p><img src="/Breaking-News/PublishingImages/740%20x%20740/senior_woman_daughter_2.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:256px;height:179px;" />Dementia is staggeringly common, with an <a href="https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf" target="_blank">overall prevalence of 11 percent in people aged 65 and over</a>. This prevalence increases markedly with age, such that it affects over half of octogenarians and one in three will ultimately die in this condition. These statistics do not include mild cognitive impairment (MCI), mental changes that are measurable but not severe enough to affect daily function and are often but not always a precursor to dementia, or <a href="https://www.cdc.gov/aging/data/subjective-cognitive-decline-brief.html" target="_blank">subjective cognitive decline</a>, self-reported mental fogginess or memory depreciation that aren't able to be measured by a test.</p><h3>Detecting and Diagnosing Dementia</h3><p>Despite being widespread, official diagnosis lags behind the true prevalence, with only 3-4 percent of patients having “dementia" (let alone Alzheimer's disease or a specific type of dementia) written anywhere in their chart. This amounts to more than 3 million Americans lacking a diagnosis, a number which will double in the next decades if diagnosing doesn't catch up.</p><p>The early stages of dementia, particularly Alzheimer's disease, which most commonly manifests with short-term memory loss and difficulty navigating an environment, is not always obvious from a short interaction. Verbal abilities can be intact, and a patient can regale you with stories from their youth, masking the fact that when they are sent home from the doctor's office with instructions to take a medication once a day, they may not fully understand, remember, or have the capacity to follow instructions. Caring family members such as adult children living out of state may also take a long time to go from a subtle feeling or suspicion that something seems off or odd to the conclusion that there may be a real problem. This can obviously have catastrophic consequences—preventable adverse events and hospitalizations; missing the opportunity to reverse, slow, and mitigate disease; and treatment for symptoms that can improve quality of life and functional independence.</p><p>Improving detection and arriving at diagnosis before the onset of catastrophic events, more severe disease, and unmanageable symptoms begins with equipping clinicians on the front lines with validated tools to assess function rapidly, reliably, and comprehensively across <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/" target="_blank">cognitive domains</a>. Tools must be simple enough for the non-specialist to gain comfort with and fit reasonably within their established workflows. For example, a recent peer-reviewed study in the <a href="https://aging.jmir.org/2022/2/e36825/" target="_blank"><em>Journal of Medical Internet Research (JMIR) Aging</em></a> validates the efficacy of a computerized cognitive test. Conducted in-person or remotely, this type of assessment improves accessibility to testing while providing physicians with the tools necessary to diagnose and treat patients.</p><p>To better detect and diagnose dementia, physicians must go beyond patient interviews (i.e. do you feel like you are losing your memory?) and use formal assessment tools, looping in a specialist for complex cases when needed. If MCI is identified, the physician must further assess for functional impairment to arrive at a diagnosis of dementia and perform serial assessments for changes in cognitive status (improvement or decline) that could change diagnosis and management approach.</p><h3>Preventing Adverse Events and Hospitalizations</h3><p>People with dementia have much higher hospitalization rates than older adults without. According to a recent study, 40 percent of <a href="https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16636" target="_blank">hospitalizations in the dementia cohort could have been preventable</a> with proper identification, education, and outpatient care. When care teams are on the same page about a person's cognitive status, the individual can be given additional supervision or support to prevent adverse events. Consistency between caregivers is essential toward preventing trips to the hospital as well as reducing uncertainty and conflict around patient care and well-being.</p><h3>Ruling Out and Addressing Reversible Causes</h3><p>Cognitive impairment does not always spell dementia. Many cases of MCI are due to reversible causes, with the most common offenders being medication adverse events, depression, sleep apnea, infection, and thyroid disease. Long COVID is another major driver, with more than 70 percent of sufferers calling out brain fog as a chief complaint.</p><p>It is for this reason that the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/" target="_blank">American Academy of Neurology</a> cites ruling out and addressing reversible causes as a primary reason for performing cognitive assessment. Clinicians should perform a medical evaluation of common reversible causes.