1. 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
Lindsay Drevlow, PA-S2
November 28, 2011

2. 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

3. 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

4. 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

5. 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

6. Approved Cholinesterase Inhibitors
Tacrine (Cognex)
Rivastigmine (Exelon)
Galantamine (Razadyne, Reminyl)
Donepezil (Aricept
Tacrine--limited by hepatoxicity
Rivastigmine--limited by excessive cholinergic effects (N, V, anorexia, HA)
Galantamine--similar efficancy to aricpet but has more GI SE
Donepezil--preferred drug

7. 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
Efficacy demonstrated in double-blind trial and placebo-controlled trial
Response in advanced dementia is unclear but a trial of the medicine is warranted
GI SE = N, V, D

8. 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
Overstimulation of NMDA receptor by glutamate may contribute to neurodegenrative disorders
Very small benefit in mild - moderate disease
May be some added benefit when used with ChI in mod - severe disease

9. 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
Physical and interpersonal environment impacts the pt’s life. The doctor and health care team have the opportunity and responsibility to preserve the pleasures of pts with dementia beyond medication.
“Person-environment fit”--analyzed and manipulated to maximize function & QOL for each pt
“Excess disability” = when physical environment leads to loss of function. It can be reversed when the environment is changed
Perceptual ability--modifying color and light can decrease fall risk
Ability to filter multiple stimuli is decreased. Decreasing the volume of stimuli can improve function and decrease a pt’s fear and frustration
Every brain is different. Deficits and preserved function differ from pt to pt. Using observation to learn which functions are impaired can help modify things to ease the deficit.

10. Dementia and Depression/Agitation
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
Sertraline (zoloft)--possibly false negative b/c power was not calculated.

11. Dementia and Depression/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
CMAI = one of MC used agitation assessment scales
Important to identify and eliminate/prevent RF in pt’s with agitation

12. Dementia and Depression/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
Behavioral Management RCTs
Staff training vs. usual care = reduction of restraint use and severity of agitation
Person centered showering/bathing = reduction of agitation, aggression and discomfort
Family visit education program = improved depression and irritability
Drug therapy RCTs
Olanzapine vs. placebo = reduction of agitation, aggression and psychosis
Carbamazepine vs. placebo = reduction of Brief Psychiatry Rating Scale, agitation and aggression
H, O, D = Improvement of agitation and ADLs

13. 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
Hallmarks = almost a universal & expected complication
Feeding tube--evidence does not support prolongation of life, reversal of malnutrition of prevention of aspiration
It is an emotional, cultural & moral conflict for families and health care providers
Difficulty chewing/swallowing can lead to aspiration and pneumonia

14. 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

15. Evaluation and Management of Eating Problems w/ Dementia
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

16. 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

17. Medications in Long-Term Care: When Less is More
Thomas W. Meeks, MD; John W. Culberson, MD; Monica S. Horton, MD, MSc

18. 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 %
PIPE emerged due to concerns about polypharmacy & iatrogenic toxicity
1991 (Beers List) (Zhan) (HEDIS)
Focus mostly on drugs w/ CNS activity

19. Prevalence of Neuropsychiatric Illness in LTC
 50% LTC pts have dementia
% 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

20. Medication Reduction Why? When? How? What?
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

21. 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

22. 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

23. 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

24. Medication Reduction: What?
Antidepressants
MDD affects % of LTC residents
Potential SE:
SIADH, osteoporosis, falls, GI bleeding
Limited/mixed data on efficacy in older adults, especially those w/ dementia

25. 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)

26. 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

27. 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

28. 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

29. Medication Reduction: What?
Acetaminophen
Low risk for toxicity and minimal drug interactions
Limitations:
Short half-life
Potential hepatotoxicity
Best for acute intermittent pain control
Short half life provides inadequate dosing required for persistent pain
Potential hepatoxicity at 4g/day

30. 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

31. 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
Treat prophylactically with stool softener or laxative
MS contin dosed BID as opposed to q4-6h
Once pain control is achieved, the need for frequent dosing is decreased. Can keep something PRN
Studies show there is minimal risk of abuse

32. 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

33. 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
Short course of systemic steroids avoids adrenal suppression
if combined w/ PT, decreases need for additional medications

34. Evidence-Based Medicine (EBM): What Long-Term Care Providers Need to Know
Huai Y. Cheng, MD, MPH

35. 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
Clinical State & Circumstances
Clincal Expertise
Research
Evidence
Pt preference
and actions

36. 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

37. EBM Application in LTC Potential Benefits: Potential Harms:
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

38. 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

39. References
Rhodes-Kropf, Jennifer. Managing the Patient with Dementia in Long-Term Care. Clinics in Geriatric Medicine. 2011;27:
Meeks, Thomas W. Medications in Long-Term Care: When Less is More. Clinics in Geriatric Medicine. 2011; 27:
Cheng, Huai Y. Evidence-Based Medicine (EBM): What Long-Term Care Providers Need to Know. Clinics in Geriatric Medicine. 2011; 27: