Transcript 1 - RCRMC Family Medicine Residency

Longterm Care
By Joel Doughten
DEFINITION OF ASYMPTOMATIC
BACTERIURIA
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A positive urine culture does not prove that a patient has a urinary tract
infection (UTI).
The term asymptomatic bacteriuria (ASB) is used to suggest that a patient has
bacteria in the urine but not a true infection
A true UTI is bacteriuria in association with specific symptoms arising from
the urinary tract.
Women without urinary tract symptoms but with two consecutive urine cultures
containing 100,000 colony-forming units per milliliter (cfu/mL) of a single
isolate, obtained by clean catch of a voided specimen, have, by definition, ASB.
ASB in men is defined in a similar way, except that only one urine culture with
100,000 cfu/mL of a single organism is needed to meet the definition.
A catheter specimen from asymptomatic men or women that grows 100 cfu/mL
also meets the definition of ASB.
Patients without urinary tract symptoms but with significant bacteria in their
urine have ASB and not a UTI.
Asymptomatic Bacteriuria in the Nursing Home by
Timothy J. Benton, MD, Rodney B. Young, MD,
and Stephanie C. Leeper, MD, FACP
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PREVALENCE
OF
ASB
The elderly, especially those residing in long-term-care
facilities, more commonly have ASB than the general
population.
About 25-50% of women and 15-40% of men living in
long-term-care facilities have ASB.
The prevalence rates in elderly women and men outside of
the nursing home are 10.8-16% and 3.6-19%, respectively.
The high prevalence among nursing home residents
presents a particular problem since ASB resembles UTI on
paper, but treatment of ASB is unnecessary.
Clinicians caring for long-term-care residents need to be
able to recognize ASB and distinguish it from UTI,
especially as the number of elderly people residing in
nursing homes increases.
Recognizing that ASB is common among residents living
in long-termcare facilities, and that it is an entity separate
The challenge
• The challenge for the clinician is not in
deciding whether to treat the nursing home
resident with ASB, but rather in
distinguishing ASB from UTI.
• The most reliable indicator of a true UTI in
long-term care residents is symptoms
specifically arising from the urinary tract,
such as flank pain, dysuria, urinary
frequency, or any combination of these, and
not just an abnormal urinalysis, a positive
urine culture, or nonspecific clinical
changes.
Table II: Treatment Recommendations
for Asymptomatic Bacteriuria
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Type of Resident Treatment
Nursing home elderly Not recommended
Women with diabetes Not recommended
Persons with planned Start antibiotic
therapy before procedure;
• transurethral resection of prostate
discontinue after procedure unless
catheterized
• Pregnant women treat
Table III: Similarities and Differences of
ASB and UTI
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ASB UTI
Similarities Positive urine culture Positive urine culture
Pyuria present* Pyuria present*
Differences May be found in persons Less likely to be found in
with nonspecific symptoms persons with nonspecific
symptoms†‡
No localized urinary tract Symptoms localized to symptoms urinary
tract
* Pyuria present in 30% of nursing home elderly with or without
bacteriuria4 and
90% with ASB.1
† Positive predictive value of a positive urine culture and no localizing
urinary tract symptoms is 10% in nursing home residents.3
‡ Positive predictive value of fever, a positive urine culture, and no
localizing symptoms is 12% in nursing home residents.4,21
In long-term care facilities,
a fever threshold of
ºF
101 should be used as a
trigger to evaluate for
infection.
A) True
B) False
Answer
• B) False
When evaluating fever in longterm care facilities, a complete
blood cell count should be
performed within _______ of
onset of symptoms.
A) 12 to 24 hr
B) 24 to 36 hr
C) 36 to 48 hr
D) 5 days
Answer
• A) 12 to 24 hr
The degree of pyuria helps
differentiate asymptomatic
bacteruria and pyuria from
a true urinary tract
infection.
A) True
B) False
Answer
• B) False
Choose the correct statement about
respiratory tract infection in longterm care facilities.
A) Consider transferring patients
with O2 saturation <90%
B) Chest x-ray detects 75% to 90%
of pneumonia
C) Purulent sputum specimens may
help narrow antibiotic choices
D) All the above
Answer
• D) All the above
When to suspect infection in longterm care facilities
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1) decline in functional status
new or increasing confusion,
incontinence,
falls,
worsening mobility or oral intake,
or change in cooperativeness
2) presence of fever
When all patients with fever 101ºF evaluated for infection, only 40%
of infected patients detected
• consider change in patient’s baseline temperature or lower fever
threshold (99ºF-100ºF) as trigger to evaluate for infection
• as baseline temperatures tend to be lower in geriatric population, fever
threshold of 101ºF too high for this population
Evaluation
• evaluate respiratory rate, hydration
status, mental status, and organ systems
• small studies suggest breathing rate of 25
breaths/min represents lower respiratory
tract infection (RTI) 80% to 90% of time
• no data about other vital signs (eg,
tachycardia)
• likelihood of detecting RTI based on
physical examination high (93%); 80% of
patients with documented RTI have cough,
and 70% have rales “and perhaps some
fever”
Hypertensive Urgency Definition
• Common names:
High Blood Pressure Urgency
• Hypertensive Urgency
• What is hypertensive urgency?
