Transcript title here - American Academy of Home Care Medicine

HBPC Clinical Safari:
Management Pearls and
Pitfalls for the “Big 5” High
Impact Conditions
Moderator:
Tom Lally, MD
Panelists:
Duane Kirskey, MD MSCE
Lynn Beatty, MD
Jon Salisbury, MD
David Skorvan, ANP
Disclosures
• Lally – Kindred Healthcare - Employee
• Skorvan – no relevant disclosures
• Beatty – Visiting Physicians Association –
Employee
• Salisbury – no relevant disclosures
• Kirksey – no relevant disclosures
Objectives
• Explain the clinical significance of the following
conditions in the home-based setting:
• CHF
• Behaviors in Dementia
• VTE
• Recurrent Falls
• Decubitus Wounds
• Discuss potential challenges of implementing best
practices in the management of these conditions in the
home-based setting.
• Identify practical ways to incorporate treatment
strategies for these conditions into home-based
medical practice.
Heart Failure at
Home
Jon Salisbury, MD
Visiting Physician Services – A member of
VNA Health Group
Heart Failure At Home
“I haven’t sent a heart failure patient to the
hospital in over 5 years”
Heart Failure
• Pathophysiologic: Inability of heart to deliver blood
and oxygen
• Clinical: Breathlessness and fatigue associated with
cardiac disease
• Associated by: Fluid retention, edema, elevated
venous pressure
• Clinical assessment seeks to answer to questions:
• Are the symptoms cardiac of non-cardiac in origin?
• If cardiac, what is the precise problem?
Diagnostic Algorithm
•
•
•
•
•
•
•
•
•
•
Dyspnea & fatigue
Previous MI
Angina
Hypertension
Valvular disease
Palpitations
(arrhythmia?)
Smoking, alcohol abuse,
family history
•
•
•
•
•
•
Dyspnea
Fatigue
Edema
Tachycardia
Rales
Raised J.V.P.
Murmur
Edema
3rd heart sound
•
•
•
•
•
EKG
CXR
Echocardiogram
CBC, CMP, BNP
Thyroid Panel
Diagnostic Algorithm
Continued
•
•
•
•
•
•
Systolic LV dysfunction (most common)
Diastolic LV dysfunction
Valvular disease
Rhythm / conduction disturbance
Pericardial / endocardial disease
Congenital heart disease
New York Heart Assoc.
Functional Classification and
Treatment
Pharmacologic Management
• ACE Inhibitors:
• Enalapril: 10mg BID
• Lisinopril: 20 – 40mg QD
• Captopril: 100 – 150mg daily (3 times daily dosing)
• B-Blockers:
• Carvedilol: 3.125 BID x 2 weeks, then double every
2 weeks to highest level tolerated (dizziness) to
max 25mg BID
• Metoprolol succinate: 25mg QD (severe HF, start
12.5mg BID)
• Bisoprolol: 1.25mg/day, max 5mg/day
• Hydralazine: 300mg/day (divided doses)
• Isorbide dinitrate: 30 – 160 mg/day
Pharmacologic Management
Continued
• Loop Diuretics:
• Furosemide: 20 – 80mg/day
• Bumetanide: .5 – 2mg/day
• Metolazone: 2.5 – 5mg/day (often 3X/week)
• Aldosterone Antagonists:
• Spironolactone: 25 – 50mg/day
• Eplerenone: 25 – 50mg/day
• Digoxin: .125 - .25mg/day
• ARB’s
• Valsartan: 40mg/BID (start), 80 – 60mg/BID
maintenance
• Candesartan: 4mg/day start, target 32/day
• Losartan: (not approved but beneficial)
50mg/day
Non-Pharmacologic Treatment
• Diet: weight reduction, nutritional status, Na+ intake
• Fluid Intake: about 2 liters/day
• Smoking: stop or reduce
• Exercise: regular moderate physical activity should be
encouraged
• Alcohol: in moderation
• Vaccinations: influenza and pneumococcal
What We Also Do
• Education, education, education!
