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.
Creating a Behavior Enhancement Program<p>​As more states move increasingly toward the deinstitutionalization of patients from the long-term acute psychiatric setting, post-acute care communities find themselves struggling with the multiple challenges of appropriately managing this population. <br></p><p>This is especially true for those residents who are younger, many of whom have substance use issues, don’t qualify for Medicare, and who are more cognitively intact. This is compounded in some states by less than adequate Medicaid reimbursement for necessary mental health professionals, often resulting in less than adequate services.</p><h2>Other Impediments</h2><p>Poor communication from staff to the mental health team regarding specific targeted behaviors requiring interventions, or poor internal communication to staff regarding the mental health team’s recommendations, presents additional barriers.<br></p><p>With lack of continuity of care and minimal mental health training to the line staff, the interdisciplinary team often finds itself constantly dealing reactively with the fallout from the same repetitive undesirable behavioral patterns rather than proactively identifying and addressing root causes to improve them.<br></p><p>This results in multiple negative outcomes to residents, families, staff, and the long term care community as a whole. Repetitive transfers to a short-term acute psychiatric setting are of no benefit to anyone, especially the affected resident. The other long term care residents and their family members will likely voice concerns regarding the impact of certain resident behaviors. Staff will become vocal, feeling a sense of frustration and lack of support on how to manage these residents. <br></p><p>Fortunately, through commitment and dedication from ownership and the entire facility team, this cycle can be broken. </p><h2>Behavior Enhancement Plan</h2><p>So what are the key ingredients to a successful Behavior Enhancement Program and how does a community implement one?<br></p><p>The best starting point is to establish an interdisciplinary committee consisting of key managers and line staff from all departments, as well as the facility’s mental health professionals and medical director so all team members have input into developing the critical policies and parameters of the program.<br></p><p>It will be vital that this committee remain in place and meet weekly to discuss all program criteria, including policies, assigned staff, staff training monitoring, and specific residents’ behavioral progress. It is highly recommended that a dedicated, secured unit be established for the program for optimum opportunity for success. <br></p><p>The ultimate mission of the Behavior Enhancement Program would be to provide a structured environment that invites resident participation, promotes dignity and respect, and encourages positive behaviors, leading to successful residents “graduating” from the program and being transferred off-unit where they can engage socially in acceptable, meaningful interactions throughout the facility</p><h2>Establishing Standards</h2><p>The interdisciplinary committee will want to establish unit/program admission criteria to include residents with a mental health diagnosis and at least one challenging behavior, as well as a BIMS (Brief Interview for Mental Status) score high enough for the resident to appropriately participate in the program. <br></p><p>Once the admission criteria are developed, the team can then work together to identify residents they feel meet them and who may benefit from the program. Involving residents and their family members throughout the process is a critical factor for success.</p><h2>Staff and Training</h2><p>The team’s next challenge will be to identify line staff who exhibit the right qualities and have the desire to work with this population. As with any specialty program, it is important that only the primary and back-up staff designated and trained to work on this unit are assigned to work there, which will require good communication to the staffing coordinator and off-shift nursing supervisors as well. <br></p><p>The next step is to outline program training requirements to include overall program philosophy and policies, definitions of the basic mental health disorders, and to ensure each team member on all shifts is aware of each resident’s specific targeted behaviors, triggers to those behaviors once identified, and interventions to proactively minimize those triggers from occurring. <br></p><p>This is where a strong relationship between the facility’s mental health team and line staff is extremely beneficial. The clinical team will also be focusing on developing policies regarding critical assessments such as the Trauma Assessment Tool or Functional Assessment Observation Form they may want to implement in order to best document resident behaviors, the interventions implemented, and their rates of success.</p><h2>Recreation Program Options</h2><p>No Behavior Enhancement Program will be successful without a structured, individualized recreation program ideally seven days a week between the hours of 9 a.m. and 8 p.m. Managing residents’ behaviors by providing nursing staff with additional support especially on the 3 p.m. to 11 p.m. and weekend shifts is completely necessary. Various groups can be fused into the recreation calendar. <br></p><p>While psychotherapy groups are highly effective, the benefit of other groups involving team members should not be underestimated. For example, does one of the certified nurse assistants have a musical background and would like to lead a weekly music group for the residents?