A person with hypertensive urgency has a severely elevated blood
pressure, but has no symptoms. In someone with hypertensive urgency,
the systolic blood pressure (top number) is over 220 or the diastolic
blood pressure (bottom number) is over 115. Hypertensive urgency
requires treatment within a few days, and usually responds well
to blood pressure medication.
What are the symptoms of a hypertensive urgency?
There are usually no symptoms associated with hypertensive urgency.
Hypertensive urgency becomes hypertensive emergency if symptoms
develop, such as chest pain, difficulty breathing, headacheor vision
changes.
How does the doctor treat a hypertensive urgency?
Treatment for a hypertensive urgency includes medications to slowly
bring down the blood pressure.
Hypertensive emergencies
• Hypertensive emergencies are characterized by severe elevations in BP
(>180/120 mmHg) complicated by evidence of impending or
progressive target organ dysfunction.
• They require immediate BP reduction (not necessarily to normal) to
prevent or limit target organ damage.
• Examples include hypertensive encephalopathy, intracerebral
hemorrhage, acute MI, acute left ventricular failure with pulmonary
edema, unstable angina pectoris, dissecting aortic aneurysm, or
eclampsia.
• Hypertensive urgencies are those situations associated with severe
elevations in BP without progressive target organ dysfunction.
• Examples include upper levels of stage II hypertension associated with
severe headache, shortness of breath, epistaxis, or severe anxiety.
• The majority of these patients present as noncompliant or inadequately
treated hypertensive individuals, often with little or no evidence of
target organ damage.
Hypertensive Emergency
• Acutely elevated blood pressure, particularly diastolic pressure > 120–
130 mmHg without evidence of target organ damage. Goals: Lower
mean arterial pressure to goal or near goal within several hours. Oral
medications can be used.
Hypertensive emergency: Hypertension with evidence of target organ
damage ( brain, heart, kidneys, eyes). Goals: The goal of initial therapy
is to terminate ongoing target organ damage. Lower mean arterial
pressure by 20- 25% or diastolic pressure to <100 to 110 mmHg within
30–60 minutes.
(JNC VI) states that the initial goal of therapy in hypertensive
emergencies is to reduce mean arterial pressure (MAP) by 20 to 25%
(within minutes to 2 hours), then toward 160/100 mmHg within 2 to 6
hours, avoiding excessive falls in pressure that may precipitate renal,
cerebral, or coronary ischemia.9 If symptoms worsen (e.g., an increase
in chest pressure, a decline in mental status) during the reduction of
systemic blood pressure, the rate of the reduction should be slowed or
treatment should be temporarily halted.
How Aggressive to treat BP in
Urgency
• there is no evidence to suggest that failure to
aggressively lower BP in the ER or any other
location is associated with any increased shortterm risk to the patient who presents with severe
hypertension and no symptoms.
• Such a patient may benefit from adjustment in
their antihypertensive therapy, particularly the use
of combination drugs, or reinstitution of
medications if noncompliance is a problem.
• Most importantly, patients should not leave the ER
without a confirmed followup visit within several
days.
Oral agents for Hypertensive
Emergencies
Captopril
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• Dose: 12.5 to 25 mg orally repeat as needed or give SL.
Onset/ duration: 15-30 min/6-8 hr, SL 10-20 min/2-6 hr.
• Clonidine Dose: Clonidine 0.1-0.2 mg orally x 1, followed
by 0.05 to 0.1 mg every 1 to 2 hours to a maximum dose of
0.6 to 0.7 mg.
Onset/ duration: 30-60 min/8-16 hr.
• Labetalol Dose: 200-400 mg orally, repeat every 2-3
hours. Onset/ duration: 1-2 hr/2-12 hr.
• Other Many patients may require at least 2 agents.
Additional agents to consider are
(1) lasix 20mg (rpt as necessary)
(2) nifedipine SR 30mg x1
(3) felodipine 5 mg x 1.
Treatment of behavioral
symptoms related to dementia
• Neuropsychiatric symptoms are common in
dementia.
• These symptoms include agitation,
aggression, delusions, hallucinations, and
wandering.
• Depression and sleep disturbances can also
occur with dementia.
Aggression
• Agitation and aggression may be provoked by
several mechanisms in Alzheimer disease (AD):
• Confusion or misunderstanding due to cognitive,
language, or memory deficits
• Frightening, paranoid delusions
• Depression in a patient too impaired to express
distress in any other manner
• Sleep disorders
• If aggression appears to emerge in moments of
confusion, management is probably behavioral
after analysis of the antecedent episodes. If
delusions appear to trigger aggression, treatment
with antipsychotic medication may be helpful
Psychosis
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Delusions are more common than hallucinations in demented patients, with a reported
prevalence of 30 percent of patients with severe AD [1]. A long-term follow-up study
suggests that it may be more pervasive; among 456 patients with mild to moderate AD
followed for a mean of 4.5 years, 34 percent had delusions at baseline, but 70 percent
had them during at least one evaluation [10]. Hallucinations were present in 7 percent at
baseline and in 33 percent at some point over the course of follow-up.