</p><h3>Addressing Risk Factors to Slow Progression</h3><p>The landmark FINGER study and subsequent <a href="https://pubmed.ncbi.nlm.nih.gov/32627328/" target="_blank">World-Wide FINGERS network</a> found that 40 percent of dementia is preventable by addressing certain modifiable risk factors. These include:<br></p><ol><li>high blood pressure,</li><li>smoking,</li><li>diabetes,</li><li>obesity,</li><li>physical inactivity,</li><li>poor diet,</li><li>high alcohol consumption,</li><li>low cognitive engagement,</li><li>depression,</li><li>traumatic brain injury,</li><li>hearing loss,</li><li>social isolation, and</li><li>air pollution.</li></ol><p></p><p>The physician is charged with the task of working with the patient and caregivers to put together a comprehensive cognitive care plan that addresses these modifiable factors in a holistic manner. By giving them the knowledge, resources, and motivation to see the patient through the long journey of cognitive change, they can slow dementia's progression and give the patient a better prognosis.</p><p>There are now few pharmaceutical options to treat dementia, with cholinesterase inhibitors showing efficacy in dementia's early stages. There are multiple medications at different stages of the drug development pipeline, and all of them depend on patients being identified as early as possible to have the best chance of success.</p><p>Behavioral and psychiatric symptoms are common in dementia, and an early and specific diagnosis enables clinicians to treat these with the best approaches available.</p><p><em>Yael Katz, Ph.D., is co-founder and CEO of BrainCheck. Katz received her Ph.D. in neuroscience from Northwestern University and conducted her postdoctoral work at Princeton University.</em><br><br></p> | 2022-06-23T04:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/2022/YaelKatz.jpg" style="BORDER:0px solid;" /> | Dementia;Clinical | Yael Katz, Ph.D. | The early stages of dementia, particularly Alzheimer’s disease, which most commonly manifests with short-term memory loss and difficulty navigating an environment, is not always obvious from a short interaction |
| Cleaning With a Vengeance Gets Results | <p></p><p>Covenant Living Communities and Services has taken a full-scale approach to infection control and prevention. With 16 communities in nine states, it is one of the largest not-for-profit retirement living organizations in the nation. Its continuing care retirement communities offer independent living plus many more levels of care, including assisted living, skilled nursing, and, often, memory care and rehabilitation.</p><p><img src="/Topics/Special-Features/PublishingImages/2021/1121/BillRabe.jpg" alt="Bill Rabe" class="ms-rtePosition-2" style="margin:5px;width:210px;height:210px;" />Cleaning and disinfection of all skilled nursing rooms happens at least twice a day as a practice the company implemented at the beginning of the COVID pandemic and continues to employ amid different COVID-19 variants. Leadership took the step of reviewing all of Covenant’s housekeeping policies in each level of care and released an organization-wide safety program known as Our Safer Home Commitment. </p><p>“This program focuses specifically on examining cleaning frequencies and practices and retraining our staff on how to properly clean and disinfect rooms and spaces that our residents visit frequently,” says Bill Rabe, senior vice president of enterprise operations at Covenant. “It also allowed us to make a fresh, new commitment to our residents and their families that their safety is our No. 1 priority.”<br></p><h2>How Disinfection Measures Up</h2><p>With Covenant’s new commitment, leadership wanted to take the next step of ensuring the new practices really measured up. “We quickly realized we wanted feedback and a quantifiable way to assess our cleaning practices,” says Rabe. “To do that we made an investment in ATP luminometer testing, which is a way to test the cleanliness of hard surfaces by scrubbing for a molecule.” </p><p>Adenosine triphosphate (ATP) is a molecule found in all living cells that is responsible for transferring and storing energy. The effectiveness of a cleaning process can be checked by testing surfaces for ATP levels, which act as an indicator of whether an environment has been properly cleaned.</p><p>“This is a practice used in the food service industry and acute-care setting, but we find it extraordinarily valuable given the higher risk that COVID-19 puts our residents in,” says Rabe. “It helps us understand, first, how clean our facilities are overall and, second, how effective our cleaning is.”<br></p><h2>How It’s Going<br></h2><p>Staff have appreciated the clarity that Our Safer Home Commitment procedures provided, says Rabe. They also appreciate the tangible, quantifiable feedback that the ATP testing provides. </p><p>“The feedback on the results of the cleaning process is captured and tracked for accountability,” says Rabe. “This helps us identify opportunity for improvement in our cleaning and disinfecting process.”