Age-Friendly Health Systems 4Ms: Implementing Medication Management in Hamad Medical Corporation, Qatar.

PURPOSE: To implement the Age-Friendly Health Systems (AFHS) 4Ms framework, focusing on Medication and its impact on Mobility, Mentation, and What Matters, within Hamad Medical Corporation in Qatar. METHOD: A quality improvement approach was used to implement, extend, and sustain the AFHS 4Ms framework at Hamad Medical Corporation. The Medication "M" was described as the use case to illustrate the impact of high-risk medications on Mobility, Mentation, and What Matters, using an evidence-based, interdisciplinary approach. RESULTS: Implementation of the AFHS 4Ms framework revealed success in aligning multidisciplinary teams to prioritize patient-centered care and caregiver engagement. Through this collaboration, a process map, modified medication screening tool, documentation templates, and educational efforts were developed. CONCLUSION: Applying the AFHS 4Ms framework into health care settings is crucial to improve the care of older adults. Medication management is a cornerstone, involving interdisciplinary team input during screening and act phases to ensure proper medication prescribing and use in older adults. [Journal of Gerontological Nursing, 50(6), 6-9.].

Discovering "What Matters" to patients: A quality improvement project.

PURPOSE: Age-Friendly Health Systems were developed to provide an evidenced based framework to provide high-quality care to older adults. The purpose of this quality improvement initiative was to increase the completion of the "What Matters" section of the "Get to Know Me" boards. METHODS: Face-to-face training was provided to staff via individual sessions on "What Matters" to patients and how to complete the boards. Re-education continued weekly over a 15 week period. Board Completion rates were collected weekly. RESULTS: 60 nurses participated in this project. The "What Matters" completion rates increased from 27 % to 59 % over the intervention period on the SACU and 16 % to 32 % on the SIMC . CONCLUSIONS: The "Get to Know Me Boards" are a visible way to describe "What Matters" to patients. Education helped to increase the completion rate of the boards allowing for "What Matters" to be accessible to members of the healthcare team.

Understanding Long-Stay Gabapentin Use Increases: A National Nursing Home Clinician Survey on Prescribing Intent.

OBJECTIVES: Explore the indications for long-stay gabapentin use and elucidate the factors spurring the rapid increase in gabapentin prescribing in nursing homes (NHs). METHODS: National cross-sectional survey of NH prescribers distributed anonymously using SurveyMonkey. Sampling for convenience was obtained through crowdsourcing, leveraging collaborations with NH clinician organizations. Developed by a multidisciplinary team, pilot data/existing literature informed survey content. RESULTS: A total of 131 surveys completed. Participants: 71% white, 52% female, 71% physicians. Off-label gabapentin prescribing was ubiquitous. Nearly every clinician used gabapentin for neuropathic pain, most for any form of pain. Many clinicians also prescribe gabapentin to moderate psychiatric symptoms and behaviors. Clinicians' prescribing was influenced by opioid, antipsychotic, and anxiolytic reduction policies because gabapentin was perceived as an unmonitored and safer alternative. CONCLUSIONS: Off-label gabapentin increases are closely linked to opioid reduction efforts as more NH clinicians utilize gabapentin as an unmonitored opioid alternative. Our results highlight, however, the less recognized significance of long-stay prescribing for psychiatric symptoms and the similar contribution of psychotropic reduction initiatives, a phenomenon warranting further scrutiny. CLINICAL IMPLICATIONS: Clinicians perceive gabapentin as safer than the drugs it is replacing. Whether this is true remains unclear; the individual- and population-level risks of increased gabapentin use are largely unknown.

Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI).

OBJECTIVES: To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI). METHODS: Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses. RESULTS: There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant. CONCLUSIONS: Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff. CLINICAL IMPLICATIONS: Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Examining transitions of care among nursing home residents with and without antipsychotic medication use.

OBJECTIVES: This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. METHODS: This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. RESULTS: Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. CONCLUSIONS: Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Navigating Disease-Modifying Treatments for Alzheimer's Disease: Focusing on Medications in Phase 3 Clinical Trials.

Over the past 18 months, there has been scrutiny and controversy over the U.S. Food and Drug Administration's accelerated approval of aducanumab, a novel monoclonal antibody to treat Alzheimer's disease and prevent disease progression. As clinicians, educators, and advocates for our patients and caregivers impacted daily by this debilitating illness, this approval reinforces the need to maintain vigilance and awareness about emerging agents. The intent of the current article is to highlight some of the medications in Phase 3 clinical trials and share resources and updates on disease-modifying agents and their unique pharmacology. [Journal of Gerontological Nursing, 49(1), 6-10.].

Nurse staffing and deficiency of care for inappropriate psychotropic medication use in nursing home residents with dementia.