Paranoid delusions in particular can be very distressing to the patient or caregivers.
Common paranoid delusions include beliefs that the house has been invaded, that
personal objects have been misplaced or stolen, that family members have been replaced
by impostors (Capgras syndrome), or that spouses have been unfaithful.
The presence of visual hallucinations early in the course of a dementing illness suggests
Dementia with Lewy bodies (DLB) disease, a disorder with very specific management
issues.
Nonetheless up to 20 percent of patients with AD can present with hallucinations,
mostly commonly visual, less commonly auditory and rarely olfactory hallucinations.
Delusions or hallucinations may be fleeting or unobtrusive. Pharmacotherapy is not
necessary if neither the patient nor the family are disturbed by them; therapy is
warranted if these symptoms become problematic. The presence of either delusions or
hallucinations is associated with increased risk for cognitive and functional decline;
hallucinations predict institutionalization and death
Sleep
disorders
Dementias may produce different sleep disturbances:
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• Patients who have PD or progressive supranuclear palsy
(PSP) appear to have very shallow sleep - mostly stage 1
and 2 - and are probably awakened easily. They also have
trouble turning in bed, and that may make them more
restless in bed.
• Patients with PSP may be awakened by choking episodes
at night that are triggered by sleeping on their backs.
• Patients with PD also probably have more periodic leg
movements of sleep (PLMS or restless legs). These are
highly treatable by shifting or adding a small dopamine
agonist dose at bedtime.
• Patients with dementia with Lewy bodies (DLB) disease
have a high incidence of rapid eye movement (REM) sleep
behaviors. Nocturnal confusion may arise from awakening
out of REM sleep into a dark room. This is also treated
SPECIFIC TREATMENTS
• A number of treatment options exist for the
management of neuropsychiatric symptoms
in dementia. However, efficacy is
incomplete and often comes at a cost of side
effects, including increased mortality. A
proactive approach, with collaboration
between health care providers, patients,
caregivers, and community agencies may
provide additional benefits in managing
these troublesome symptoms
Nonpharmacologic management
• Increasing evidence suggests that
nonpharmacologic measures, including
behavioral methods, may be effective in
reducing agitation and anxiety in patients
with dementia [26]. Behavioral
interventions employ different strategies
and techniques. These include identifying
any preceding events that generate
agitation, determining whether unmet needs
can be anticipated and alleviated, and
avoiding environmental triggers such as a
sudden change in surroundings
aggression or agitation with
assisted bathing
• "person-centered bathing," an intervention focused
on resident comfort and preferences, and "towelbath," an in-bed bag bath method that kept the
resident covered at all times and cleansed by using
gentle massage. Both treatment groups showed
significant declines in all measures of agitation,
aggression, and discomfort compared with
controls. The postulated mechanism underlying
the effectiveness of the improved personal care
involved a reduction in the insistent, task focused,
impersonal, and intrusive "usual care" methods
that can provoke agitation and aggression [27].
Other therapies
• At least three placebo-controlled trials have
reported a significant benefit of
aromatherapy compared with placebo in
patients with dementia and agitation, with
almost complete compliance and no adverse
effects [28-30]. Lemon balm or lavender
oil are most frequently used and can be
delivered by either inhalation or skin
application. The mechanism by which these
agents may be effective is unclear.
Other therapies
• Exercise training in combination with caregiver-education may
improve outcomes in patients with Alzheimer disease (AD). A
randomized trial in 153 community-dwelling patients with AD found
that compared with routine medical care, patients who were assigned
to exercise (goal minimum of 30 minutes per day) and whose
caregivers received training in managing behavioral problems had
improved physical functioning and less depression
• Music therapy and pet therapy also have some evidence of efficacy
• In preliminary studies, massage and touch therapy appear to be
potentially beneficial in the immediate management of agitated
behavior and in encouragement to eat
• Certain behavioral problems may respond better to behavioral
therapies than to medical therapy. These include wandering, hoarding
or hiding objects, repetitive questioning, withdrawal, and social
inappropriateness
A randomized, controlled trial of bright light
therapy for agitated behaviors in dementia
patients residing in long-term care.
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nt J Geriatr Psychiatry. 1999 Jul;14(7):520-5.
Lyketsos CG, Lindell Veiel L, Baker A, Steele C.
Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins
University, Baltimore, Maryland 21287, USA. [email protected]
BACKGROUND: Agitated behaviors are common in dementia patients residing in chronic care
settings. Their occurrence may be associated with lack of adequate exposure to sunlight and with
circadian rhythm disturbances.OBJECTIVE: Prior research has suggested that bright light therapy
(BLT) may reduce agitated behaviors in dementia patients. The aim of this study was to test the
efficacy of BLT in a randomized, controlled, crossover clinical trial. METHOD: Fifteen patients with
dementia and agitated behaviors residing in a chronic care facility were randomized in a crossover
design to morning BLT for 1 hour per day or to a control condition with dim light exposure. Patients
were treated in either condition for 4 weeks, followed by 1 week on no treatment, prior to being
crossed over to the other condition. RESULTS: Eight out of 15 patients completed the entire study.
