Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies.

BACKGROUND: Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC. METHODS: This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications. RESULTS: Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs. CONCLUSIONS: By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives. TRIAL REGISTRATION: NCT04242186.

Healthcare for older adults in North America: challenges, successes and opportunities.

Older adults in North America face similar challenges to successful ageing as other adults around the world, including an increased risk of geriatric syndromes and functional decline, limited access to healthcare professionals specialising in geriatrics and constraints on healthcare spending for Long-Term Services and Supports. Geriatrics as a specialty has long been established, along with the creation of a variety of screening tools for early identification of geriatric syndromes. Despite this, workforce shortages in all older adult care service areas have led to significant gaps in care, particularly in community settings. To address these gaps, innovative programs that expand the reach of geriatric specialists and services have been developed. Opportunities exist for further dissemination of these programs and services, as well as for expansion of an ageing capable workforce.

Interprofessional competencies of students in a geriatric case competition.

This paper presents a valuable activity to teach health professions students - the interprofessional geriatric case competition. This program brought together students from multiple health professions to design and present a comprehensive care plan using a simulated complex geriatric patient case. Student participants demonstrated beginning skills in interprofessional collaboration based on the IPEC competencies. The case competition provides a positive, engaging experience to introduce health professions students to geriatric principles and develop their readiness for collaborative interprofessional practice. The competition could be conducted virtually, providing a supplement to on-site education.

Updates in nutrition and polypharmacy.

PURPOSE OF REVIEW: Medications have the potential to affect nutritional status in negative ways, especially as the number of medications increase. The inter-relation between polypharmacy and malnutrition is complex and not fully delineated in previous studies. More research has been done and compiled in the last year, which helps to clarify this relationship. This review brings together the most recent literature with the previous research to help healthcare providers to better assess and manage medication therapy in older adults. RECENT FINDINGS: Recent evidence confirms a synergistic negative effect of polypharmacy and malnutrition on outcomes of older adults. In addition, several drug classes, including common antihypertensive agents, acetylcholinesterase inhibitors, multivitamins, proton pump inhibitors, HMG-CoA reductase inhibitors (statins), antiplatelet agents and metformin, have been implicated in important drug-nutrient interactions. These are reviewed in detail here. Ongoing research endeavors are described. SUMMARY: Healthcare practitioners can use this review to identify potentially inappropriate medications and patients at highest risk of experiencing a medication-related adverse reaction in order to systematically deprescribe these high-risk medications.

Nutrition and skin ulcers.

PURPOSE OF REVIEW: Skin ulcerations cause significant morbidity and mortality, while driving up healthcare utilization and costs. Interventions to prevent ulcers and improve wound healing times are needed to reduce the burden on patients and healthcare systems. It has been well established that weight loss, protein-calorie malnutrition, and dehydration are risk factors for pressure ulcers. Many nutritional interventions have been studied, with studies being of variable quality and producing mixed results. This review aims to clarify the current evidence and highlights the recent advances in the area of nutrition for the prevention and management of skin ulceration. RECENT FINDINGS: Markers for assessing nutritional status will be reviewed first, followed by a discussion on the theoretical benefit of various nutritional interventions on wound healing. Recommendations for nutrient repletion are also included. Finally, the most recent or important literature will be highlighted and the risks and benefits of supplementation are debated. There is mixed evidence for most nutritional interventions, with most studies being of poor quality with variable study designs, lack of control groups, small sample sizes, and short study lengths. SUMMARY: Long-term randomized trials of individual nutrients and clinically relevant endpoints are needed to definitively show the benefit of additional nutritional supplementation over dietary interventions. Until those studies become available, best evidence suggests the importance of screening for malnutrition, calculating resting energy expenditure and caloric needs, and monitoring dietary intake of essential nutrients.

Improving shared decision-making for osteoporosis pharmacologic therapy in nursing homes: a qualitative analysis.

Decisions on whether to use pharmacologic osteoporosis therapy in skilled nursing facility residents are complex and require shared decision-making. Residents, proxies, and staff desire individualized fracture risk estimates that consider advanced age, dementia, and mobility. They want options for reducing administration burden, monitoring instructions, and periodic reassessment of risk vs. benefit. PURPOSE: Decisions about pharmacologic osteoporosis treatment in nursing home (NH) residents with advanced age and multimorbidity are complex and should occur using shared decision-making. Our objective was to identify processes and tools to improve shared decision-making about pharmacologic osteoporosis treatment in NHs. METHODS: Qualitative analysis of data collected in three NHs from residents at high fracture risk, their proxies, nursing assistants, nurses, and one nurse practitioner (n = 28). Interviews explored participants' stories, attitudes, and experiences with oral osteoporosis medication management. Framework analysis was used to identify barriers to shared decision-making regarding osteoporosis treatment in this setting. RESULTS: Participants wanted individualized fracture risk estimates that consider immobility, advanced age, and comorbid dementia. Residents and proxies expected nursing staff to be involved in the decision-making; nursing staff wished to be informed on the relative risks vs. benefits of medications and given monitoring instructions. Two important competing demands to address during the shared decision-making process were burdensome administration requirements and polypharmacy. Participants wanted to reassess pharmacologic treatment appropriateness over time as clinical status or goals of care change. CONCLUSIONS: Shared decision-making using strategies and tools identified in this analysis may move osteoporosis pharmacologic treatment in NHs and for other older adults with multimorbidity from inappropriate inertia to appropriate prescribing or appropriate inaction.

