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.
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.