Emerging Pharmacotherapy and Health Care Needs of Patients in the Age of Artificial Intelligence and Digitalization.

Advances in the application of artificial intelligence, digitization, technology, iCloud computing, and wearable devices in health care predict an exciting future for health care professionals and our patients. Projections suggest an older, generally healthier, better-informed but financially less secure patient population of wider cultural and ethnic diversity that live throughout the United States. A pragmatic yet structured approach is recommended to prepare health care professionals and patients for emerging pharmacotherapy needs. Clinician training should include genomics, cloud computing, use of large data sets, implementation science, and cultural competence. Patients will need support for wearable devices and reassurance regarding digital medicine.

Perceptions of Nursing Facility Providers on the Utility of Deprescribing.

OBJECTIVE: Potentially inappropriate medications carry significant burden and costs to nursing facility residents and health systems. The goal of this study was to survey nursing facility providers from across the United States to describe the current utilization of deprescribing, and perceptions and desired components of a deprescribing program, in nursing facilities to reduce potentially inappropriate medications. DESIGN/SETTING/PARTICIPANTS/MEASUREMENT: We surveyed health care providers who attended the 2017 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference-in Phoenix, Arizona. Returned surveys were entered into an electronic database from paper copies. Survey responses were summarized using descriptive statistics. RESULTS: Of the 1,431 conference attendees, 637 surveys were returned for a 45% response rate. Most respondents were physicians (n = 563, 88%). Respondents indicated a strong agreement with the potential for deprescribing to reduce cost to residents and nursing administration time and burden, while disagreeing that deprescribing may be depersonalizing. Respondents indicated clear preference for deprescribing programs to target medications that are no longer indicated and are "high risk," and that such programs should include discussions with the resident. Respondents also agreed that deprescribing programs are successful if the resident, or the resident's family and/or caregivers, reports an improvement in quality of life. CONCLUSION: Among respondents there was a high degree of confidence in the potential impact of deprescribing initiatives, as well as a broad consensus of desired components. This information may increase consultant pharmacist engagement and drive future proactive deprescribing initiatives.

Clinical and Functional Characteristics of Nursing Facility Residents with Opioid-Induced Constipation.

OBJECTIVE: Our goal was to determine the prevalence, clinical characteristics, and treatment differences of opioid-induced constipation (OIC) in older adults with noncancer pain compared with opioid-treated patients without OIC. DESIGN: Retrospective database analysis. SETTING: United States nursing facilities: Patients, Participants, facility residents. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Minimum data set and prescription claims, pain, impaired cognition, falls, delirium, and drug treatment. RESULTS: We found an OIC prevalence of 8.9%. Nursing facility residents with OIC are more likely to have severe pain (31.3% vs. 29%; P < 0.001), pain in the last 5 days (71.2% vs. 69.2%; P < 0.001), almost constant pain (18.1% vs.13.3%; P < 0.001), and pain interfering with daily activities (36.1% vs. 30%; P < 0.001). Strong opioids were more likely prescribed and the duration of use was longer than in non-OIC nursing facility residents. Cognitive impairment (56.3% vs. 49.8%; P < 0.001), fall rate (4.8% vs. 2.5%; P = 0.023), delirium indicators (confusion assessment method; P < 0.001), urinary incontinence (59.1% vs. 54.9%; P < 0.001), depression (66.5% vs. 61.6%; P < 0.001), and depression severity score (4.7% vs. 4.3%; P < 0.001) were higher in nursing facility residents with OIC. Nursing facility residents with OIC had a higher percentage of concomitantly prescribed anticholinergic medications (76.7% vs. 70.0%; P < 0.001) and a higher mean anticholinergic burden score (1.4% vs. 1.1%; P < 0.001). Over-the-counter laxatives were used more often than prescription laxatives: polyethylene glycol (43%), docusate (31.1%), and senna/sennosides (23%) vs. lactulose (18.1%) and lubiprostone (2.2%). CONCLUSION: Nursing facility residents with OIC experience suboptimal pain relief, additional anticholinergic adverse drug-related effects, and a decreased quality of life.

Aligning care initiatives to reduce medication adverse effects in nursing homes.

