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Yeung GYC, Joling KJ, Dash D, Jepma P, Costa AP, Katz PR, Hertogh CMPM, de Bruijne MC, Smalbrugge M. Compiling a Set of Actionable Quality Indicators for Medical Practitioners in Dutch Nursing Homes: A Delphi Study. J Am Med Dir Assoc 2024; 25:105089. [PMID: 38908400 DOI: 10.1016/j.jamda.2024.105089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/10/2024] [Accepted: 05/10/2024] [Indexed: 06/24/2024]
Abstract
Most quality indicators (QIs) currently used in nursing homes reflect the care delivered by the entire multidisciplinary team and are not specific for medical practitioners. International experts have proposed a set of QIs that specifically reflect the quality of medical care in nursing homes. The objective of the Delphi study described here was to compile a set of actionable QIs tailored for medical practitioners working within Dutch nursing homes. This was achieved through the evaluation of 15 existing national QIs and 35 international QIs by a panel of medical practitioners, comprising medical specialists, nurse practitioners, and physician assistants, who are working in Dutch nursing homes. Panelists rated each QI on (1) level of direct control by medical practitioners and (2) its relevance to the quality of medical care. QIs progressing to subsequent rounds required panel agreement on both direct control (≥70% ≥3 points on a 4-point scale) and relevance (≥70% ≥8 on a 10-point scale). In the last round, each panelist selected the 5 most relevant QIs and arranged them in order of importance. These top 5 rankings were converted into points for an overall final ranking. There was consensus on 42 QIs being under the control of medical practitioners, and 21 of these QIs were considered relevant for quality of care. Most of the 21 QIs originated from the international QI set. This finding supports the transferability of the internationally developed QIs to the Dutch nursing home context and provides opportunities to compare the quality of medical care in nursing homes across countries. In the final ranking, the QI related to new medication prescriptions received the highest rating, followed by 3 QIs related to advance care planning. Future research should focus on evaluating the feasibility of measuring the selected QIs and assessing their measurement properties before implementing them in professional learning and quality improvement initiatives for medical practitioners in nursing homes.
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Affiliation(s)
- Gary Y C Yeung
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Karlijn J Joling
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Patricia Jepma
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul R Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Martine C de Bruijne
- Department of Public and Occupational Health, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Malena K, Rao S, Mosler C. Review of Current Clinical Options for the Management of Behavioral and Psychological Symptoms of Dementia. Sr Care Pharm 2024; 39:300-310. [PMID: 39080869 DOI: 10.4140/tcp.n.2024.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Dementia is a disease most prevalent in the older adult population. The cognitive symptoms of dementia include impairments in problem-solving, memory, and language. Some patients experience noncognitive symptoms in addition to the cognitive symptoms of dementia. These noncognitive symptoms are called behavioral and psychological symptoms of dementia or BPSD. The primary objective of our study was to examine the therapeutic options, guidelines, and clinical considerations for the management of BPSD. The existing literature about BPSD was reviewed with searches in PubMed, MEDLINE, and online search platforms. Dysregulation of neurotransmission involving acetylcholine, dopamine, and serotonin has been shown to cause behavioral and psychological symptoms of Alzheimer's disease. BPSD can include hallucinations, agitation, delusions, anxiety, apathy, abnormal body movements, irritability, depression, disinhibition, and sleep or appetite changes. Pharmacologic therapies used in the treatment of BPSD include antidepressants, antipsychotics, anxiolytics, and anticonvulsants. Treatment can be tailored to the specific noncognitive symptoms that are experienced. The use of these agents may be limited based on recommendations from the Beers Criteria®, STOPP criteria, treatment guidelines, and FDA warnings.
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Lam K, Gan S, Nguyen B, Jing B, Lee SJ. Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2008-2018. [PMID: 35357692 PMCID: PMC9283241 DOI: 10.1111/jgs.17771] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen. METHODS In an observational study from October 1, 2013, to June 30, 2017 of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short-acting insulin regimens - fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) - from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia). RESULTS In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate-severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors. CONCLUSIONS SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.
