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Update in the Medical Management of the
Long-Term Care Patient
Paniagua, Miguel A., Clinics in Geriatric Medicine, May 2011, Volume 27, Number 2, Pages 135 - 198
Lindsay Drevlow, PA-S2
November 28, 2011
Overview
Managing the Patient with Dementia in Long-Term Care
Medications in Long-Term Care: When Less is More
Evidence-Based Medicine (EBM): What Long-Term Care Providers Need to Know
Managing the Patient with Dementia in Long-Term Care
Jennifer Rhodes-Kropf, MD; Huai Cheng, MD, MPH; Elizabeth
Herskovits Castillo, MD, PhD; Ana Tuya Fulton, MD
Background
70 - 80% have some degree of dementia Efficacy of Cholinesterase Inhibitors and
Memantine Optimal Environment for Maintenance of
Function in Moderate Dementia Treatment of Depression and Agitation Evaluation and Management of Eating
Problems
Efficacy of Cholinesterase Inhibitors and Memantine
Alzheimer’s Disease Decreased cerebral synthesis of choline
acetyltransferase
Decreased acetylcholine production and impaired cortical cholinergic function
Cholinesterase Inhibitors Increase cholinergic transmission Use is controversial in other types of dementia
Approved Cholinesterase Inhibitors
Tacrine (Cognex) Rivastigmine (Exelon) Galantamine (Razadyne, Reminyl) Donepezil (Aricept
Donepezil
Efficacy demonstrated for mild - moderate cognitive impairment
Effective dose = 10 mg Titrate over a few weeks to decrease GI side
effects Titrate down when stopping
Improvement in outcomes is controversial
Memantine
N-methyl-D-aspartate receptor antagonist Overstimulation of receptor by glutamate Efficacy demonstrated in moderate - severe
Alzheimer’s Disease Effective dose = 10 mg BID
Start 5 mg QD Increase by 5 mg Qwk until reach effective dose
Optimal Environment for Maintenance of Function in Moderate Dementia
Function and QOL are contingent on surroundings Finding the right “person-environment fit” Prevent “excess disability”
Changes in brain function Perceptual ability decreases Ability to filter multiple stimuli decreases Impaired vs. preserved functions
Dementia and Depression/Agitation
Depression MC psychological sx a/w dementia in LTC pts 29% had major depressive disorder Randomized Control Trials:
Sertraline vs. placebo showed no improvement in depressive symptoms
Comprehensive exercise, supervised walking or social conversation reduced depression in all 3 groups
W/o treatment, tends to be persistent
Dementia and Depression/Agitation
Agitation = distinct syndromes, including physically
aggressive behaviors, physically non-aggressive behaviors and verbally agitated behaviors
Study: 85% of 1322 dementia pts had at least 1 symptom of agitation
Cohen-Mansfield Agitation Inventory RF
Pain, ADL dysfunction, cognitive impairment, depression, mental/medical dz, physical restraints, psychosis, anti-psychotics, anxiolytics, total # drugs/day, physical/social environment factors
Dementia and Depression/Agitation
Agitation Approach to Treatment:
Assess & remove potentially correctable RF Behavioral management
Staff training vs. usual care Person-centered showering/bathing Family visit education program
Drug therapy Olanzapine (Zyprexa) Carbamazepine (Tegretol) Haloperidol, oxazepam, diphenhydramine
Evaluation and Management of Eating Problems w/ Dementia
Eating Problems a/w Dementia Hallmarks = difficulty eating and maintaining wt, loss of
appetite Problems include:
Difficulty chewing/swallowing, pocketing or spitting, loss of appetite, decreased interest in food, inability to sense hunger/thirst
Of pts with advanved dementia: 30% have a feeding tube 86% have eating difficulty when followed over 18 months
Failure to Thrive must be considered
Evaluation and Management of Eating Problems w/ Dementia
Workup & Evaluation Complete H&P, including medication review Labs:
CBC, fasting glucose, electrolytes, LFTs, TSH, UA, albumin, prealbumin
Dental Care Assessment for dysphagia and/or odynophagia Depression screening Poor access to food? Forgetting to eat? Evaluation for malignancy, HIV, syphilis, Tb
Evaluation and Management of Eating Problems w/ Dementia
Management Targeted tx of underlying conditions Increase physical activity, resistance/endurance
training Improve meal time environment Speech therapy evaluation Change to 5 smaller meals Supplements b/t meals
Evaluation and Management of Eating Problems w/ Dementia
Management, cont’d D/c offending meds if possible
Affect taste, olfaction or cause anorexia Meds to stimulate appetite
Mirtazapine 7.5/15 mg Megestrol 800 mg liquid
Medications in Long-Term Care: When Less
is More
Thomas W. Meeks, MD; John W. Culberson, MD; Monica S.
Horton, MD, MSc
History of Medication Reduction in LTC
OBRA-87 changed standards of care in NH Potentially inappropriate prescribing in older
adults occurs at a rate of 12 - 40% PIPE emerged due to concerns about
polypharmacy & iatrogenic toxicity 1991 (Beers List) 2001 (Zhan) 2006 (HEDIS) Focus mostly on drugs w/ CNS activity
Prevalence of Neuropsychiatric Illness in LTC
50% LTC pts have dementia 80 - 100% of these pts experience dementia-
associated neuropsychological symptoms Psychosis, aggression, depression NO FDA approved therapy
Therefore, use of psychotropic meds is very common due to the prevalence of this disease
Medication Reduction
Why? Older pts are on more meds and have a higher risk for
adverse effects Polypharmacy must be carefully monitored
When? Medication review 2x/yr and during transitions of care
How? Discuss changes based on risk/benefit profile
What? Meds/classes commonly seen on PIPE lists
Medication Reduction: What? Antipsychotics
Many recent black box warnings Toxicity becomes more concerning when efficacy is
questionable Clearest indication = bipolar and schizophrenia Proposed algorithm for choosing to use:
Assess imminent danger Attempt behavioral/psychosocial interventions first
Choose based on SE profile Atypical vs. typical
If used, consider trial taper q3-6mo
Medication Reduction: What?