The rest completed at least 2 weeks of study. Patients randomized to the BLT condition exhibited a
statistically significant improvement in nocturnal sleep from a mean of 6.4 hours/night to 8.1
hours/night 4 weeks later (p<0.05). The sleep of patients in the control condition did not improve
significantly. There were no other significant differences between baseline and follow-up, nor
between BLT and control treated patients on the other outcome measures, which included the
Behavioral Pathology in Alzheimer Disease scale (Behave-AD) and the Cornell Scale for Depression
in Dementia. CONCLUSION: Patients with dementia in chronic care who exhibit agitated behaviors
sleep more hours at night when administered morning BLT. However, BLT does not lead to
improvements in agitated behaviors in institutionalized patients with dementia with non-disturbed
sleep-wake cycles. Copyright 1999 John Wiley & Sons, Ltd.
Other therapies
• Behavioral approaches can be combined
with medications. As an example, a sleep
disorder may require both behavioral and
pharmacological management
(eg, trazodone). An activity program,
avoidance of daytime naps, elimination of
evening alcohol and coffee, and delaying
bedtime are all useful.
Antipsychotic agents
• Atypical neuroleptics have been the agents of
choice for treating hallucinations in patients with
dementia. However, these drugs may increase
mortality and are not approved for the treatment of
behavioral disorders in patients with dementia by
the US Food and Drug Administration (FDA).
Nonetheless, their benefits often still outweigh
their risks in patients with dementia when
treatment of hallucinations and delusions is
critical. In the absence of other effective agents,
we continue to use them cautiously, after
informing the patients and families of the potential
risks.
Mortality risk
• The US Food and Drug Administration (FDA) reported in
a public health advisory that the use of second generation
antipsychotic
medications, aripiprazole, olanzapine, quetiapine,
and risperidone, for the treatment of behavioral symptoms
in elderly patients with dementia is associated with
increased mortality [43,44]. Their findings were confirmed
in an independently conducted meta-analysis, as well as a
subsequent randomized, placebo-controlled study [45,46].
The reported odds ratio for increased mortality in these
analyses ranged from 1.54 to 1.7. Similar concerns have
been raised for haloperidol and other conventional
antipsychotics as well; and short-term and long-term
treatment appear to be problematic [45,47,48].
(See "Antipsychotic medications: Treatment issues",
section on Mortality issues in elderly patients.)
Typical antipsychotics
• A systemic review of typical antipsychotics
included two meta-analyses of 12 trials plus two
additional studies
ofhaloperidol, thioridazine, thiothixene, chlorprom
azine, trifluoperazine and acetophenazine, and
concluded that, in the aggregate, there was no
clear evidence of benefit for these agents in
patients with dementia [36]. A Cochrane review
concluded that haloperidol may help control
aggression, but not other neuropsychiatric
manifestations of dementia [37]. No trials
compared agents with one another.
Atypical antipsychotics
• These agents
include clozapine, olanzapine,risperidone,
and quetiapine and have been somewhat
more extensively studied. Two
independently conducted systematic
reviews have concluded that these agents
have, at most modest efficacy. Of seven
trials studied, four found a statistically
significant benefit for the primary endpoint
with olanzapine or risperidone; there were
no studies of clozapine and quetiapine for
this indication at the time of this analysis.
Lewy Body Dementia
• Patients who have dementia with Lewy
bodies (DLB) disease may be especially
sensitive to antipsychotic medication and
may experience idiosyncratic, lifethreatening adverse reactions. Very low
doses of the atypical neuroleptics
(ie, olanzapine, quetiapine, and clozapine)
should be used to initiate treatment for
patients who have behavioral symptoms
related to DLB. Risperidone and the typical
antipsychotic agents should not be used in
patients who have DLB. ]
Clinical Use
• We reserve their use for patients who have
neuropsychiatric symptoms, particularly
psychosis, that are severe and debilitating
and inform patients and families of the
risks.
• There is often no good alternative.
Somnolence is also concern with all of these
agents, and may be dose limiting.
Atypical antipsychotics
• Olanzapine can be started at a dose of 2.5 mg daily and
titrated up to a maximum of 5 mg twice a day. This drug
appears to be at least modestly effective for treating the
neuropsychiatric symptoms of dementia in patients with
AD or vascular dementia. The incidence of extrapyramidal
symptoms is low at this dose.
• Quetiapine is an alternative, starting at a dose of 25 mg at
bedtime and titrating up to a maximum of 75 mg twice a
day. There is little data regarding the effectiveness
of quetiapine in this setting.
• Risperidone at no more than 1 mg daily also appears to be
at least modestly effective, but higher doses are associated
with increased side effects.
Atypical antipsychotics
• Treatment should be
maintained only if benefits
are apparent.
