Spasticity in adults living in a developmental center

Long-Term Care Resident Awareness and Interest in Spasticity Treatments

Spasticity is common in long-term care settings (affecting up to one in three residents), yet it remains under-treated despite safe and effective, Food and Drug Administration (FDA)-approved therapies. One barrier to treatment may be lack of awareness of available therapies for long-term care residents living with spasticity. A standardized spasticity treatment awareness and interest interview was conducted with 18 nursing home residents and 11 veterans’ home residents in this cross-sectional study. Veterans’ home residents were also asked about potential barriers to receiving spasticity treatment. Many residents across both long-term care facilities were unaware of most of the treatment options for spasticity. Participants were most aware of physical/occupational therapy (83%, 95% CI: 65–93%) and least aware of intrathecal baclofen (21%, 95% CI: 9–39%). After learning about treatments, only 7% of participants (95% CI: 0–23%) were not interested in receiving any form of spasticity treatment. Among residents previously unaware of spasticity treatments, at least one quarter became interested in receiving treatment and at least one-fifth indicated possibly being interested in the treatment after learning about it. Potential barriers to receiving treatment included traveling to see a doctor and limited knowledge of insurance coverage of spasticity treatments. These results suggest that patient-centered approaches, including education and discerning patient preferences, may improve spasticity treatment in long-term care settings.

The Minimum Data Set: An Opportunity to Improve Spasticity Screening

Spasticity is a common movement disorder that arises from trauma or disease affecting the central nervous system. Untreated spasticity can result in limitations in completing activities of daily living, painful limb contractures, and other conditions associated with loss of mobility. In the long-term care setting, this treatable condition is prevalent, yet often unrecognized likely because of a lack of spasticity-trained practitioners. A recently published spasticity referral tool holds promise for addressing the underdiagnosis of spasticity in the long-term care population. The Minimum Data Set (MDS) would be an ideal mechanism for increasing the diagnosis and treatment of spasticity because it is a government-directed comprehensive screening tool that informs care plans for all residents residing in federally funded long-term care facilities. The MDS could easily integrate the published referral assessment to record the presence of spastic postures and muscle rigidity. We propose expanding the MDS to include 3 questions related to spasticity to improve the recognition and treatment of this prevalent and treatable condition.

A Simple Bedside Screening Tool for Spasticity Referral

Background and Objectives

Spasticity is common in long-term care facilities; however, this often-disabling condition is largely underdiagnosed in this setting and therefore left untreated. This study aimed to test the ability of a three-question flowchart used at the bedside by primary care providers in the long-term care setting to identify residents in need of referral to a specialist for spasticity consultation.

Methods

All residents of a single long-term care facility were approached for participation in this cross-sectional, observational study. Spasticity diagnostic evaluations by a movement disorders specialist neurologist (reference standard) were compared with referral determinations made by two primary care providers [a primary care physician (PCP) and a nurse practitioner (NP)] using the simple flowchart.

Results

The analysis included 49 residents (80% male, age 78.2±9.0 years) who were evaluated by the reference standard neurologist and at least one primary care provider. The bedside referral tool demonstrated high sensitivity and moderate specificity when used by the PCP (92% and 78%, respectively; AUC=0.84) and NP (80% and 53%, respectively; AUC=0.67).

Conclusion

This simple tool may be useful for primary care providers to identify residents to be referred to a specialist for evaluation and treatment of spasticity. These results warrant further investigation of the potential utility of this screening tool across multiple long-term care facilities and various types of care providers.

Prevalence of Spasticity in Nursing Home Residents

OBJECTIVES

To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services.

METHODS

Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency.

RESULTS

Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ² = 51.72, P < .001), which was driven by lower limb spasticity (χ² = 14.56, P = .006).

CONCLUSIONS AND IMPLICATIONS

These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities.

In vivo study of flow-rate accuracy of the MedStream Programmable Infusion System

OBJECTIVE

  Flow-rate accuracy and precision are important parameters to optimizing the efficacy of programmable intrathecal (IT) infusion pump delivery systems. Current programmable IT pumps are accurate within ±14.5% of their programmed infusion rate when assessed under ideal environmental conditions and specific flow-rate settings in vitro. We assessed the flow-rate accuracy of a novel programmable pump system across its entire flow-rate range under typical conditions in sheep (in vivo) and nominal conditions in vitro.

MATERIALS AND METHODS

  The flow-rate accuracy of the MedStream Programmable Pump was assessed in both the in vivo and in vitro settings. In vivo flow-rate accuracy was assessed in 16 sheep at various flow-rates (producing 90 flow intervals) more than 90 ± 3 days. Pumps were then explanted, re-sterilized and in vitro flow-rate accuracy was assessed at 37°C and 1013 mBar (80 flow intervals).

RESULTS

  In vivo (sheep body temperatures 38.1°C-39.8°C), mean ± SD flow-rate error was 9.32% ± 9.27% and mean ± SD leak-rate was 0.028 ± 0.08 mL/day. Following explantation, mean in vitro flow-rate error and leak-rate were -1.05% ± 2.55% and 0.003 ± 0.004 mL/day (37°C, 1013 mBar), respectively.

CONCLUSIONS

  The MedStream Programmable Pump demonstrated high flow-rate accuracy when tested in vivo and in vitro at normal body temperature and environmental pressure as well as when tested in vivo at variable sheep body temperature. The flow-rate accuracy of the MedStream Programmable Pump across its flow-rate range, compares favorably to the accuracy of current clinically utilized programmable IT infusion pumps reported at specific flow-rate settings and conditions.

Discordance in informed consent response on the basis of demographic factors: brief report

During an outcomes study of spasticity treatment at a developmental center for 62 residents with profound intellectual disabilities, either botulinum toxin A (BTX-A), intrathecal baclofen (ITB), or both were recommended with physical and occupational therapy. Conservators consented to BTX-A more than ITB (p = .021). Court-appointed conservators were more likely to provide consent for treatment than family members (p = .026). Nonparents consented more than parents (p = .009). Finally, Caucasian conservators were more likely to consent to treatment than African American conservators (p = .036), but ethnicity of the resident did not influence consent. Gender of resident or conservator did not influence rate of consent. This report highlights disparities in surrogate consent giving for individuals with intellectual disabilities and indicates a need for more research to ensure that this vulnerable population has access to appropriate treatments.