PURPOSE: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. DESIGN: This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018. METHODS: Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. RESULTS: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26). CONCLUSION: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use. CLINICAL RELEVANCE: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

Opioid Use Disorder and Older Adults: Navigating Treatment Options.

The intent of the current article is to highlight via a case vignette challenges faced when managing pain across care transitions in an older adult with multiple comorbidities, including, but not limited to, opioid use disorder (OUD). This case will highlight the role of different medications for OUD, namely buprenorphine/naloxone, methadone, and naltrexone. Furthermore, the case illustrates medication-related considerations in addition to action steps that are needed when working with older adults. [Journal of Gerontological Nursing, 48(7), 4-9.].

Sodium-Glucose Cotransporter-2 Inhibitors: Risks vs. Rewards When Caring for Older Adults.

Managing multiple comorbidities is common in older adults. Thus, when a medication class, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, can potentially treat multiple conditions and prevent progression of chronic kidney disease, multiple guidelines must be followed when using these agents. The current article discusses risks and benefits of SGLT2 inhibitors, especially in the context of new evidence, and presents a case example. [Journal of Gerontological Nursing, 48(10), 7-13.].

Interprofessional Education and Older Adults in the Shared Virtual Classroom: Lessons Learned During the COVID-19 Pandemic.

The current article provides an overview of an interprofessional service-learning course that became virtual in the setting of the coronavirus disease 2019 pandemic. Telehealth video technologies were used to build an intergenerational, virtual classroom and increase engagement of older adults with interdisciplinary health professional students. The virtual classroom involved group health education sessions, individualized Medicare wellness visits, and a clinical huddle. The course addressed the public health need for reliable health information during the early days of the pandemic, social connection, and meeting the educational goals for health care students and older adults in a novel virtual setting. Lessons learned for the interdisciplinary team and for engaging older adults included the need for preparation reading, team building exercises, training videos, and telehealth competency checklists. Beyond the pandemic, adoption of virtual methods enables hybrid approaches to interprofessional education and builds competencies for delivery of telehealth and computer-based visits in professional practice settings. [Journal of Gerontological Nursing, 48(8), 52-56.].

Challenges and Successes of Global Deprescribing Networks: A Qualitative Key Informant Study.

The landscape of deprescribing has been rapidly evolving and expanding globally with the formation of regional and national deprescribing networks. The work of these networks is primarily focused on older adults and high-risk medications. The purpose of the current qualitative study is to describe successes and challenges of deprescribing from thought-leaders across the world. Fourteen key informant interviews were conducted from various disciplines, levels of experiences, and regions around the globe. From the interviews, six major themes across two domains were identified: (a) network structure, (b) public perception, (c) policy implications, (d) implementation, (e) challenges, and (f) recommendations. These domains, themes, and insight provided by deprescribing leaders contribute to the advancement of deprescribing networks as global efforts continue to focus on optimizing medication management. Collaboration among interprofessional team members will be critical to the expansion as well as sustainability of this important work. [Journal of Gerontological Nursing, 48(1), 7-14.].

Post-acute long-term care COVID-19 medication optimization survey: Informing medication management initiatives.

The Medication Management Guide (MMG) provides guidance on strategies to optimize medication management in PA-LTC and simplify administration to reduce the transmission risk of COVID-19. The objectives of this study were to evaluate the utility of the MMG, determine the barriers and facilitators of the MMG implementation in PALTC sites to help inform future research and initiatives. Individuals who accessed MMG during the pandemic (April 2020-March 2021) were contacted to elicit feedback on this tool via an online survey. The survey response rate was 7.7% (156/2,018) after three rounds of emails. Respondents consisted of 31% (n=49) pharmacists, 27% (n=42) physicians, 11% (n=18) nurses, and 12% (n=19) nurse practitioners. The "Other" respondents (11%, n=17) included dieticians (n=4), physician assistants (n=3), pharmacy technicians (n=3), students (n=1), consultants (n=1), and educators (n=2). From these respondents, 77% (n=122) took tactics to optimize medications at their facilities during COVID-19.

Pragmatic trials in long-term care: Research challenges and potential solutions in relation to key areas of care.

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.

Medication Safety in Older Adults: Learning From 2020 as We Launch into 2021.

In health care, the year 2020 is marked by the ongoing coronavirus (COVID-19) pandemic, with much research published to clarify infection risk, treatment approaches, and proposed interventions to reduce spread and combat complications. Although much work focused on COVID-19, medication safety remains a priority, and studies on adverse drug reactions, high-risk medications, and approaches to mitigate risk associated with chronic medication use, such as inappropriate dosing in hospital settings, were published. A continued commitment to patient-centered care, such as the approach put forth by the Age-Friendly Health Systems initiative and telehealth initiatives, ensures that even as health care practice strives to meet the challenge of an unprecedented global pandemic, safe medication use informed by patient needs continues to guide best practices through lessons learned. [Journal of Gerontological Nursing, 47(1), 7-11.].