• Discontinuation should be
attempted at regular intervals
Antidepresents
A systematic review published in 2005
analyzed five randomized controlled trials
that investigated the use of serotonergic
antidepressants
including sertraline, fluoxetinecitalopram,
and trazodone in the treatment of
neuropsychiatric symptoms.
It showed some minor benefits with sertraline,
citalopram and trazodone
Cholinesterase inhibitors
• A 2005 systematic review reported that two
meta-analyses and six randomized
controlled trials of cholinesterase inhibitors
for neuropsychiatric symptoms of dementia
generally found small but statistically
significant efficacy.
Memantine
• Has some data for improvement of the NPI
in moderate to severe dementia.
Antiepileptic drugs
• Carbamazepine was effective in a placebocontrolled study of agitation in nursing
home patients with advanced dementia [72].
Relatively low doses were used, with a
modal dose of 300 mg/day achieving a
mean serum level of 5.3 mcg/mL. However,
a subsequent trial found no benefit [73], and
a systematic review concluded that there is
currently not enough evidence of benefit for
carbamazepine to recommend its use for
neuropsychiatric symptoms
Antiepileptic drugs
• Valproate improved aggressive behavior in
several earlier reports. However, a
systematic review that analyzed three
randomized controlled trials and two studies
of valproate concluded that neither the short
or long-acting preparations were effective
for treatment of neuropsychiatric symptoms
of dementia
Antiepileptic drugs
• Gabapentin is often used because of its
relatively mild side effect profile, but its
efficacy is questionable, with one openlabel prospective study showing little
benefit.
• Lamotrigine has been advocated based on
case reports, but no randomized, placebocontrolled studies have been published to
date.
Benzodiazepines
• Benzodiazepines have limited value in patients with AD.
They are not recommended for the management of
neuropsychiatric symptoms of dementia. One randomized
controlled trial of a benzodiazepine for neuropsychiatric
symptoms of dementia found benefit for both
intramuscular lorazepam and
intramuscular olanzapine compared with placebo at two
hours after treatment; the benefit of lorazepam was not
sustained at 24 hours on one outcome scale [77].
• Benzodiazepine side effects include worsening gait,
potential paradoxical agitation, and possible physical
dependence. Benzodiazepine use should be limited to brief
stressful episodes, such as a change in residence or an
anxiety-provoking medical event
Sexually inappropriate
behavior
• Given the absence of controlled clinical data, treatment for
this problem is necessarily empiric. Behavioral
interventions (redirection, distraction, avoiding stimulants)
should be tried first. If this is insufficient, medication trials
seem reasonable [14,20]. One systematic review concluded
that the preponderance of anecdotal data provided the most
support for antidepressant agents, making these the first
drug of choice (see'Antidepressants' below [21]. Another
valid approach may be to examine the context of other
behavioral symptoms that the patient may be experiencing
and to try an agent that seems most appropriate for the
overall symptom complex [17].
Sexually inappropriate
behavior
• A limited number of studies have investigated this
problem, almost always in men, and usually in the
form of small case series or case reports. Efficacy
has been reported with a variety of psychotropic
medications including antidepressants,
antipsychotic agents, and cholinesterase inhibitors,
as well as gabapentin, pindolol, and cimetidine.
Hormonal agents have also been used with
anecdotal reports of efficacy. However, given
their side effect profile, these are not considered
first line agents.
Hormonal agents
• While hormonal agents (eg,
medroxyprogesterone acetate,
diethylstilbestrol, estrogen, leuprolide) have
also been used with anecdotal reports of
efficacy in treating sexually inappropriate
behavior in individuals with dementia, these
are not considered first line agents given
their side effect profile
Drug Categories of Concern in
the Elderly
• Analgesics: NSAIDs are widely used; several are available without
prescription. Serious adverse effects include peptic ulceration and
upper GI bleeding; risk is increased when an NSAID is begun and
when dose is increased. Risk of upper GI bleeding increases when
NSAIDs are given withwarfarin or aspirin . NSAIDs may increase risk
of cardiovascular events and can cause fluid retention. Selective COX2 inhibitors (coxibs) cause less GI irritation and platelet inhibition than
other NSAIDs. Nonetheless, coxibs have a risk of GI bleeding,
especially in patients taking warfarin or aspirin (even at low dose) and
in those who have had GI events. Coxibs, as a class, appear to increase
risk of cardiovascular events, but that risk may vary by drug; their use
should be approached cautiously. Coxibs have renal effects
comparable to those of other NSAIDs. Monitoring serum creatinine is
necessary, especially in patients with other risk factors (eg, heart
failure, renal impairment, cirrhosis with ascites, volume depletion,
diuretic use).
Drug Categories of Concern in
the Elderly
Digoxin: Digoxin clearance decreases an average of 50% in
elderly patients with normal serum creatinine levels.
Therefore, maintenance doses should be started low (0.125
mg/day) and adjusted according to response and
serum digoxin levels. Digoxin must be used with caution
in patients with heart failure. In men with heart failure and
a left ventricular ejection fraction of ≤ 45%,
serum digoxin levels > 0.8 ng/mL are associated with
increased mortality risk. Among women with heart failure
and depressed left ventricular function, digoxin , regardless
of serum level, is associated with increased mortality risk.