Strengthening Resident, Proxy, and Staff Engagement in Injury Prevention in Skilled Nursing Facilities.

BACKGROUND AND OBJECTIVES: Engaging residents, their proxies, and skilled nursing facility (SNF) staff through effective communication has potential for improving fall-related injury prevention. The purpose of this study was to understand how multiple stakeholders develop and communicate fall-related injury prevention plans to enhance sustained implementation. RESEARCH DESIGN AND METHODS: Descriptive qualitative study using framework analysis applied to open-ended semistructured interviews (n = 28) regarding experiences of communication regarding fall-related injury prevention, guided by the Patient and Family Engaged Care framework. Participants included residents at high risk of injury and their proxies, nursing assistants, nurses, and a nurse practitioner from 3 SNFs in the Eastern United States (Massachusetts and North Carolina). RESULTS: Interdisciplinary teams were viewed as essential for injury prevention. However, the roles of the interdisciplinary team members were sometimes unclear. Communication structures were often hierarchical, which reduced engagement of nursing assistants and frustrated proxies. Practices that enhanced engagement included knowing the residents, active listening skills, and use of strategies for respecting autonomy. Engagement was inhibited by time constraints, lack of proactive communication among staff, and by challenges eliciting the perspectives of residents with dementia. Resident barriers included desire for autonomy, strong preferences, and language differences. DISCUSSION AND IMPLICATIONS: Strengthening team meeting processes and cultivating open communication and collaboration could facilitate staff, resident, and proxy engagement in injury prevention planning and implementation. Skill building and targeting resources to improve communication can address barriers related to staff practices, resident characteristics, and time constraints.

High prevalence of geriatric syndromes in older adults.

INTRODUCTION: The geriatric syndromes of frailty, sarcopenia, weight loss, and dementia are highly prevalent in elderly individuals across all care continuums. Despite their deleterious impact on quality of life, disability, and mortality in older adults, they are frequently under-recognized. At Saint Louis University, the Rapid Geriatric Assessment (RGA) was developed as a brief screening tool to identify these four geriatric syndromes. MATERIALS AND METHODS: From 2015-2019, the RGA, comprised of the FRAIL, SARC-F, Simplified Nutritional Appetite Questionnaire (SNAQ), and Rapid Cognitive Screen (RCS) tools and a question on Advance Directives, was administered to 11,344 individuals ≥ 65 years of age across Missouri in community, office-based, hospital, Programs of All-Inclusive Care for the Elderly (PACE), and nursing home care settings. Standard statistical methods were used to calculate the prevalence of frailty, sarcopenia, weight loss, and dementia across the sample. RESULTS: Among the 11,344 individuals screened by the RGA, 41.0% and 30.4% met the screening criteria for pre-frailty and frailty respectively, 42.9% met the screening criteria for sarcopenia, 29.3% were anorectic and at risk for weight loss, and 28.1% screened positive for dementia. The prevalence of frailty, risk for weight loss, sarcopenia, and dementia increased with age and decreased when hospitalized patients and those in the PACE program or nursing home were excluded. CONCLUSIONS: Using the RGA as a valid screening tool, the prevalence of one or more of the geriatric syndromes of frailty, sarcopenia, weight loss, and dementia in older adults across all care continuums is quite high. Management approaches exist for each of these syndromes that can improve outcomes. It is suggested that the brief RGA screening tool be administered to persons 65 and older yearly as part of the Medicare Annual Wellness Visit.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care.

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

Reversible Dementias.

As the worldwide prevalence of dementia increases, there is a greater and more urgent need for all health care providers to understand how to evaluate and manage cognitive impairment. Many people presenting with a dementing illness have one or more reversible underlying conditions that worsen prognosis and, if treated, can improve cognitive function. This article reviews the major potentially reversible dementias, including the basic workup and management of each condition.

Clinical Update on Nursing Home Medicine: 2017.

This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered are hypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary disease risk factors, diagnosis and management including end-of-life planning, and the difficulties with exacerbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; and wound care and pressure ulcer management.

Clinical Update on Nursing Home Medicine: 2016.

This is the tenth clinical update. It covers chronic kidney disease, dementia, hypotension, polypharmacy, rapid geriatric assessment, and transitional care.

Clinical update on nursing home medicine: 2014.

This is the eighth yearly update on clinical care in the nursing home. Topics covered this year are heart failure, delirium, nutrition, hospice, diabetes mellitus, frailty, and sarcopenia.

International survey of nursing home research priorities.

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

Nursing home research: the first International Association of Gerontology and Geriatrics (IAGG) research conference.

The International Association of Gerontology and Geriatrics held its first conference on nursing home research in St Louis, MO, in November 2013. This article provides a summary of the presentations.