<br></p><p>Additionally, incorporating residents’ life skills to better engage them can have significant positive effects on behavior reduction. Perhaps one of the residents has a background in maintenance. Assigning the resident basic beneficial maintenance tasks such as identifying stained ceiling tiles and loose handrails and even offering them participation in the facility’s Safety Committee can help reinstate the resident’s sense of self-worth and esteem.<br></p><p>Finally, it is highly recommended that the facility establish behavior session and recreation attendance goals for the residents, offering reasonable rewards of the resident’s choice upon successfully achieving one of these goals, including increasing off-unit privileges per program policy.<br></p><p>Other program considerations may include use of Behavior Contracts, Smoking Program overview, and Alcoholics Anonymous or similar substance abuse support as necessary.</p><h2>Many Benefits</h2><p>There are many post-acute care communities that have placed effort and focus on developing structured, person-centered specialty dementia units/programs for residents with cognitive impairments, and the same can be accomplished for higher-functioning residents who are cognitively intact but with psychiatric diagnoses and behavior challenges as well. <br></p><p>A holistic, well-structured Behavior Enhancement Program will have positive ripple effects on many levels. Significant reduction in behavior transfers can be expected through proactive versus reactive behavior management methods. A decrease in psychotropic medications is also highly likely for a number of participating residents. Other benefits include enhanced collaboration between mental health professionals and the facility team, reduction in staff stress, and diminished resident- and family-related complaints. Increased revenue potential through the patient-driven payment model may be achieved by capturing depression or other related mental health diagnoses, or increased Part A census potential by admitting residents into the program who also have other skilled service needs.<br></p><p>But, most importantly, the greatest benefit is to the residents who realize more positive behavior outcomes, self-worth, and an improved sense of quality of life through participation in a Behavior Enhancement Program. <br><br><strong><img src="/Monthly-Issue/2021/May/PublishingImages/cgiving_RonDenti.jpg" class="ms-rtePosition-1" alt="" style="margin&#58;5px;width&#58;116px;height&#58;150px;" />Ron Denti, LNHA,</strong> is a nursing home administrator with more than 30 years of experience who has developed the DIAMONDS<sup>©</sup> Behavior Enhancement Program geared toward residents in the post-acute care setting. For more information, go to <a href="http&#58;//www.behaviormanagementltc.com/" target="_blank">www.behaviormanagementltc.com</a>.</p>2021-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/May/PublishingImages/0521-cgiving.jpg" style="BORDER&#58;0px solid;" />ClinicalRon Denti, LNHAAs more states move increasingly toward the deinstitutionalization of patients from the long-term acute psychiatric setting, post-acute care communities find themselves struggling with the multiple challenges of appropriately managing this population.
GERD Medicine Needs to Be Doled Out Smartly, Says New Report<p>A new report says while proton pump inhibitors (PPIs), like Nexium, are proven medications of choice for gastroesophageal reflux disease (GERD) and other disorders, the significant increase in the use of PPIs for ill-defined indications over the years has been associated with adverse outcomes and increased health care costs. </p><p>The findings in a study in the January issue of JAMDA suggests that provider awareness of best practice guidelines on PPI use, along with a focus on patient education, may help promote safe and effective use of this treatment.</p><p>In “The Use and Misuse of Proton Pump Inhibitors&#58; An Opportunity for Deprescribing,” the author, T.S. Dharmarajan, MD, said PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. </p><p>The catch is that he cited evidence suggesting that excessive and inappropriately prolonged PPI use is associated with various adverse effects. These include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions.</p><p>In addition, the report said there are potential complications due to gastric acid inhibition, such as gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth. </p><p>Dharmarajan concluded that education of providers and patients, stewardship, and motivation are key to appropriate use of PPIs for the right indications. He said efforts at deprescribing a PPI “may be attempted following discussion with the patients.” Deprescribing approaches include stopping the drug, reducing the dose, or using “on-demand” therapy after completing the course of treatment for the specific indication. </p><p>Follow-up is recommended, he observed, for “recurrence of manifestations.” In the event of recurrence, he said, the PPI may need to be reinstituted.</p><p>Researchers at the Montefiore Medical Center, Wakefield Campus, Bronx, N.Y., conducted the study. Click <a href="https&#58;//www.jamda.com/article/S1525-8610%2820%2930989-0/fulltext">here </a>for more information on the details about the study.<br></p>2021-02-05T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/0920_News1.jpg" style="BORDER&#58;0px solid;" />ClinicalPatrick ConnoleProlonged use of proton pump inhibitors has been associated with various adverse effects.