Medication adverse effects in nursing homes continue to be an ongoing issue in long-term care, resulting in adverse events and temporary harm that lead to increased hospitalizations. In 2014, the Office of the Inspector General report noted that among Medicare beneficiaries in Part A stays less than 35 days, 22% experienced an adverse event and 11% experienced temporary harm. Ongoing initiatives and clinical services that can be aligned to address medication adverse events are discussed within the current article.

Clinical Burden and Nonpharmacologic Management of Nursing Facility Residents with Overactive Bladder and/or Urinary Incontinence.

OBJECTIVE: To identify clinical characteristics of residents with a diagnosis of overactive bladder (OAB) and/or urinary incontinence (UI) to determine the prevalence of comorbidities, severe mobility impairment (SMI), moderate-to-severe cognitive impairment (MSCI), and a toileting program and the response to that program. DESIGN: Cross-sectional retrospective analysis. SETTING: Skilled nursing facilities. PATIENTS, PARTICIPANTS: Residents with a diagnosis of OAB and/or UI and an age range, and gender frequency-matched 1:1 control cohort without OAB and/or UI. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): De-identified Minimum Data Set data 3.0 records (October 1, 2010, to September 30, 2012). RESULTS: Of the 175,632 residents, 65% had a diagnosis of UI and 1% had a diagnosis of OAB. Those with UI and/or OAB were more likely to have MSCI (mean Brief Inventory of Mental Status score 10.2 ± 4.5 vs. 12.5 ± 3.6; P = 0.001) and SMI (49.4% vs. 26.4%; P < 0.001), multiple comorbid conditions, falls and falls with injury, hip fractures (5.5% vs. 4.9%; P < 0.001), urinary tract infections (21.4% vs. 16.5%; P = 0.001), and moisture-associated skin damage (5.2% vs. 2.6%; P = 0.001) than the control cohort. Toileting programs were attempted more often (17.0% vs. 5.1%; P < 0.001) in those with UI and/or OAB but were only minimally successful, with 4.2% having decreased wetness and 0.9% being completely dry. CONCLUSION: Residents with UI and/or OAB exhibit a higher burden of MSCI, SMI, and comorbidities than do residents without these diagnoses. Nonpharmacologic therapies such as toileting programs should be a primary focus in the nursing facility.

High-risk medication use by nursing home residents before and after hospitalization.

BACKGROUND: Two prominent challenges in nursing home care are ensuring appropriate medication use and achieving high-quality care as residents transition from the hospital to the nursing home. Research about prescribing practices at this important clinical juncture is limited. OBJECTIVE: To analyze the use of high-risk medications by nursing home residents before and after being hospitalized. We define high-risk medications using the Beers criteria for potentially inappropriate medication use. RESEARCH DESIGN, SUBJECTS, MEASURES: Using a dataset with Medicare claims for inpatient and skilled nursing facility stays and pharmacy claims for all medications dispensed in the nursing home setting, we examine high-risk medication use for hospitalized nursing home residents before and after being hospitalized. Our study population includes 52,559 dual-eligible nursing home residents aged 65 and older who are hospitalized and then readmitted to the same nursing home in 2008. Our primary outcome of interest is the use of high-risk medications in the 30 days before hospitalization and the 30 days following readmission to the same nursing home. RESULTS: Around 1 in 5 (21%) hospitalized nursing home residents used at least 1 high-risk medication the day before hospitalization. Among individuals with high-risk medication use at hospitalization, the proportion using these medications dropped to 45% after nursing home readmission but increased thereafter, to 59% by the end of the 30-day period. CONCLUSION: We found moderate levels of high-risk medication use by hospitalized nursing home residents before and after their hospital stays, constituting an important clinical and policy challenge.

Medicare Part D plan generosity and medication use among dual-eligible nursing home residents.