• Patient and family involvement and decision
making
• Assess the patient for depression and stressors
• Involvement of home nursing care, PT,
medications management, CHF programs
• Telemonitoring
Education
• Explain clearly what heart failure is
• Explain medications, how they work, dosing
schedule, etc…
• Explain how their disease may be just as
easily be well managed at home
• Reassure patient that the diagnosis of heart
failure does not have to be a death sentence
• Include family / caregivers in education
process
Additional Management
• Daily weights:
• Gain > 3lbs, take extra Lasix first, then call us!
• Sliding scale of diuretics:
• Involve patient and family in dosing schedules
• What triggers ER visits?
• Usually dyspnea, suggest use of pulse oximetry for
reassurance
• Anxiety / panic: frequently will use a short acting
anxiolytic
• Have occasionally utilized MSIR for air hunger /anxiety
• Treat depression
• Have discussion about Palliative Care and Hospice
Care
Conclusion
• Heart failure can be well treated at home
• Admission and readmissions can be significantly reduced
• Follow treatment guidelines
• Involve patient, family, and caregivers in decision making
• Educate!
• Discuss hospice / palliative with critical patients
• Be reassuring that there can be life after diagnosis of
heart failure!
Dementia
What is dementia?
Normal Aging
Chart Title
120%
100%
99%
90%
85%
80.00%
Axis Title
80%
70.00%
60%
40%
20%
0%
Age 20
Age 40
Age 60
Age 80
Axis Title
Normal Aging
Dementia
Column1
Age 100
Mild Cognitive Impairment
Chart Title
120%
Cognitive Function
100%
99%
90%
85%
80.00%
80%
MCI
60%
70.00%
40%
20%
0%
Age 20
Age 40
Normal Aging
Age 60
Column2
Age 80
Column1
Age 100
Dementia
Chart Title
120%
100%
99%
90%
85%
80.00%
Axis Title
80%
70.00%
60%
40%
20%
0%
Age 20
Age 40
Age 60
Age 80
Axis Title
Normal Aging
Dementia
Column1
Age 100
Dementia Subtypes
Subtype
% of dementia
patients afflicted
Progressive
Life Expectancy
from onest
Alzheimer’s
65%
Yes
12
Vascular
30%
Maybe
?
Lewy Body
10%
Yes
6
Frontal Temporal
10%
Yes
6
ETOH
<5%
Maybe
?
Parkinson’s
Dementia
<3%
Probably
?
Other….
Understanding Alzheimer’s
• Notebook Analogy: memories are stored
much like writing notes in a notebook.
• You need both a pen and a notebook!
• Page one are your oldest historical
memories, (Age three)
• Memories are stored in sequential order on
subsequent pages.
• Onset of Alzheimer’s is when the pen begins
to run out of ink!
• Next the pages are torn from the notebook,
starting from the back and slowly moving
forward.
Behaviors, Non-Pharmaceutical
Treatments
• Engagement, (preventive)
• Games, hangman vs trivial pursuit…..
• Activities: art, music
• Outings
• Meals
• Redirection
• The first chapter of their memory book
• Distraction
• One to one sitter
• Music
• Sensory room
• MORE INFO AT:
https://www.effectivehealthcare.ahrq.gov/ehc/products/559/2199/
dementia-agitation-aggression-report-160314.pdf
Pharmaceutical Interventions
for Behaviors
1.
2.
3.
4.
5.
6.
Make sure there are no reversible causes!
Diagnose the subtype of dementia
Exhaust non pharm interventions
Implement robust behavioral tracking system
Consider medical options
Evaluate urgency, is there high short term
risk?
7. Select a pharmaceutical intervention
8. Discuss and document Risk Benefit
discussion
9. NOTHING IS FDA APPROVED!!!!
Classification of Behaviors in
Dementia
Primary
Symptom
Examples
Medication Class
Psychotic
Paranoia, delusions,
halluciantions, confabulation
Antipsychotic (many
options)
Neurotic
Anxiety, depression, OCD
???
Impulsive
Physical or verbal abuse without
warning (no filter)
Antiepileptic, Valproic
Acid or Carbamazepine
Pain Response
Pain can cause a variety of
responses and should be
considered as a potential cause of
any class of behaviors
Pain Medication, APAP to
MSO4
Agitation
General agitation that cannot be
classified elsewhere. Yelling and
pacing are common examples.