Drug Categories of Concern in
the Elderly
• Antihyperglycemics: Doses of antihyperglycemics
should be titrated carefully in patients with
diabetes mellitus. Risk of hypoglycemia due to
sulfonylureas may increase with
aging. Chlorpropamide is not recommended
because elderly patients are at increased risk of
hyponatremia due to syndrome of inappropriate
antidiuretic hormone secretion (SIADH) and
because the drug's long duration of action is
dangerous if adverse effects or hypoglycemia
occurs. Risk of hypoglycemia is greater
with glyburide than with other oral
antihyperglycemics.
Beers' List—Drugs NOT to Use
Tracking Prescriptions In the Elderly
can be a Quality Measure
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Some Of the Drugs On the List
A few trade names are listed after the generic name. The medication may also be
prescribed under other names or be incorporated in another combination product.
Older people are very susceptible to adverse effects of drugs with anticholinergic
effects.
cyproheptadine (Periactin)
diphenhydramine (Benadryl)
belladonna alkaloids (Bentyl, Donnatal, many others in combination products)
Many other drugs can contribute to confusion, delirium, and other brain dysfunction
meperidine (Demerol)
methocarbamol (Robaxin)
propoxyphene (“Darvon,” Darvocet”)
propanatheline (Pro-Banthine)
barbituates
Other drugs are on the list for miscellaneous reasons.
thyroid, desiccated (Armour Thyroid)
estrogens
Commonly Used Medications
May Produce Cognitive
Impairment In Older Adults
• Many drugs commonly prescribed to older adults for a variety of
common medical conditions including allergies,hypertension, asthma,
and cardiovascular disease appear to negatively affect the aging brain
causing immediate but possibly reversible cognitive impairment,
including delirium, in older adults according to a clinical review now
available online in the Journal of Clinical Interventions in Aging, a
peer reviewed, open access publication.
Drugs, such as diphenhydramine, which have an anticholinergic effect,
are important medical therapies available by prescription and also are
sold over the counter under various brand names such as Benadryl®,
Dramamine®, Excederin PM®, Nytol®, Sominex®, Tylenol PM®,
and Unisom®. Older adults most commonly use drugs with
anticholinergic effects as sleep aids.
Pressure ulcers
• INTRODUCTION — Pressure ulcers are a
significant problem in institutionalized
elderly patients and critically ill patients,
causing pain, decreasing quality of life, and
leading to significant morbidity and
prolonged hospital stays.
• Pressure ulcers are ischemic soft tissue
injuries resulting from pressure, usually
over bony prominences.
ASSESSMENT AND
STAGING
• The treatment of pressure ulcers begins with
a comprehensive assessment of both the
patient's general medical condition and the
wound.
• Wounds should be evaluated for stage, size,
sinus tracts, necrotic tissue, exudate, and the
presence of granulation.
• Photographs of all wounds are helpful.
Staging of pressure ulcers
• Stage Description
• I Skin intact but with non-blanchable redness for >1 hour after relief
of pressure.
• II Blister or other break in the dermis with partial thickness loss of
dermis, with or without infection.
• III Full thickness tissue loss. Subcutaneous fat may be visible;
destruction extends into muscle with or without infection.
Undermining and tunneling may be present.
• IV Full thickness skin loss with involvement of bone, tendon, or joint,
with or without infection. Often includes undermining and tunneling.
• Unstageable Full thickness tissue loss in which the base of the ulcer is
covered by slough and/or eschar in the wound bed.
• Suspected deep tissue injury Purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of
underlying tissue from pressure and/or shear.
• * From the National Pressure Ulcer Advisory Panel.
GENERAL TREATMENT
PRINCIPLES
• Preventive measures, with a focus on
positioning and support to minimize tissue
pressure, should be provided for all patients,
including those with pressure ulcers. Any
ulcer development should underscore the
need to review and intensify preventive
measures that are already in place.
Treatment of pressure ulcers
• Treatment of pressure ulcers depends on the stage and
severity of the ulcer, The general approach to management
of a patient with a pressure ulcer should include the
following:
• Reduce or eliminate underlying contributing factors by
providing pressure relief with proper positioning and
support surfaces.
• Provide appropriate local wound care, which may include
debridement for patients with necrotic tissue, based on the
ulcer's characteristics.
• Consider adjunctive therapies, such as vacuum-assisted
closure
• Monitor and document the patient's progress
Monitoring
• The following parameters of care should be
monitored daily and documented
• Evaluation of the ulcer
• Status of the dressing, if present
• Status of the area surrounding the ulcer
• Presence of pain, and adequacy of pain control
• Presence of possible complications, such as
infection
• Documentation may be facilitated by using one of
the scales for healing ulcers
• Appropriate therapeutic goals should be set that
consider discharge potential, quality of life, and
prognosis.