BACKGROUND: In 2006, dual-eligible nursing home residents were randomly assigned to a Medicare Part D prescription drug plan (PDP). Subsequently, residents not enrolled in qualified plans at the start of the next year were rerandomized. PDPs vary in generosity through differences in medication coverage and utilization management. Therefore, residents' assigned plans may be relatively more or less generous for their particular drugs. The impact of generosity on residents' medication use and health outcomes is unknown. METHODS: Using data from 2005 to 2008, we estimated logistic regression models of the impact of coverage and utilization management on the risk for medication changes and gaps in use, hospitalizations, and death among elderly nursing home residents using 1 of 6 selected drug classes, adjusting for patient characteristics. RESULTS: Few current medication users faced noncoverage of their drug (0.4% to 8.7%) or prior authorization or step therapy requirements if the drug was covered (1.1% to 37.4%). After adjusting for individual-level covariates, residents with noncovered drugs were more likely than residents with covered drugs to change medications in most classes studied (eg, for 2006 angiotensin receptor blocker users, the adjusted average probability of medication change was 0.35 when uncovered vs. 0.11 when covered). Those subjected to prior authorization or step therapy were more likely to change in a subset of classes. There were no statistically significant differences in the rates of hospitalization or death after correcting for multiple comparisons. CONCLUSIONS: The Part D benefit's special protections for nursing home residents may have ameliorated the health impact of coverage limits on this frail elderly population.

Comprehensive medication review--coming soon to a nursing home near you!

There remain numerous unanswered questions pertaining to the roll-out and implementation of the CMR requirement in LTC. Some Part D plans have established relationships with MTM providers and are prepared to launch the expanded MTM program in January while others may be slow to apply the standard in a nursing home population. How Part D plans define "cognitive impairment" and the alternate individual acceptable to participate on behalf of the beneficiary in the CMR may vary widely. Quarterly TMRs may be added on to monthly DRR/MRR reviews or may replace monthly reviews at least 4 times during the calendar year.

Demographic and clinical profile of nursing facility residents with gout.

OBJECTIVE: To develop a demographic and clinical profile of nursing facility residents with a diagnosis of gout. DESIGN: Descriptive, retrospective database analysis. SETTING: U.S. nursing facilities. PATIENTS, PARTICIPANTS: Nursing facility residents with a diagnosis of gout. INTERVENTIONS: Minimum Data Set and prescription claims records of residents served by Omnicare, Inc., with an International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis of gout, for the time period of October 1, 2009, to September 30, 2010, were linked and de-identified. Acute gouty attacks were defined by a proxy measure of a ? 14-day course of oral nonsteroidal anti-inflammatory drugs (NSAIDs), oral or injectable steroids, or oral colchicine. RESULTS: In the 138,724 residents (36.8% male: 76.8% white, 11.6% black) evaluated, the incidence of gout was 1.8% (n = 2,487). Of those with gout, males and females were represented relatively equally. There were 1,420 (57.2%) residents 80 years of age or older. Two-thirds of residents with gout required at least extensive assistance with most activities of daily living. Comorbid conditions-hypertension (82.2%), diabetes mellitus (46.6%), arthritis (43.7%), and renal failure (22.4%)-were common. Pain was reported in 68.7% of residents. Allopurinol (60.2%), colchicine (18.6%), febuxostat (2.3%), probenecid (1.1%), and probenecid/colchicine (< 1%) were prescribed in treated residents. While treatment may or may not have been indicated, 375/2,152 (17.4%) received no treatment. Diuretic therapy was received by 75.8% of residents. Acute gouty attacks were noted in 38% of residents; 53%, 25.2%, and 21.8% received short-course treatment with oral or injectable steroids, oral colchicines, or oral NSAIDs, respectively. CONCLUSIONS: Despite the limitations of a retrospective database analysis, this study reveals that nursing facility residents with a diagnosis of gout have significant disease burden. Clinicians should be aware of the potential impact of this disease on physical functioning, pain, and falls in this often-frail population.

Venlafaxine deprescribing and thyroid function.