Citalopram, escitalopram,
memantine
Antipsychotic Choice
Antipsychotic
FDA
approved
Movement
Side
Effects
Activating or
Sedating
Dose Range
Cost
Liquid Form
Available
Frequency
Quetiapine
NO
Low
Sedating
12.5 –
400
mg/day
$$$
No
BID-TID
Risperidone
NO
High
Activating
0.25 – 4
mg/day
$$$
Yes
BID
Olanzapine
NO
High
2.5 – 10
mg/day
$$
No
QD-BID
Haloperidol
NO
High
0.5 –
6mg/day
₵₵
No
BID-TID
Summary
• Rule out other causes, infection, medication, metabolic…?
• Investigate and document specifics about the behaviors,
behavioral log?
• Risk Stratify the patient and behavior
• Select medication and sig that best matches patient needs
• Review and document Informed Consent while establishing
realistic expectations
• Educate staff or family about what to monitor
• Schedule a close follow up, generally <10 days
• Evaluate effect with staff and family
• Repeat process as needed….
• ALWAYS CONSIDER WEANING OR DISCHARGE OF
THESE MEDS. We give all stable patients a weaning trial
after 30 days of stability.
Venous
Thromboembolic
Disease
Duane Kirksey, MD MSCE
Cleveland Clinic Medical Care at Home
Venous Thromboembolic
Disease (VTE)
• HBPC Prevalence and Significance
• Best Practices
• Diagnosis
• Treatment / Management
• Challenges in Home Based Primary Care
• When to Refer / Send to Hospital
VTE: Prevalence
• 3rd Leading Cause of Death1
• Prevalence directly associated with Age2
• Risk Factors
• Virchow’s Triad:
• Stasis
• Hypercoagulability
• Endothelial Injury
VTE: Prevalence
• Home Bound Adults
• Lower Risk Than Community Dwelling
Adults3,4
• Risk Factors
• Respiratory Infection, Recent General
Surgery, Mobility Limitation5
• Spinal Cord Injury (Paraplegia / Quadriplegia)
• Low Risk after 90 days from injury6
VTE: Significance
• Home Bound Adults
• Cross-sectional Study of Homebound Adults
• 18% with asymptomatic DVT7
• No cases of symptomatic DVT
VTE: Best Practice
• Diagnosis
• Venous Ultrasound
• Mobile Radiology
• Trained Clinician
VTE: Best Practice
• Acute Management / Treatment
• Anti coagulation
• Low Molecular Weight Heparin (LMWH)
• Direct Oral Anticoagulants (DOA)
• Long Term Management / Treatment
• Vitamin K Agonist (VKA)
• Direct Oral Anticoagulants
VTE: Home Based
Practice
• Diagnostic Challenges
• Availability of Ultrasound
• Pulmonary Embolism
• Acute Management Challenges
• LMWH Delivery
• DOA Cost / Formulary
VTE: Home Based
Practice
• Long Term Management
• VKA
• Monitoring
• Interactions
• DOA8,9
• Chronic Kidney Disease
• Weight Extremes
• CYP3A4 and P-gp Interactions
VTE: Referral
• Diagnostics Unavailable
• DOA to start if clinical suspicion and obtain
diagnosis later
• Clinically Unstable
• Hypoxia
• Hypotension
VTE References
1
Goldhaber SZ. Venous Thromboembolism: epidemiology and magnitude of the problem. Best Practice & Research Clinical
Haematology 25 (2012): 235-242.