Pressure Ulcer Scale for Healing
(PUSH)
2
• AssessmentsInstructionsAssign a subscore (cm )Total the
subscores
• Size (length x width)Measure the greatest length and width using a
centimeter ruler. Multiply the two measurements to obtain an estimate
of surface area.0 – 0Subscore
• 1 - <0.3 2 - 0.3-0.63 - 0.7-1.04 - 1.1-2.05 - 2.1-3.06 - 3.1-4.07 - 4.18.08 - 8.1-129 - 12.1-24.010 - >24
• Exudate Estimate the amount of drainage after removal of the
dressing.0 - NoneSubscore1 - Light 2 - Moderate3 - HeavyTissue type
• Assess the presence of sloughing or necrosis0 - ClosedSubscore1 Epithelial tissue 2 - Granulation tissue3 - Slough4 - Necrotic tissue
• Add together all subscores =Total score
• Changes in the score over time provide an indication of the healing
process. The score goes down with improvement and increases with
wound deterioration.
* Version 3.0 National Pressure Ulcer Advisory Panel
(www.npuap.org).
Adapted with permission from: National Pressure Ulcer Advisory
Panel. Version 3.0 Pressure Ulcer Scale for Healing (PUSH).
Healing
• Ulcers heal through a process that includes
granulation, wound contraction,
reepithelialization, and scar formation.
• Thus, a stage 4 ulcer remains stage 4
throughout the healing process.
• The practice of changing the stage as the
ulcer heals, known as reverse staging, is not
recommended
Nutrition
• Nutritional intake should be assessed. This assessment may
include protein and caloric intake, hydration status, serum
albumin and/or prealbumin, and total lymphocyte count’
Nutritional deficiencies should be corrected.
• If oral intake is not adequate to ensure sufficient calories,
protein, vitamins, and minerals, nutritional
supplementation with enteral and parenteral nutrition is
recommended to correct deficiencies. A retrospective
cohort study of 882 patients with pressure ulcers at 95
long-term care facilities demonstrated that total caloric
intake of at least 30 kcal/kg promoted healing and
decreased the size of stage 3 and 4 pressure ulcers.
• Increased dietary protein intake also promotes the healing
of pressure ulcers.
• The protein target is usually 1.5 g/kg/day, although some
authors advocate higher protein intake.
Supplements
• Data do not support nutritional
supplementation for patients who do not
have nutritional deficiencies
• Vitamin C and zinc supplementation are
commonly employed to promote healing but
their efficacy has not been conclusively
demonstrated.
• A number of small randomized trials have
evaluated the role of nutritional
supplements but methological flaws and
study size preclude confirmation of
clinically significant results.
Mattresses and tissue pressure relief
•
•
•
•
To date, there are no randomized trials available to identify whether
repositioning makes a difference in the healing rates of pressure ulcers or what
the optimal repositioning regimen would be. Nevetheless, in the absence of
data, as a practice with good face value, patients should be positioned to
minimize or avoid all pressure on the wound. Pressure-relieving support
surfaces are also helpful in reducing tissue pressure. These support devices, as
defined by the National Pressure Ulcer Advisory Panel Support Surface
Standards Initiative, are outlined below:
Non-powered support surfaces (previously known as static), such as foam, do
not require electricity. These supports can be used if the patient can assume a
variety of positions without bearing weight on the ulcer.
Overlays are an additional support surface, designed to be placed on top of
another support surface. Foam, air, or water overlays are useful for patients
who can assume a variety of positions without bearing weight on the ulcer.
Powered or dynamic support surfaces require electricity. Air currents or
mechanical rotation regulate or redistribute pressure against the body.
Examples of such beds include alternating pressure mattresses, low air loss
beds, and air fluidized mattresses. Specialized powered beds should be
considered when the patient cannot readily be repositioned, has a large ulcer or
ulcers at multiple sites, or if the pressure ulcer does not show evidence of
healing.
Stage 1 treatment
• The development of stage 1 ulcers is a
warning that more serious lesions may
follow if appropriate preventive measures
are not instituted in a timely fashion. Stage
1 ulcers may be dressed with transparent
films for protection. Most importantly,
preventive measures should be reviewed
and intensified.
Stage 2 treatment
• Stage 2 treatment — Stage 2 pressure
ulcers usually require an occlusive or
semipermeable dressing that will maintain a
moist wound environment. Wet-to-dry
dressings are avoided since these wounds
generally require little debridement.
Dressing choices
• Dressings serve to protect the wound from trauma
and contamination, and facilitate healing by
absorption of exudate and protection of healing
surfaces.
• Excess fluid causes wound maceration, while
dessication will slow epithelial cell migration.
• Many different types of dressings are available.
Although varying circumstances may favor
choosing one dressing over another, no dressing
has been shown to be consistently superior to
another in clinical trials. Factors to keep in mind
while selecting an appropriate dressing include the
presence of heavy exudate, dessication, infected or
necrotic tissue.
Stages 3 and 4
• Treatment of wound infections,
debridement of necrotic tissue, and
appropriate dressings will accelerate healing
of Stage 3 and 4 pressure ulcers.
• Surgery is necessary for some full thickness
pressure ulcers.