STUDY OBJECTIVE: This report highlights the effects of discontinuing venlafaxine on thyroid function in an older adult with previously well-managed Hashimoto thyroiditis and sleep apnea. DESIGN: Concurrent intervention. CASE STUDY: Setting Community-based psychiatry practice Patient - 66 year old female Intervention Over 8 months, a 66-year-old patient slowly reduced the venlafaxine dose. She was treated simultaneously for sleep apnea. Measurements Clinical data including venlafaxine and levothyroxine dosing, thyroid hormone laboratory values, subjective complaints, and objective electrocardiographic (ECG) findings were aggregated and analyzed. MAIN RESULTS: As venlafaxine dose was decreased over time, the patient complained of bounding heart palpitations shown to be premature ventricular contractions, and wide and narrow complex ventricular tachycardia on ECG. Thyroid-stimulating hormone decreased from a baseline value of 0.791 uIU/mL to a nadir of 0.18 uIU/mL during venlafaxine dosage reduction from 225 mg/day to 155 mg/day. Cardiac symptoms subsided following levothyroxine dosage reduction. CONCLUSIONS: There was a direct relationship between antidepressant dosage reduction and levothyroxine dosage requirements. Cautious monitoring is recommended during venlafaxine deprescribing in patients with pre-existing thyroid disease.

Social determinants predict whether Medicare beneficiaries are offered a Comprehensive Medication Review.

BACKGROUND: Medication reviews through Medicare's Medication Therapy Management (MTM) program may improve patient outcomes and lower health system costs, but these effects could be limited by a program design that does not address social determinants of health. OBJECTIVE: To analyze the effects of social determinants of health on the odds of an eligible Medicare beneficiary not being offered Comprehensive Medication Review (CMR). METHODS: Using the full 100% sample of the 2016 Part D Medication Therapy Management Data File linked to Medicare Master Beneficiary Summary File, a retrospective, cross-sectional analysis was conducted to determine which social and demographic variables are most strongly associated with being eligible for a CMR but not being offered one. Descriptive statistics were generated using SAS studio 3.8. RESULTS: Variables associated with the highest odds of not receiving a CMR when eligible are residence in Louisiana OR 1.79 (95%CI 1.70-1.88), receiving the LIS OR 1.76 (1.73-1.79), dual eligibility for Medicare and Medicaid OR 1.25 (1.12-1.41), and Black race OR 1.19 (1.16-1.21). CONCLUSIONS: Social determinants of health, most strongly geography and low-income status, predict being eligible for but not being offered CMR. Race continues to be a factor in disparate access to MTM services.

Opportunity to optimize management of benign prostatic hyperplasia.

Five-alpha reductase inhibitor may be underused and their value underappreciated in nursing home residents with enlarged prostates due to BPH. Initiation of a 5-alpha reductase inhibitor with an alpha-1 selective blocker may reduce the occurrence of acute urinary retention, decrease the risk of developing incontinence, and avoid or significantly delay the need for surgical intervention in this highly vulnerable male population.

Navigating the Minefield of QTc Interval-Prolonging Therapy in Nursing Facility Residents.

BACKGROUND: The exponential increase in the number of medications associated with clinically important prolongation of the heart rate-corrected QT interval (QTc) places older adults at increased risk of arrhythmias including life-threatening torsade de pointes (TdP) and sudden death. Risk factors, other than age older than 65 years and female sex, include multiple concurrent drugs that prolong QTc and a variety of underlying predisposing conditions. Although electronic medical records and pharmacy dispensing systems can alert clinicians to the risk of QTc-prolonging therapy, more than 95% of safety alerts are overridden, and many systems have deactivated QTc drug interaction alerts. The clinical consequences, magnitude of the effect, mitigation strategies, and recommended monitoring are not well defined for nursing facility (NF) residents. DESIGN: Narrative review. SETTING: NFs in the United States. PARTICIPANTS: NF residents. RESULTS: Medications known to prolong QTc include selected anti-infectives, antidepressants, urinary anticholinergics, antipsychotics, and cholinesterase inhibitors (eg, donepezil), used commonly in NFs. Drug-drug interactions are a risk when adding a medication that exaggerates the effect or inhibits the metabolism of a QTc-prolonging medication. The vast majority of patients in whom TdP is induced by noncardiac drugs have risk factors that are easily identifiable. CONCLUSIONS: Recommendations are provided to improve standardization and use of drug interaction alerts, evaluate the risk of QTc-prolonging drugs in older adults receiving generally lower doses, validate a QTc risk score addressing complex multimorbidity, garner evidence to guide clinical decision making, avail NFs of access to electrocardiograms and interpretive recommendations, and develop standards of practice for hosting risk discussions with residents and their families. J Am Geriatr Soc, 1-8, 2019.

Quality Clinical Care in Nursing Facilities.

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.