Cardiac Resuscitation Procedures in US Nursing Facilities: Time to Reevaluate the Standard of Care?

Although the use of automated external defibrillators (AEDs) in out-of-hospital cardiac arrest (OHCA) response has become the standard of care in many community settings over the past 20+ years, the adoption of AEDs in US nursing facilities is variable and the current number of facilities with AEDs is unknown. Recent research into the use of AEDs as part of cardiopulmonary resuscitation (CPR) procedures for nursing facility residents with sudden cardiac arrest demonstrates improved outcomes in the limited cohort with witnessed arrests, early bystander CPR, and an initial amenable rhythm, shocked with an AED before the arrival of Emergency Medical Services (EMS) personnel. This article reviews data about outcomes of CPR in older adults and nursing facility settings and proposes that standard procedures for CPR attempts in US nursing facilities should be reevaluated and continue to evolve, commensurate with the evidence and community standards.

Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care.

Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services' reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids. Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases. This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.

DEA enforcement in long-term care: is a collaborative correction feasible?

The prescribing and dispensing of controlled substances within long-term care facilities is an important and complex issue from both the clinical and the public policy perspectives. This article reviews the regulatory background and clinical concerns regarding the enforcement of the Controlled Substances Act by the Drug Enforcement Administration within the institutional pharmacies serving long-term care facilities. The article argues that the processes implemented since 2009 in response to concerns about Drug Enforcement Administration enforcement are suboptimal at many levels. A robust solution that meets the needs of all parties involved will require multiple levels of collaboration and respect for several legitimate agendas pertinent to this issue. The comprehensive solution must address at least 4 concerns. It must ensure that (1) residents and patients of long-term care facilities receive appropriate and timely administration of controlled substances when they are part of their individualized plans of care; (2) long-term care facilities have rigorous processes in place to prevent diversion of controlled substances; (3) required processes for prescribing controlled substances are reasonable and not overly burdensome to the clinicians caring for this population; and (4) all parties are in compliance with statutory and regulatory requirements. The solution, however, will likely require legislative amendments to the Controlled Substances Act and regulatory revisions for optimal outcomes. The debate surrounding the enforcement of the Controlled Substances Act within long-term care facilities is ongoing and the parameters are in flux. This article provides a historical perspective and policy framework for understanding the topic, reviews various proposed solutions, and suggests a collaborative process for resolution.

Perspectives on the future of geriatric medicine.

The following comments were presented to the 20th anniversary celebration of the geriatric medicine fellowship training program at the Baylor College of Medicine in the Texas Medical Center, Houston, Texas, on June 24, 2005. The author, who was the first graduate of the geriatric medicine training program at Baylor, proposes that geriatrics is at a critical juncture and that the voice and identity of geriatric medicine should be that of advocacy for our patients, and that in such a role geriatric medicine is well suited to become the "soul of medicine." She encourages all geriatricians to read the report of the Task Force on the Future of Geriatric Medicine and to look for opportunities to personally be involved in implementing the recommendations. She suggests that since our visions of the future are often only caricatures of our past, we must be creative and dream big dreams of what the future may hold. She challenges each of us to get involved in actively creating the future of geriatric medicine.