Arden Courts: 25 Years of Dementia Care<div><div><div>​​</div><div> <img src="/Monthly-Issue/2019/December/PublishingImages/Arden_backyard2.jpg" class="ms-rteImage-0 ms-rtePosition-1" alt="" style="margin&#58;5px 15px;" />In 1994, President Ronald Reagan penned a letter announcing to the American public that he had Alzheimer’s disease. Having a prominent statesman admit his battle with Alzheimer’s put the discussion of caring for people with memory care into the public eye. Up until that point, the 4 million Americans living with Alzheimer’s, most aged 65 and older, had very few care options other than nursing facilities and hospitals. </div><div> <br> </div><div>Today, there are 5.8 million people in the U.S. living with Alzheimer’s and other related dementias, with another person diagnosed with the disease every 65 seconds. As baby boomers reach retirement, memory care has again returned to the forefront of discussion.</div><div> <br> </div><div>Long term and post-acute care organizations are now offering a spectrum of services for patients living with memory loss who require long term care. Twenty-five years ago, HCR ManorCare was one of the first providers to address care settings to offer quality care in an engaging and social environment by creating Arden Courts Memory Care Communities.</div><h2 class="ms-rteElement-H2">At the Beginning</h2><div>The first Arden Courts Memory Care Community was built in 1994 in Potomac, Md. Five years of research and planning by dementia experts went into developing an assisted living environment that would help people living with Alzheimer’s maximize their sense of independence and increase their self-esteem by utilizing their cognitive abilities in a safe and secure environment. “Arden Courts set out to specifically design an environment that could provide a living option for persons living with Alzheimer’s disease and related forms of dementia to receive the unique care needed without sacrificing their quality of life,” says Mark McBride, vice president and general manager of Arden Courts. </div><div> <br> </div><div>Since building that first location in 1994, Arden Courts has opened 52 memory care communities located in 11 states. Originally designed for a resident population comprised of persons living in the early to middle stages of dementia, Arden Courts has adapted dementia caregiving techniques for all stages of Alzheimer’s, Parkinson’s disease, Lewy body dementia, frontotemporal degeneration, and early-onset and other forms of dementia.</div><div> <br> </div><div>Arden Courts now has increased its clinical staff and its number and types of programming, as well as changed the food and dining protocol to maximize self-function and independence for residents.</div><h2 class="ms-rteElement-H2">Experience Makes a Difference</h2><div>“Our 25 years of experience caring for over 43,500 residents not only has improved and transformed the way Arden Courts delivers care, but has also evolved how the community is designed in order to better meet the changing needs of the resident population,” says Pauline Coram, director of executive learning for Arden Courts.</div><div> <br> </div><div>“Arden Courts was among the first standalone, purposefully built memory care communities to feature a ‘house’ design that evokes a sense of home,” she says. </div><div> <br> </div><div>Each house has a living room, laundry, kitchen, and dining room. In addition, doors lead to an enclosed, protected outdoor courtyard with garden areas and landscaped walking paths and sitting areas.</div><div> <br> </div><div>The four houses at Arden Courts were designed in a homelike manner. Initially, the houses were planned as four separate living quarters, each with a porch, front door, mailbox, door knocker, foyer, and hallway leading to the common areas and bedrooms, Coram says. </div><div> <br> </div><div>“Arden Courts found its residents enjoyed exploring and purposeful wandering, so the front doors of the houses were left open to the communal areas, and residents could visit the social gathering places, such as the studio, health center, beauty salon, and shop windows, or simply sit on one of the porches for awhile,” she says. “This area also had additional access to the secured outdoor areas with guided <br></div><div>pathways, gardens, and foliage.”</div><div> <br> </div><div>The organization also retrofitted some living rooms in the houses to be able to conduct Namaste Care™ for individuals with advanced dementia. The Namaste program focuses on persons living in the latter stages of dementia with a “loving touch” in an environment that nurtures and stimulates the senses. The environment is carefully created with scents of lavender, soft music, nature scenes, hydration, and nurturing appealing to the senses of smell, touch, taste, hearing, and vision.</div><div> <br> </div><div>The soothing, slower-paced environment can help reduce agitation and anxiety in persons living with dementia by providing respite for the resident. Namaste also creates opportunities to increase hydration, which can help avoid dehydration issues and infections. Arden Courts was the first national assisted living company to embrace Namaste Care in its communities.