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Affiliation(s)
- Kenneth Lam
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
| | - Siqi Gan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Brian Nguyen
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
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Jeon SY, Shi Y, Lee AK, Hunt L, Lipska K, Boscardin J, Lee S. Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus. J Am Geriatr Soc 2020; 69:424-431. [PMID: 33064879 DOI: 10.1111/jgs.16880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND/OBJECTIVE Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM). DESIGN AND SETTING National retrospective cohort study in 140 VA NHs. PARTICIPANTS NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital. MEASUREMENTS NH residents were classified into five groups based on their highest hypoglycemia risk glucose-lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long-acting insulin; and any short-acting insulin. Our outcome was a daily count of FS measurements. RESULTS Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short-acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8-1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3-1.4) by day 90. NH residents on short-acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9-3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5-2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long-acting insulin (2.1 (95% CI = 2.0-2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5-1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1-1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4-0.6) measurements on day 90. CONCLUSION Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.
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Affiliation(s)
- Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Lauren Hunt
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Kasia Lipska
- Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA
| | - John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sei Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Liau SJ, Lalic S, Sluggett JK, Cesari M, Onder G, Vetrano DL, Morin L, Hartikainen S, Hamina A, Johnell K, Tan ECK, Visvanathan R, Bell JS. Medication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education. J Am Med Dir Assoc 2020; 22:43-49. [PMID: 32669236 DOI: 10.1016/j.jamda.2020.05.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/25/2020] [Accepted: 05/02/2020] [Indexed: 12/18/2022]
Abstract
Frailty is a geriatric condition associated with increased vulnerability to adverse drug events and medication-related harm. Existing clinical practice guidelines rarely provide medication management recommendations specific to frail older people. This report presents international consensus principles, generated by the Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network, related to medication management in frail older people. This consensus comprises 7 principles for clinical practice, 6 principles for research, and 4 principles for education. Principles for clinical practice include (1) perform medication reconciliation and maintain an up-to-date medication list; (2) assess and plan based on individual's capacity to self-manage medications; (3) ensure appropriate prescribing and deprescribing; (4) simplify medication regimens when appropriate to reduce unnecessary burden; (5) be alert to the contribution of medications to geriatric syndromes; (6) regularly review medication regimens to align with changing goals of care; and (7) facilitate multidisciplinary communication among patients, caregivers, and healthcare teams. Principles for research include (1) include frail older people in randomized controlled trials; (2) consider frailty status as an effect modifier; (3) ensure collection and reporting of outcome measures important in frailty; (4) assess impact of frailty on pharmacokinetics and pharmacodynamics; (5) encourage frailty research in under-researched settings; and (6) utilize routinely collected linked health data. Principles for education include (1) provide undergraduate and postgraduate education on frailty; (2) minimize low-value care related to medication management; (3) improve health and medication literacy; and (4) incorporate evidence in relation to frailty into clinical practice guidelines. These principles for clinical practice, research and education highlight different considerations for optimizing medication management in frail older people. These principles can be used in conjunction with existing best practice guidelines to help achieve optimal health outcomes for this vulnerable population. Implementation of the principles will require multidisciplinary collaboration between healthcare professionals, researchers, educators, organizational leaders, and policymakers.
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Affiliation(s)
- Shin J Liau
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, Australia
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; Pharmacy Department, Monash Health, Melbourne, Australia
| | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia; NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, New South Wales, Australia
| | - Matteo Cesari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Davide L Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden; Centro Medicina dell'Invecchiamento, IRCCS Fondazione Policlinico Universitario A. Gemelli, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Inserm CIC 1431, University Hospital of Besançon, Besançon, France
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Aleksi Hamina
- Kuopio Research Centre of Geriatric Care, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Edwin C K Tan
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, Australia
| | - Renuka Visvanathan
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, Australia; Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, Australia; Kuopio Research Centre of Geriatric Care, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
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Jones ME, Petersen I, Walters K, Bhanu C, Manthorpe J, Raine R, Mukadam N, Cooper C. Differences in Psychotropic Drug Prescribing Between Ethnic Groups of People with Dementia in the United Kingdom. Clin Epidemiol 2020; 12:61-71. [PMID: 32021472 PMCID: PMC6980848 DOI: 10.2147/clep.s222126] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/04/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To test hypotheses that minority ethnic people with dementia in the UK receive fewer anti-dementia drugs and more psychotropic and anticholinergic drugs associated with harms. Patients and Methods We analyzed UK primary care electronic health records from The Health Improvement Network (THIN) database (2014–2016), comparing psychotropic drug prescribing initiation and duration between people with dementia from White, Black, and Asian ethnic groups. We repeated analyses in people (aged 50+) without dementia, to explore whether any differences found reflected prescribing patterns in the general older population, or were specific to dementia. Results We included 53,718 people with and 1,648,889 people without dementia. Among people with dementia, compared to White ethnic groups, Asian people were less likely to be prescribed anti-dementia drugs when they were potentially indicated (adjusted prevalence rate ratio 0.86 (95% Confidence Interval 0.76–0.98)), and received them for on average 15 days/year less. Compared to White groups, Asian and Black individuals with dementia were no more likely to take an antipsychotic drug, but those that had were prescribed them for 17 and 27 days/year more, respectively (190.8 (179.6–199.1) and 200.7 (191.1–206.5) days). Black people were less likely to be prescribed anxiolytics/hypnotics (0.60 (0.44–0.8)), but the duration these drugs were prescribed was similar across ethnic groups. Asian people were more likely to be prescribed anticholinergic drugs (1.43 (1.19–1.73)), in analyses unadjusted for cardiovascular comorbidities. Among people without dementia, those in the Asian and Black ethnic groups were less likely to be prescribed psychotropic drugs, relative to people from White groups. Conclusion Among people with dementia, Asian groups received less potentially beneficial symptomatic treatments, and Asian and Black groups were prescribed antipsychotic drugs for longer than White ethnic groups. Our findings may indicate care inequalities.