Dressing
choices
• Dressings serve to protect the wound from trauma
and contamination, and facilitate healing by
absorption of exudate and protection of healing
surfaces. Excess fluid causes wound maceration,
while dessication will slow epithelial cell
migration.
• Many different types of dressings are available.
Although varying circumstances may favor
choosing one dressing over another, no dressing
has been shown to be consistently superior to
another in clinical trials. Factors to keep in mind
while selecting an appropriate dressing include the
presence of heavy exudate, dessication, infected or
Ulcers with heavy exudate
• An absorptive dressing should be employed to avoid build up of
chronic wound fluid that can lead to wound maceration and inhibition
of cell proliferation and healing. An appropriate wound dressing can
remove excess wound exudate while maintaining a moist environment
to accelerate wound healing.
• Dressings with absorptive qualities include alginates, foams, and
hydrofibers.
• Calcium alginates are highly absorptive and are useful for wounds with
significant exudate. Calcium alginates are derived from brown
seaweed and form a gel on contact, promoting moist interactive
healing.
• Foams provide thermal insulation, high absorbency, and a moist
environment. They can be easily cut to shape and do not shed fibers.
Foams are useful for sloughy or exudative wounds.
• Hydrofibers can also be used for highly exudative wounds and are
highly absorbent. They are appropriate for sloughy or exudative
wounds.
Dessicated ulcers
•
•
•
•
•
Dessicated ulcers lack wound fluids, which provide tissue growth factors to facilitate
reepithelialization. Thus, pressure ulcer healing is promoted by dressings that maintain a
moist wound environment while keeping the surrounding intact skin dry. Choices for a
dry wound include saline moistened gauze, transparent films, hydrocolloids, and
hydrogels.
Saline moistened gauze that is not allowed to dry will promote a moist wound
environment, although occlusive dressings are equally effective and reduce the nursing
time required for wound care.
Transparent films provide an effective barrier for retaining moisture; they are good
secondary dressings when combined with another product for stage 3 or 4 ulcers (full
thickness wounds) or may be used alone for stage 2 ulcers (partial thickness wounds).
Films are especially useful at the later stages of wound healing when there is no
significant exudate.
Hydrocolloids generally provide an effective barrier for retaining moisture and are
useful for promoting autolytic debridement. They come in a variety of sizes and shapes
for use on different parts of the body. A comparison randomized trial of transparent
films with hydrocolloid dressing in the management of stage 2 and shallow stage 3
pressure ulcers demonstrated the transparent film dressing improved the ability to assess
the ulcer and improved patient comfort although the time to wound closure was nearly
identical between the two groups.
Hydrogels provide a high concentration of water contained in insoluble polymers and
provide a good choice for dry sloughy wounds with low levels of exudate.
Debridement
• Necrotic tissue promotes bacterial growth
and impairs wound healing. Accordingly, it
would seem that removal of necrotic tissue
by wound debridement is an important
element of pressure ulcer treatment.
Randomized trials, however, compare
different methods of debridement but have
not focused on the effectiveness of
debridement per se.
•
•
•
•
•
•
•
Debridement
Five approaches to debridement are available; they are often used in combination.
Sharp debridement involves the use of a scalpel or scissors. This is the most rapid form of
debridement; it is indicated when there is evidence of cellulitis or sepsis. Sharp debridement is also
used to remove thick eschar and when there is extensive necrotic tissue. The exception is patients
with heel ulcers covered by a thick, dry eschar. Sharp debridement is not recommended at this site,
because of the proximity of bone.
Mechanical debridement is a nonselective method of removing necrotic tissue and debris from a
wound. This is most commonly done with wet-to-dry dressings. Mechanical debridement is best for
wounds that contain thick exudate, slough, or loose necrotic tissue. Wet-to-dry dressings will remove
both nonviable and viable tissues; caution is required to avoid damaging healthy tissue.
Enzymatic debridement is done with the topical application of proteolytic enzymes such
as collagenase, fibrinolysin, and deoxyribonuclease to remove necrotic tissue. The topically applied
enzymes work synergistically with endogenous enzymes to debride the wound. These agents may
produce excess exudate and cause local irritation to the surrounding skin. Papain was used for
debridement in the past but was removed from the US market due to hypersensitivity reactions.
Autolytic debridement uses semiocclusive (transparent film) or occlusive dressings (hydrocolloids or
hydrogels) to cover a wound so that necrotic tissue is digested by enzymes normally present in
wound tissue. This often works best on wounds with minimal exudate. It should not be used in the
presence of infection.
Biosurgery or the use of maggots is another effective method of debridement. The larvae produce
enzymes to break down dead tissue without harming healthy tissue. This can be considered when
sharp debridement is contraindicated due to exposed bone, joint, or tendon. Sterile larvae of the
Lucilia sericata fly are utilized.
Debridement should stop once necrotic tissue has been removed and granulation tissue is present.
Care should be taken with respect to debridement of the ischial spine as this will potentially affect
weightbearing and can lead to breakdown of the ischium on the opposite side. Removal of both
ischial spines will increase the risk of perineal problems and the formation of urethocutaneous
fistulas.