2
Martinez C, Cohen AT, et al. Epidemiology of first and recurrent venous thromboembolism: A population-based cohort study in
patients without active cancer. Blood Coagulation, Fibrinolysis and Cellular Haemostasis. 2014:112 255 – 263
3
Ahmed J, Ornstein K, Dunn A, Gilatio P. Incidence of Venous Thromboembolism in a Homebound Population. J Community Health
2013 38:480-485
4
Arpais G, Ambrogi F, et al. Risk of Venous Thromboembolism in Patients Nursed at Home or in Long-Term Care Residential
Facilities. Int J of Vascular Medicine, 2011
5
Leibosn CL, Peterson TM, et al. Rethinking Guidelines for VTE Risk Among Nursing Home Residents: A population-Based Study
Merging Medical Record Detail with Standardized Nursing Home Assessments. CHEST 2014;146(2):412-421
6
Jones T, Ugalde V, et al. Venous Thromboembolism after spinal cord injury: Incidence, Time Course, and Associated Risk Factors in
16,240 Adults and Children. Arch Phys Med Rehabil December 2005 Vol 86 2240 – 2247
7
Arpais G, Ambrogi F, et al. Risk of Venous Thromboembolism in Patients Nursed at Home or in Long-Term Care Residential
Facilities. Int J of Vascular Medicine, 2011
8
Cabral KP, Ansell JE The role of Factor Xa inhibitors in venous thromboembolism treatment. Vascular Health and Risk Management
2015:11 117-123
9
Adams SS, et al. Comparative Effectiveness of Warfarin and New Oral Anticoagulants for the Management of Atrial Fibrillation and
Venous Thromboembolism: A Systematic Review. Annals of Internal Medicine 2012;157:796-807
Falls in the Elderly –
The Sensory
Connection
Lynn Beatty, MD
Demographics
In patients over 65:
•
•
•
•
20%of falls result in severe injuries (fracture or TBI)
2.5 million ER visits annually
700,000 patients/year hospitalized due to fall
>95% of hip fractures are caused by falling (usually
falling sideways)
• Direct medical costs for fall injuries = $34 billion
annually (2/3 are for hospital costs)
-CDC Home and Recreational Safety, Falls among older adults, updated1-20-16
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
Approach to Management of
Fall Risk
Manage Modifiable Risk Factors
• Environmental hazards
• Medications
• Metabolic factors
• Musculoskeletal factors
• Neuropsychologic factors
• Sensory impairment
invisible and often overlooked
• Disease/Illness related
Moncada, Management of Falls in Older Persons, A Prescription for
Prevention, American Family Physician 2011;84(11):1267-1276
Sensory Impairment
• 3 key sensory components of balance function:
• Somato-sensory (touch, vibratory,
proprioception)
• Visual
• Vestibular – the most “invisible” but also
highly treatable
Vestibular Dysfunction
From 2001-2004 35.4% of US adults >40 had
vestibular dysfunction (69 million Americans)
• Increased prevalence with age (mediated by
vestibular dysfunction)
• 40.3% lower risk in individuals with > high
school education
• 70% higher among people with diabetes
• Borderline increased risk in hypertension
• 8-fold increased risk of falling if symptomatic
with dizziness; subclinical vestibular dysfunction
also associated with increased risk
Agrawal, et al, Disorders of Balance and Vestibular function in US Adults, Data from the
NHANES 2001-2004, Arch Intern Med, 169(10):938-944, May 25, 2009
Vestibular Intervention
Vestibular evaluation
Vestibular exercises
Dynamic Visual Acuity
(DVA)
 Stare at object while
shaking head; if
object appears to
shake or becomes
blurry = deficit
Modified CTSiB
 Stand upright under 4
sensory conditions x
30 s each
Stare at object
while shaking
head; while
nodding head.
Goal = 5 minutes
total per day;
safe to do alone
on couch; PT can
help increase
challenge &
duration
Principles of Wound Care
David Skovran, ANP
Mount Sinai Visiting Doctors Program
Prevalence
• An estimated 2.5 million pressure ulcers are
treated each year in acute care facilities in the
United States
• Prevalence of pressure ulcers is widespread
in all settings with estimates of 10% to 18% in
acute care, 2.3% to 28% in long term care,
and up to 29% in home care (National
Pressure Ulcer Advisory Panel, 2009)
Agency for Healthcare
Research and Quality
(2006 Analysis of pressure ulcers)
• Pressure ulcer related hospitalizations ranged
from 13 to 14 days and cost $16,755 to
$20,430 per patient compared with average
stay of 5 days and cost of about $10,000
• Pressure ulcers were a secondary diagnosis in
457,800 hospital admissions, up from 245,600
in 1993. These patients admitted primarily for
pneumonia, infections, or other medical
problems, either developed pressure ulcers
before or after admission
Pressure Ulcer Staging
• Stage/Category I ulcers emerge without
frank denudation or ulceration of skin that
is red and nonblanchable.