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Affiliation(s)
- Mary Elizabeth Jones
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Cini Bhanu
- Department of Primary Care and Population Health, University College London, London, UK
| | - Jill Manthorpe
- NIHR Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Rosalind Raine
- Epidemiology and Public Health, University College London, London, UK
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
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Blanco JR, Morillo R, Abril V, Escobar I, Bernal E, Folguera C, Brañas F, Gimeno M, Ibarra O, Iribarren JA, Lázaro A, Mariño A, Martín MT, Martinez E, Ortega L, Olalla J, Robustillo A, Sanchez-Conde M, Rodriguez MA, de la Torre J, Sanchez-Rubio J, Tuset M. Deprescribing of non-antiretroviral therapy in HIV-infected patients. Eur J Clin Pharmacol 2019; 76:305-318. [PMID: 31865412 DOI: 10.1007/s00228-019-02785-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/18/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use. METHODS Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription. RESULTS There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication. CONCLUSIONS The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.
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Affiliation(s)
- José-Ramón Blanco
- Hospital Universitario San Pedro - CIBIR de Logroño, Logroño, La Rioja, Spain.
| | | | - Vicente Abril
- Hospital General Universitario de Valencia, 46014, València, Valencia, Spain
| | - Ismael Escobar
- Hospital Infanta Leonor del Madrid, Universidad Complutense, 28040, Madrid, Spain
| | - Enrique Bernal
- Hospital General Universitario Reina Sofía de Murcia, 30003, Murcia, Spain
| | - Carlos Folguera
- Hospital Puerta de Hierro de Madrid, 28222, Majadahonda, Madrid, Spain
| | - Fátima Brañas
- Hospital Infanta Leonor del Madrid, Universidad Complutense, 28040, Madrid, Spain
| | | | - Olatz Ibarra
- Hospital de Urduliz, Bizkaia, 48610, Urduliz, Biscay, Spain
| | - José-Antonio Iribarren
- Hospital Universitario Donostia, Instituto BioDonostia de San Sebastián, 20014, San Sebastián, Spain
| | | | - Ana Mariño
- Complejo Hospitalario Universitario de Ferrol, 15405, Ferrol, A Coruña, Spain
| | | | | | | | - Julian Olalla
- Hospital Costa del Sol de Marbella, 29603, Marbella, Málaga, Spain
| | | | | | | | | | | | - Montse Tuset
- Hospital Clinic de Barcelona, 08036, Barcelona, Spain
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Salem‐Schatz S, Griswold P, Kandel R, Benjamin‐Bothwell S, DeMaria A, McElroy N, Bolstorff B, McHale E, Doron S. A Statewide Program to Improve Management of Suspected Urinary Tract Infection in Long‐Term Care. J Am Geriatr Soc 2019; 68:62-69. [DOI: 10.1111/jgs.16261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/18/2019] [Accepted: 09/21/2019] [Indexed: 02/05/2023]
Affiliation(s)
| | - Paula Griswold
- Massachusetts Coalition for the Prevention of Medical Errors Burlington MA
| | | | | | - Alfred DeMaria
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Nora McElroy
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Barbara Bolstorff
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Eileen McHale
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Shira Doron
- Division of Infectious DiseaseTufts Medical Center Boston Massachusetts
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9
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Mays AM, Saliba D, Feldman S, Smalbrugge M, Hertogh CM, Booker TL, Fulbright KA, Hendriks SA, Katz PR. Quality Indicators of Primary Care Provider Engagement in Nursing Home Care. J Am Med Dir Assoc 2018; 19:824-832. [DOI: 10.1016/j.jamda.2018.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
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10
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Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, Klein-Fedyshin M, Wessel CB, Mulligan M, Drinka PJ, Crnich CJ. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Assoc 2018; 19:765-769.e3. [PMID: 30037743 PMCID: PMC8043108 DOI: 10.1016/j.jamda.2018.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/11/2022]
Abstract
Objectives: To identify a set of signs and symptoms most likely to indicate
uncomplicated cystitis in non-catheterized nursing home residents ≥
65 years of age using consensus based methods informed by a literature
