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.

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.