Transcript Update in the Medical Management of the Long

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
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Managing the Patient with Dementia in LongTerm 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
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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
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Alzheimer’s Disease
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Decreased cerebral synthesis of choline
acetyltransferase
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Decreased acetylcholine production and impaired
cortical cholinergic function
Cholinesterase Inhibitors
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Increase cholinergic transmission
Use is controversial in other types of dementia
Approved Cholinesterase
Inhibitors
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Tacrine (Cognex)
Rivastigmine (Exelon)
Galantamine (Razadyne, Reminyl)
Donepezil (Aricept
Donepezil
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Efficacy demonstrated for mild - moderate
cognitive impairment
Effective dose = 10 mg
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Titrate over a few weeks to decrease GI side
effects
Titrate down when stopping
Improvement in outcomes is controversial
Memantine
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N-methyl-D-aspartate receptor antagonist
Overstimulation of receptor by glutamate
Efficacy demonstrated in moderate - severe
Alzheimer’s Disease
Effective dose = 10 mg BID
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Start 5 mg QD
Increase by 5 mg Qwk until reach effective dose
Optimal Environment for Maintenance
of Function in Moderate Dementia
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Function and QOL are contingent on
surroundings
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Finding the right “person-environment fit”
Prevent “excess disability”
Changes in brain function
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Perceptual ability decreases
Ability to filter multiple stimuli decreases
Impaired vs. preserved functions
Dementia and
Depression/Agitation
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Depression
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MC psychological sx a/w dementia in LTC pts
29% had major depressive disorder
Randomized Control Trials:
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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
Dementia and
Depression/Agitation
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Agitation
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= 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
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Pain, ADL dysfunction, cognitive impairment,
depression, mental/medical dz, physical restraints,
psychosis, anti-psychotics, anxiolytics, total #
drugs/day, physical/social environment factors
Dementia and
Depression/Agitation
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Agitation
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Approach to Treatment:
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Assess & remove potentially correctable RF
Behavioral management
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Staff training vs. usual care
Person-centered showering/bathing
Family visit education program
Drug therapy
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Olanzapine (Zyprexa)
Carbamazepine (Tegretol)
Haloperidol, oxazepam, diphenhydramine
Evaluation and Management of
Eating Problems w/ Dementia
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Eating Problems a/w Dementia
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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
Evaluation and Management of
Eating Problems w/ Dementia
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Workup & Evaluation
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Complete H&P, including medication review
Labs:
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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
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Management
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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
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Management, cont’d
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D/c offending meds if possible
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Affect taste, olfaction or cause anorexia
Meds to stimulate appetite
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Mirtazapine 7.5/15 mg
Megestrol 800 mg liquid
Medications in LongTerm Care: When Less
is More
Thomas W. Meeks, MD; John W.
Culberson, MD; Monica S.
Horton, MD, MSc
History of Medication
Reduction in LTC
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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
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1991 (Beers List) 2001 (Zhan) 2006 (HEDIS)
Focus mostly on drugs w/ CNS activity
Prevalence of Neuropsychiatric
Illness in LTC
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 50% LTC pts have dementia
80 - 100% of these pts experience dementiaassociated neuropsychological symptoms
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Psychosis, aggression, depression
NO FDA approved therapy
Therefore, use of psychotropic meds is very
common due to the prevalence of this
disease
Medication Reduction
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Why?
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When?
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Medication review 2x/yr and during transitions of care
How?
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Older pts are on more meds and have a higher risk for
adverse effects
Polypharmacy must be carefully monitored
Discuss changes based on risk/benefit profile
What?
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Meds/classes commonly seen on PIPE lists
Medication Reduction: What?
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Antipsychotics
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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?
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Benzodiazepines
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Should generally be avoided
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Studies show risk  benefit
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However, 30% LTC pts still take
Excessive sedation
Tolerance/dependance even if not abused
Hepatic metabolism
If used, should be short term for appropriate
conditions
Medication Reduction: What?
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Other Sedatives/Hypnotics
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Z-drugs = zolpidem, zaleplon, eszopiclone
Act on benzo-type 1 receptor
SE = postural instability, hallucinations, amnestic
episodes
Insomnia
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Look for a cause
Commonly used meds:
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Lunesta, Rozerem, Trazodone
Sedating antihistamines
Medication Reduction: What?
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Antidepressants
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MDD affects 10 - 15% of LTC residents
Potential SE:
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SIADH, osteoporosis, falls, GI bleeding
Limited/mixed data on efficacy in older adults,
especially those w/ dementia
Medication Reduction: What?
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Antidepressants--drug options:
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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?
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Analgesics Overview
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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?
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Analgesics Overview
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Why is pain treatment so complicated?
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Broad variety of causes
Diagnostic uncertainty and fluctuating course
Multiple treatment options available
Regulatory and administrative guidelines
Medication Reduction: What?
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Topical Analgesics and Local Injections
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Great way to lower systemic analgesic dose
required to control chronic pain
Options:
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Topical lidocaine 5% patches
Topical NSAIDs
Intra-articular injections
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Steroids
Hyaluronic acid
Trigger-point IM injections
Medication Reduction: What?
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Acetaminophen
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Low risk for toxicity and minimal drug interactions
Limitations:
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Short half-life
Potential hepatotoxicity
Best for acute intermittent pain control
Medication Reduction: What?
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NSAIDs
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Best used sporadically at low doses for acute
intermittent pain
Risks:
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GI bleeding
Renal dysfunction
Cardiovascular complications
Avoid nonselective and cyclooxygenase 2
selective inhibitors
Medication Reduction: What?
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Opiate Analgesics
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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
Medication Reduction: What?
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Anticonvulsants
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Gabapentin and pregabalin
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Reduce neuropathic pain due to a variety of conditions
Low SE profile
Long-acting
Titrate to maximum tolerated dose
Medication Reduction: What?
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Other Common Adjuvant Medications
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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
Evidence-Based Medicine
(EBM): What Long-Term
Care Providers Need to
Know
Huai Y. Cheng, MD, MPH
EBM
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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
Pt preference
and actions
Research
Evidence
The EBM Concept
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Developed in 1991
Offers a framework to make the best
decisions for individual pts
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Relevant to LTC b/c pt preferences are often
different
Research evidence
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Strongest = systematic review of large wellperformed RCTs
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Minimal in NH setting
EBM Application in LTC
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Potential Benefits:
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Better decision making for pts & families
Improved quality of care
Potential Harms:
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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
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Challenges:
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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 ptcentered care difficult
Many clinical questions are difficult to answer
based on RCT
References
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Rhodes-Kropf, Jennifer. Managing the Patient with
Dementia in Long-Term Care. Clinics in Geriatric
Medicine. 2011;27:135-152.
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Meeks, Thomas W. Medications in Long-Term Care:
When Less is More. Clinics in Geriatric Medicine. 2011;
27:171-192.
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Cheng, Huai Y. Evidence-Based Medicine (EBM): What
Long-Term Care Providers Need to Know. Clinics in
Geriatric Medicine. 2011; 27:193-198.