review. Design: Literature review and modified Delphi survey with strict inclusion
criteria. Setting and Participants: Expert panel of 20 physicians certified in geriatric medicine and /
or medical direction, actively practicing in post-acute and long-term care
settings. Methods: The authors performed a literature review to produce a comprehensive
list of potential signs and symptoms of presumptive uncomplicated cystitis,
including non-specific “quality control” items deemed unlikely
to indicate uncomplicated cystitis. The expert panel rated their agreement
for each sign/symptom using a 5-point Likert scale (1= strongly disagree to
5= strongly agree). Agreed upon signs and symptoms were summarized using a
diagnostic algorithm for easy clinical use. Results: The literature review identified 16 signs and symptoms that were
evaluated in three Delphi survey rounds. The response rate was 100% for
round one and 95% for the second two rounds. Consensus agreement for
inclusion was achieved for dysuria on round one with exclusion of the three
quality controls, and “offensive smelling urine”. Consensus in
the second round was reached for including 4 additional items (gross
hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round
three evaluated dysuria alone and combinations of symptoms. Consensus that
dysuria alone is sufficient for diagnosis of cystitis was not reached. Conclusions/Implications The panel identified 5 signs and symptoms likely indicative of uncomplicated
cystitis in nursing home residents and developed a diagnostic algorithm that can be
used to promote antibiotic stewardship in nursing homes. Given similarities in
populations, the algorithm may also be applicable to the older adult and the broader
post-acute / long-term care populations.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Subashan K Perera
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stacey Saracco
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gulsum Anderson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Charles B Wessel
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA
| | - Mary Mulligan
- AMDA-The Society of Post-Acute and Long-Term Care Medicine, Columbia, MD
| | - Paul J Drinka
- Division of Internal Medicine and Geriatrics, University of Wisconsin, Madison, WI
| | - Christopher J Crnich
- Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton VA Hospital, Madison, WI
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Farlow MR, Shamliyan TA. Benefits and harms of atypical antipsychotics for agitation in adults with dementia. Eur Neuropsychopharmacol 2017; 27:217-231. [PMID: 28111239 DOI: 10.1016/j.euroneuro.2017.01.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/13/2016] [Accepted: 01/05/2017] [Indexed: 01/12/2023]
Abstract
We evaluated the most current evidence regarding the benefits and harms of atypical antipsychotics in adults with dementia. In June 2016, following a protocol developed a priori, we systematically searched several databases for published and unpublished data from randomized controlled trials (RCT), observational studies, and meta-analyses; conducted direct meta-analyses using a random effects model; and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. One high-quality meta-analysis and published and unpublished data from 8 RCTs and 12 large observational studies met inclusion criteria. When compared with placebo, aripiprazole, risperidone, and olanzapine but not quetiapine result in modest (standardized mean difference <0.5 standard deviations) improvement in neuropsychiatric symptoms. Aripiprazole, risperidone, quetiapine, and olanzapine are associated with increased odds of acute myocardial infraction, and risperidone and olanzapine are associated with increased odds of hip fracture. Observational studies suggest no differences in all-cause mortality between atypical antipsychotics. Observational studies suggest that atypical antipsychotics are associated with lower risk of all-cause mortality and extrapyramidal symptoms but higher risk of stroke when compared with conventional antipsychotics. To manage agitation in adults with progressive dementia, clinicians may recommend atypical antipsychotics with continuous monitoring of behavioral symptoms, informing patients and their families or caregivers of the significant risk of adverse effects and baseline risk of acute myocardial infraction and bone fractures.
