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 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

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

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

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.

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.

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

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

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

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 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? 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

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 Short half life provides inadequate dosing required for persistent pain Potential hepatoxicity at 4g/day

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 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

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

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

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: 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

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.