&#160;</div><h2 class="ms-rteElement-H2">Living Spaces Evolve, Indoors and Out</h2><div>A staple for the design of Arden Courts is the courtyard, which has been beneficial physically and emotionally for the residents. Courtyards are designed with meandering paths, garden areas, and outdoor birdbaths and water features to encourage residents to explore and be involved with nature. It also provides an opportunity to exercise, while keeping residents safe. </div><div> <br> </div><div>Additionally, certain aspects of the outdoor area have been redesigned to serve more as destination opportunities, such as the installation of sitting areas and gazebos, places where families are able to interact and relax with their loved ones. The added elements of design such as gardening areas, bird-feeding stations, and flower beds also encourage the resident to explore, engage, and be involved with nature. </div><div> <br> </div><div>Connecting each of the four houses, Arden Courts features a core area that contains an art studio, porches, community center, health center, and a beauty/barber salon. Originally designed with the resident in mind, it quickly became obvious that this area is a great location where families can gather. “The core design has also evolved by enhancing the porches and common areas into destinations where families would mingle with their loved ones,” says Coram. Renovations included opening up the space between the community center and studio, which was originally designed as two separate rooms. </div><div> <br> </div><div>“Before the two spaces were separated, programming personnel recommended joining the spaces for two reasons&#58; to create a larger common area that allowed for more programming flexibility with family and themed events, and to provide an opportunity for residents to stay together with purposeful environmental movement and structured programming throughout the day,” Coram says.</div><div> <br> </div><div>Practical changes have also been necessary. Replacement finishes and furniture in the houses and the core areas were adjusted to accommodate the ever-changing needs of residents, while maintaining the residential focus of Arden Courts.</div><h2 class="ms-rteElement-H2">Design Based on Visual Cueing </h2><div>Arden Courts management knew from their original research that visual cueing is critical for persons living with dementia. Multiple and varied prompts are offered throughout the residence to help define the spaces and provide residents way-finding success, which encourages a sense of control and purpose. Each house has always featured a different color scheme and theme, as well as memory boxes outside each resident room containing personal photos and mementos to help residents recognize their house and own rooms. A name plate and bedroom room number serve as additional cueing prompts.</div><div> <br> </div><div> <img src="/Monthly-Issue/2019/December/PublishingImages/Arden_park-2.jpg" class="ms-rtePosition-2" alt="" style="margin&#58;5px 15px;" />Even in the common areas, signage offers both pictures and words, including the beauty/barber salon signage that features a picture of a brush and scissors and the art studio’s picture of a paintbrush with a palette. </div><div> <br> </div><div>“As times have changed, so has the color palette at Arden Courts to correspond with current design trends,” says Coram. “In addition to aesthetic updates, more signage was created in common areas to offer simple instructions for residents to increase engagement with their environment, both indoors and outdoors.”</div><div> <br> </div><div>Signs have been added to common areas engaging residents to comment on colors of flowers located in the garden area. Inside, signs encourage residents to help sort linens and ask them to comment on the different scenes within artwork on the walls. “Intended to be self-starters, these guided requests encourage the resident to read and partake in activities. Accomplishing these activities leads to increased engagement and self-esteem,” says Coram. </div><h2 class="ms-rteElement-H2">The Future and Changing Demographics</h2><div>When originally designed in 1994, Arden Courts worked primarily with the spouse of the resident. This has changed. As people with dementia stay home longer and come to Arden Courts reflecting differing dementias and the varying phases of the disease process, adult children now share in the decision process.</div><div> <br> </div><div>“The many health discoveries in care delivery, research, and medications have changed the way we view the world of dementia, and they are influencing the changes of the future,” says McBride.</div><div> <br> </div><div>“Despite all the change, Arden Courts continues to offer families the peace of mind they deserve, knowing their loved ones are being cared for by experienced people and in a proven environment, which is continuously evolving.” </div><div>&#160;</div><div>Brandon Smeltzer, MHA, is director of market development with HCR ManorCare, Assisted Living Division. He can be reached at <a href="mailto&#58;brandon.smeltzer@hcr-manorcare.com">brandon.smeltzer@hcr-manorcare.com</a>.</div> <span style="display&#58;inline-block;"> <span style="display&#58;inline-block;"></span></span></div></div>2019-11-01T04:00:00Z<img alt="" src="/Monthly-Issue/2019/December/PublishingImages/Arden_t.jpg" style="BORDER&#58;0px solid;" />Caregiving;ClinicalBrandon SmeltzerHaving a prominent statesman admit his battle with Alzheimer’s put the discussion of caring for people with memory care into the public eye.