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Affiliation(s)
- Martin R Farlow
- Department of Neurology, IU Alzheimer׳s Disease and Related Disorders, 355 W. 16th Street, Suite 4700, Indianapolis, IN 46202, USA.
| | - Tatyana A Shamliyan
- Evidence-Based Medicine Quality Assurance, Elsevier, 1600 JFK Blvd 20th floor, Philadelphia, PA 19103, USA.
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Morin L, Laroche ML, Texier G, Johnell K. Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review. J Am Med Dir Assoc 2016; 17:862.e1-9. [PMID: 27473899 DOI: 10.1016/j.jamda.2016.06.011] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 01/07/2023]
Abstract
IMPORTANCE As older adults living in nursing homes are at a high risk of adverse drug-related events, medications with a poor benefit/risk ratio or with a safer alternative should be avoided. OBJECTIVES To systematically evaluate the prevalence of potentially inappropriate medication use in nursing home residents. EVIDENCE REVIEW We searched in PubMed and EMBASE databases (1990-2015) for studies reporting the prevalence of potentially inappropriate medication use in people ≥60 years of age living in nursing homes. The risk of bias was assessed with an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. FINDINGS A total of 91 articles were assessed for eligibility, and 48 met our inclusion criteria. These articles reported the findings from 43 distinct studies, of which 26 presented point prevalence estimates of potentially inappropriate medication use (227,534 nursing home residents). The overall weighted point prevalence of potentially inappropriate medication use in nursing homes was 43.2% [95% confidence interval (CI) 37.3%-49.1%], increasing from 30.3% in studies conducted during 1990-1999 to 49.8% in studies conducted after 2005 (P < .001). Point prevalence estimates reported in European countries were found to be higher (49.0%, 95% CI 42.5-55.5) than those reported in North America (26.8%, 95% CI 16.5-37.1) or in other countries (29.8%, 95% CI 19.3-40.3). In addition, 18 studies accounting for 326,562 nursing home residents presented 20 distinct period prevalence estimates ranging from 2.3% to 50.3%. The total number of prescribed medications was consistently reported as the main driving factor for potentially inappropriate medications use. CONCLUSIONS AND RELEVANCE This systematic review shows that almost one-half of nursing home residents are exposed to potentially inappropriate medications and suggests an increase prevalence over time. Effective interventions to optimize drug prescribing in nursing home facilities are, therefore, needed.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | - Marie-Laure Laroche
- University Hospital of Limoges, Service de Pharmacologie, Toxicologie et Pharmacovigilance, Limoges, France; Université de Limoges, Faculté de Médecine, Limoges, France
| | - Géraldine Texier
- University Hospital of Rennes, Palliative Care Support Team, Rennes, France
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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Little MO. The Burden of Overmedication: What Are the Real Issues? J Am Med Dir Assoc 2016; 17:97-8. [DOI: 10.1016/j.jamda.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/04/2015] [Indexed: 11/26/2022]
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Gogol M, Siebenhofer A. Choosing Wisely – Gegen Überversorgung im Gesundheitswesen – Aktivitäten aus Deutschland und Österreich am Beispiel der Geriatrie. Wien Med Wochenschr 2016; 166:155-60. [DOI: 10.1007/s10354-015-0424-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
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Bell CL, Lopez RP, Mahendra N, Tamai A, Davis J, Amella EJ, Masaki K. Person-centered Feeding Care: A Protocol to Re-introduce Oral Feeding for Nursing Home Patients with Tube Feeding. J Nutr Health Aging 2016; 20:621-7. [PMID: 27273351 DOI: 10.1007/s12603-016-0699-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs. METHODS This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai'i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014. RESULTS Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF). CONCLUSION Using findings from our retrospective study of usual care, our NH's interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.
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Affiliation(s)
- C L Bell
- Christina L. Bell, MD, PhD, Department of Geriatric Medicine, University of Hawaii John A. Burns School of Medicine, 347 N. Kuakini St. HPM 9, Honolulu HI 96817, Phone: 8085238461, Fax: 8085281897,
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Nace DA, Drinka PJ. Cranberry capsules reducing the incidence of what? J Am Geriatr Soc 2014; 62:1616-7. [PMID: 25116998 DOI: 10.1111/jgs.12950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Interventions to Reduce Inappropriate Prescribing of Antipsychotic Medications in People With Dementia Resident in Care Homes: A Systematic Review. J Am Med Dir Assoc 2014; 15:706-18. [DOI: 10.1016/j.jamda.2014.06.012] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 06/13/2014] [Indexed: 11/22/2022]
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