• Stage/Category II ulcers are partial
thickness wounds involving the epidermis
and dermis
• Stage/Category III ulcers appear as fullthickness skin loss involving damage or
necrosis of subcutaneous fat that may
extend down to, but not through,
underlying fascia
Pressure Ulcer Staging
continued
• Stage/Category IV ulcers present with full
thickness tissue loss; deep tissue layers such as
muscle, tendon, ligaments or bone are visible.
• Unstageable ulcers present as full thickness skin
loss but the true depth of the ulcer is obstructed by
necrotic tissue in the form of slough or eschar.
• Suspected Deep Tissue Injury (DTI)
characteristically presents as either a blood-filled
blister or ecchymosis with purple or maroon
colored intact skin
Stage 1
Stage 2
Stage 3
Stage 4
Stage 4
Pressure Ulcer Prevention
• Turning and positioning
• Frequently turn and reposition lying
patients every 2 hours and seated
patients every 15 minutes.
• Friction and Shear forces:
• Prolonged upright positioning and
repositioning of the body without surface
barriers such as a sheet can subject the
body to both persistent and dynamic
shear forces.
Pressure Ulcer Prevention
• Support Surfaces
Group 1: considered preventative –
composed of gels, foam, water or air
Group 2: Composed of powered low air loss
mechanism
Group 3: Composed of fluidized-air
and particulates such as silicone beads
Cleansing Wounds
• Clean with each dressing change
• Minimizing trauma to the surrounding skin.
• Recommended that the ulcers be cleaned with noncytotoxic cleansers such as saline or water
• In general, povidone-iodine solution, hydrogen
peroxide, isopropyl alcohol and sodium hypochlorite
(bleach) marketed as Dakin’s solution should be
avoided given their high destruction of viable tissue
and imposed delay in wound healing except in
select circumstances.
Debriding the Wound
1. Autolytic:
1. the use of dressings and formulations that promote the
body’s natural enzymes to continually remove cellular
debris from the wound
2. Usually done by any dressing that keeps wound moist, such
as hydrocolloids and hydrogels
2. Enzymatic:
1. Enzymes degrade and remove necrotic tissue (examples:
Collagenase, Sodium Chloride marketed as Hypergel)
2. Used when large amounts of slough or with some eschar
3. Some sting/inflammation
Debriding the Wound
3. Non-enzymatic debridement: Sodium
hypochlorite (bleach) or marketed as Dakin’s
Solution™
• Topical, broad spectrum antimicrobial with
efficacy in the clinical setting of MRSA,
Vancomycin-resistant enterococcus and
other antibiotic resistant bacteria, is widely
used in a variety of difficult wound types
• It is often used at ¼ strength to limit
toxicity to surrounding tissue
Debriding the Wound
• Sharp Debridement
• Indicated when chemical debridement has
been unsuccessful or when more rapid
tissue closure is desired
• Necrotic tissue is removed using a scalpel,
scissors, forceps, or curette
Choice of Wound Care
Dressings
• Stage 1 ulcers and Suspected Deep Tissue
Injury
• In areas of moisture or irritation from urine
or feces, an moisture barrier such as vitamin
A/D cream or zinc oxide may be used.
• A thin adhesive barrier such as a
transparent dressing or thin hydrocolloid is
advised to limit friction.
Choice of Wound Care
Dressings
• Hydrocolloids (marketed as:
DuoDerm, Comfeel, Tegasorb,
Restore):
• Hydrophillic colloid
particles bound to
polyurethane foam
• Remain in place for 5-7
days. Often used to “seal”
a wound that is otherwise
clean in order to promote
healing.