Optimizing Medication Management During the COVID-19 Pandemic: It Takes a Village.

Coronavirus disease 2019 (COVID-19) is an unprecedented pandemic that has particularly affected nursing homes and long-term care facilities. To support frontline health care professionals caring for older adults, the current article provides guidance on strategies to optimize medication management within nursing homes and long-term care facilities. In addition, the article reviews two medications that have been granted U.S. Food and Drug Administration emergency use authorization for treatment of COVID-19: hydroxychloroquine and remdesivir. Finally, this article highlights resources and strategies for improving communication among an interprofessional team during the ongoing pandemic, as well as education on COVID-19. Although the COVID-19 pandemic has had many negative implications, it has also brought to attention opportunities to improve the delivery of care and increase the importance of working as an interprofessional team ("village") during these challenging times. [Journal of Gerontological Nursing, 46(7), 3-8.].

Update on Type 2 Diabetes Mellitus and Older Adults.

In 2020, the American Diabetes Association released an update to their standards of care guideline, which included special considerations for older adults. Care of older adults with type 2 diabetes mellitus needs to be individualized and incorporate patient preferences. Guideline updates provide specific goals for older adults based on their ability to perform activities of daily living, comorbidities, and health prognosis. The current article aims to illustrate updates through an older adult case and key medication-related considerations. [Journal of Gerontological Nursing, 46(4), 7-12.].

An Interdisciplinary Approach to Implementing the Age-Friendly Health System 4Ms in an Ambulatory Clinical Pathway With a Focus on Medication Safety.

MedStar's Center for Successful Aging (CSA) participated in the Age-Friendly Health Systems initiative led by The John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States. This initiative focuses on bringing the 4Ms framework-What Matters, Medication, Mentation, and Mobility-to caring for older adults. A quality improvement project was conducted at the CSA to integrate the 4Ms framework into the CSA ambulatory clinical pathway. Our interventions found upward trends in patients receiving 4Ms care during their new patient visits. Positive preliminary feedback was also obtained from providers following the incorporation of the 4Ms framework in the high-risk rounds discussion. A focus on high-risk medications and deprescribing illustrated positive clinical outcomes. This ongoing interprofessional collaboration illustrates the importance of person-centered care and quality improvement to achieve Age-Friendly Health Systems status within an ambulatory practice. [Journal of Gerontological Nursing, 46(10), 7-11.].

Identifying and Bridging the Gaps in Antimicrobial Stewardship in Post-Acute and Long-Term Care.

National organizations have developed guidelines and tools for antimicrobial stewardship (AMS) in post-acute and long-term care (PALTC), but there is a need to effectively translate these into actionable, measurable, and impactful programs. An electronic needs assessment survey was developed and distributed to health care providers and administrators involved with AMS activities in PALTC facilities in Maryland. The results of this survey were used to develop a statewide initiative to improve AMS in nursing facilities. The survey revealed that barriers to implementing AMS include limited access or poor utilization of experts in AMS and infectious disease, adverse event data collection tools, and locally developed protocols and guidelines. Strategies to improve AMS included the provision of free continuing education to a multidisciplinary audience and improved access to individuals with expertise in infectious disease and the development of an adverse drug event tool. Continuing to provide meaningful tools and resources that address the specific needs of nursing facilities should lead to improved compliance with regulations and ultimately improved resident outcomes. [Journal of Gerontological Nursing, 46(1), 8-13.].

Students' perceptions of interprofessional education in geriatrics: A qualitative analysis.

Interprofessional education (IPE) is critical for ensuring that students are prepared to collaborate with team members across disciplines once they enter clinical practice; particularly, in the complex care of the geriatric population. This qualitative study explored the experiences of interdisciplinary students in a clinical based IPE experience at a senior housing residence. Reflective journals were examined from students (n = 23) in nursing, social work, pharmacy, and medicine participating in an IPE program. Four core themes emerged in the analysis: exposure to geriatrics, IPE advantages for students, IPE advantages for older adults, and IPE challenges. Findings from this study confirmed advantages of IPE in a real-world clinical setting in terms of students learning the value and scope of practice of interdisciplinary team members. The exposure to geriatrics helped students to gain an in-depth understanding of issues affecting older adults in the community and increase professional confidence in their future clinical practice.

Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications.

Polypharmacy, defined as the use of five or more medications, is becoming increasingly prevalent in older adults throughout the United States. Depre-scribing, along with the use of existing tools, such as the American Geriatrics Society Beers Criteria, can help guide health care providers in reducing the risks associated with polypharmacy such as side effects and drug interactions. The framework of deprescribing and the use of existing guidelines and resources are valuable in guiding health care providers in addressing polypharmacy. [Journal of Gerontological Nursing, 45(1), 9-15.].