Benzodiazepines Should generally be avoided
However, 30% LTC pts still take Studies show risk benefit
Excessive sedation Tolerance/dependance even if not abused Hepatic metabolism
If used, should be short term for appropriate conditions
Medication Reduction: What?
Other Sedatives/Hypnotics Z-drugs = zolpidem, zaleplon, eszopiclone Act on benzo-type 1 receptor SE = postural instability, hallucinations, amnestic
episodes Insomnia
Look for a cause Commonly used meds:
Lunesta, Rozerem, Trazodone Sedating antihistamines
Medication Reduction: What?
Antidepressants MDD affects 10 - 15% of LTC residents Potential SE:
SIADH, osteoporosis, falls, GI bleeding Limited/mixed data on efficacy in older adults,
especially those w/ dementia
Medication Reduction: What?
Antidepressants--drug options: First line
SSRIs (celexa, lexapro, zoloft) Second line
SSRIs (prozac, paxil) SNRIs (effexor, pristiq, cymbalta) Atypicals (remeron, wellbutrin)
Less preferred, possibly appropriate at times Secondary TCAs (nortriptyline, desipramine)
Almost always inappropriate Tertiary TCAs (amitriptylline, doxepin) MAOIs (phenelzine, tranylcypromine, selegeline)
Medication Reduction: What?
Analgesics Overview Pain = MC symptom among LTC pts Identify and treat underlying cause of pain
Use pain scale Optimize meds Set realistic goals
Persistent pain Scheduled long acting preparations Physical and Occupational therapy Massage therapy, chiropractic manipulation, acupuncture Transcutaneous electrical nerve stimulation Surgical intervention
Medication Reduction: What?
Analgesics Overview Why is pain treatment so complicated?
Broad variety of causes Diagnostic uncertainty and fluctuating course Multiple treatment options available Regulatory and administrative guidelines
Medication Reduction: What?
Topical Analgesics and Local Injections Great way to lower systemic analgesic dose
required to control chronic pain Options:
Topical lidocaine 5% patches Topical NSAIDs Intra-articular injections
Steroids Hyaluronic acid
Trigger-point IM injections
Medication Reduction: What?
Acetaminophen Low risk for toxicity and minimal drug interactions Limitations:
Short half-life Potential hepatotoxicity
Best for acute intermittent pain control
Medication Reduction: What?
NSAIDs Best used sporadically at low doses for acute
intermittent pain Risks:
GI bleeding Renal dysfunction Cardiovascular complications
Avoid nonselective and cyclooxygenase 2 selective inhibitors
Medication Reduction: What?
Opiate Analgesics Essential for providing safe, effective pain control SE = constipation Suggest using long acting MS contin as opposed
to hydrocodone, hydromorphone, and oxycodone Minimal risk of abuse or drug-seeking behavior in
pts treated long term and have no h/o abuse
Medication Reduction: What?
Anticonvulsants Gabapentin and pregabalin
Reduce neuropathic pain due to a variety of conditions
Low SE profile Long-acting Titrate to maximum tolerated dose
Medication Reduction: What?
Other Common Adjuvant Medications Systemic steroids
Acute musculoskeletal pain w/ inflammatory component Short course + PT
Calcitonin Persistent pain a/w osteoporosis, vertebral compression fx
Bisphosphonates Persistent pain in pts w/ bone metastases
Baclofen Skeletal muscle relaxant in pt’s w/ severe spasticity
Evidence-Based Medicine (EBM): What Long-Term Care Providers Need to
Know
Huai Y. Cheng, MD, MPH
EBM
Disseminated to all fields of medicine, but only more recently into LTC
May play an important role in nursing homes and improving quality care
ResearchEvidence
Pt preference and actions
Clinical State & Circumstances
Clincal Expertise
The EBM Concept
Developed in 1991 Offers a framework to make the best
decisions for individual pts Relevant to LTC b/c pt preferences are often
different Research evidence
Strongest = systematic review of large well-performed RCTs Minimal in NH setting
EBM Application in LTC
Potential Benefits: Better decision making for pts & families Improved quality of care
Potential Harms: Can results from other populations be applied to
LTC w/ similar effects? Can not strictly follow disease-based guidelines Gov’t, insurance, etc may misuse EBM in policy
making
EBM Application in LTC
Challenges: Requires training & education for providers and
possibly staff Not well tested to show improvement in outcomes
and quality of care LCT pts have multiple co-existing problems Cognitive impairment makes shared or pt-
centered care difficult Many clinical questions are difficult to answer
based on RCT
References
Rhodes-Kropf, Jennifer. Managing the Patient with Dementia in Long-Term Care. Clinics in Geriatric Medicine. 2011;27:135-152.
Meeks, Thomas W. Medications in Long-Term Care: When Less is More. Clinics in Geriatric Medicine. 2011; 27:171-192.
Cheng, Huai Y. Evidence-Based Medicine (EBM): What Long-Term Care Providers Need to Know. Clinics in Geriatric Medicine. 2011; 27:193-198.
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