</p><p>As part of the program, Covenant also rolled out survey cards with access to an online survey tool to capture feedback on the program from guests staying in guest or resident rooms after cleaning and common areas such as dining. “So far, the feedback has been overwhelmingly positive,” says Rabe.<br></p><h2>Other Steps</h2><p>In addition to the statewide cleaning program, Covenant has taken other steps to control for infection, including updating its Minimum Efficiency Reporting Values (MERV)-rated filters in its HVAC systems to the highest filter that the system would allow.</p><p>Covenant has also started to roll out a new telemedicine program and equip all facilities with communication technology where physician visits and visitation can be done virtually and on demand as needed. “This includes utilization of iPads for FaceTime visits with family members or utilizing Microsoft Teams,” says Rabe. “In addition, we’re using the iPads for virtual telehealth consults with resident physicians.”</p><p>In addition, a new guest registration screening process with automated technology now allows Covenant to screen visitors with or without assistance from staff. “We use a product called VT Shield from Toshiba,” says Rabe. “This product allows us to ask questions that are in line with CDC [Centers for Disease Control and Prevention] requirements and take the temperature of our guests prior to entering the building.” Once passed, the system will provide a visitor pass. The data are saved within the system for auditing purposes.</p><h2>Communication at the Heart<br></h2><p>At the heart of all Covenant’s modifications is communication. “We have started to roll out a resident and family communication app to improve communication with our residents and their family members,” says Rabe. </p><p>The app is called myCovLife. In addition to keeping residents and families up to date on the latest company-wide infection control and prevention tactics, Covenant staff use the app’s basic features to send communication to the residents for a number of purposes. </p><p>“We can provide them access to key contacts in the community, a resident directory, information about the community, what’s on the menu for dining, transportation requests, and the ability to sign up for activities,” says Rabe. The app is being rolled out over a period of several months, and so far the residents have been enjoying becoming familiar with it and using it, he says. </p><h2>Looking Ahead <br></h2><p>Thinking about the future conjures up images of fine-tuning modifications for continued infection control. “This would include smaller, but more dining space options in our communities to reduce capacity, longer dining hours to reduce capacity based on the needs of individual communities, and extension of outside space area,” says Rabe. Enhancements in building air circulation are still in use, which are different based on each community.</p><p>Rabe says that the pandemic has reinforced the need for repetition in education and protocols. With that comes a heightened focus on training and education and more audits to ensure compliance. </p><p>Rabe’s advice: “Develop a process to follow and implement state and local regulations,” he says. This is even more difficult with national providers serving residents in multiple states. Requirements are different between states and local counties, and they can become very confusing.</p><p>Regular communication can help reduce that confusion, Rabe says. “Develop a robust communication plan,” and along with it, identify tools to deliver consistent messaging. </p><p>“During COVID we utilized several forms of communication to ensure we were able to keep residents and families up to date,” he says. “This communication came in the form of virtual town hall meetings delivered to our residents’ rooms, use of kiosks and information slides through our resident channel, push notifications and content delivered via our engagement application, along with updates on our website and family letters.” <br></p><p></p> | 2021-11-01T04:00:00Z | <img alt="" src="/Topics/Special-Features/PublishingImages/2021/1121/CF2.jpg" style="BORDER:0px solid;" /> | Clinical;Infection Control | Amy Mendoza | Cleaning and disinfection of all skilled nursing rooms happens at least twice a day as a practice the company implemented at the beginning of the COVID pandemic and continues to employ amid different COVID-19 variants. |
| 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 0.13 meters/second 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:5px;width:170px;height: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://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: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:0px solid;" /> | Clinical;Diet | Lauren Hinrichs | Researchers 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: 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:5px;width:165px;height: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:0px solid;" /> | Management;Clinical | Joanne Kaldy | Staff 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. |