• NOT for heavy drainage
Choice of Wound Care
Dressings
• Stage 2 Ulcers:
•
Superficial and minimal drainage wounds
•
•
•
•
Petrolatum dressing (example: Xeroform)
Hydrocolloid
Sodium based (example: Hydrogel)
More Exudative
•
Packing with calcium alginate (example:
Algisite) or sodium
carboxymethylcellulose (example:
Hydrofibers)
Choice of Wound Care
Dressings
• Sodium Based – (example: Hydrogels)
• Water-based, non adherent crossed linked
polymer, hydrophilic. Keep the wound bed
moist and cool
Choice of Wound Care
Dressings
• Petrolatum – (example:
Xeroform)
• A sterile, fine mesh
gauze impregnated with
a blend of 3% Bismuth
Tribromophenate USP
Petrolatum
• Helps maintain a moist
wound environment
Choice of Wound Care
Dressings
• Calcium Algisite
• Calcium-sodium salts of
alginic acid (seaweed)
• Useful to fill cavities, pockets,
undermining, moisture
retentive
• Not recommended for use in
wounds with low drainage as
the dressing can dry out the
wound
• Also available impregnated
with silver, offers additional
barrier to bacterial growth
Choice of Wound Care
Dressings
• Hydrofibers (marketed as
Aquacel):
• How it works: Like an alginate, the
absorption of wound fluid causes this
synthetic carboxymethylcellulose
fiber to create a gel with enhanced
absorption over alginates.
• Available impregnated with silver
• The benefit over alginates is that the
frequency of wound care dressings
can be several days longer.
Choice of Wound care
Dressings
• Stage III and IV Ulcers: treated similarly
• The goal is to fill the crater bed with the right
material to promote absorption while maintaining a
moist, bacteria-free wound environment
• Less Exudative:
• Pack with Hydrogels
• More Exudative
• Pack with Alginates or Hydrofibers
• Consider Silver impregnated fibers
Venous Stasis Ulcers
• Chronic leg ulcers caused by chronic venous
insufficiency (CVI) are the second most common
wound-type treated in home-based primary care
settings.
• Poorly functioning vein valves or venous occlusion
causes CVI
• Risk factors for CVI include age (over the age of
30), family history, female sex, repeated venous
thromboses, multiple pregnancies and obesity.
Behavioral factors including prolonged standing
and sitting, and heavy lifting
Venous Stasis Ulcers
• Treatment:
• Compression is the mainstay of effective
venous stasis ulcer care.
• There are two main options for
compression:
• Paste bandage impregnated with zinc
oxide, glycerin and gelatin – marketed as
the Unna boot
• Multi-layer compression bandaging
system – marketed as Profore™
Wound References
•
Haesler, E (Ed.). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and
Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference
Guide. [Internet] 2014. Available from: http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-1614-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf.
•
Krapfl, LA, Gray, M. Does Regular Repositioning Prevent Pressure Ulcers? Journal of Wound, Ostomy
and Continence Nursing 2008; 35(6): 571 - 577.
•
Alvarez OM, Kalinski C, Nusbaum J, Hernandez L. Pappous E, Kyriannis C, Parker R, Chrzanowski G,
Comfort C. Incorporating Wound Healing Strategies to Improve Palliation (Symptom Management) in
Patients with Chronic Wounds. J Pall Med. 2007; 10(5): 1161-1189.
•
Kelechi T, Johnson JJ. Guideline for the Management of Wounds in Patients With Lower-Extremity Venous
Disease. JWOCN 2012;39(6):598-606
•
Shi L, Carson D. Collagenase Santyl ointment: a selective agent for wound debridement. J Wound Ostomy
Continence Nurs. 2009;37(6 Suppl):S12–16.
•
Nisbet HO, Nisbet C, Yarim M, Guler A, Ozak A. Effects of Three Types of Honey on Cutaneous Wound
Healing. Wounds.2010;22(11):275-283.
•
Barnea Y, Weiss J, Gur E. A review of the applications of the hydrofiber dressing with silver (Aquacel Ag®)
in wound care. Therapeutics and Clinical Risk Management 2010;6:21-7.
•
Eberhardt RT, Raffetto JD. Chronic Venous Insufficiency. Circulation. 2014;130:333-46.
•
O’meara S, Cullum N, Nelson EA, Dumville JC. Cochrane Database Syst Rev. 2012 Nov
14;11:CD000265.
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