The annals of long-term care : the official journal of the American Medical Directors Association最新文献

More than 100 medications were approved by the US Food and Drug Administration as new drugs or for new indications in 2014 and 2015. Several of the new drugs may benefit older adults, but adverse events and pharmacokinetic changes due to aging must be considered. This article will focus on three recently approved drugs that are marketed for chronic conditions that can affect older adults: suvorexant, for treatment of insomnia; edoxaban, for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and for treatment of venous thromboembolism; and droxidopa, for treatment of symptomatic neurogenic orthostatic hypotension. Information about indications, mechanisms of action, dosing, efficacy, and safety are reviewed. The place of each agent in therapy for older adults is also discussed.

Residential care facilities (RCF) provide assistance to older adults who cannot live independently, but it is unclear whether these residents have retired from driving. Here, we characterize older adults living in RCFs who still drive from a national cross-sectional survey of residents (2010 National Survey of Residential Care Facilities), representing ~733,000 adults living in RCFs such as assisted living facilities and personal care homes. Key resident characteristics were health, function, mobility and community activity indicators, which could be associated with increased driving risk. Of 8,087 residents, 4.5% (95%CI=3.9-5.1) were current drivers. Many drivers were older than 80 years (74%, 95%CI=67-79), in very good health (31%, 95%CI=25-38) or good health (35%, 95%CI=29-42), and had a median of two medical conditions. Most were independent with activities of daily living, though some needed assistance with walking and used gait devices. Given these results, RCF staff and healthcare providers need a heightened awareness of factors associated with driving risk to promote safety of older drivers and provide resources for likely transition to other transportation.

Pain is underrecognized and undertreated in the long-term care (LTC) setting. To improve the management of pain for LTC residents, the authors implemented a quality improvement (QI) initiative at one LTC facility. They conducted a needs assessment to identify areas for improvement and designed a 2-hour educational workshop for facility staff and local clinicians. Participants were asked to complete a survey before and after the workshop, which showed significant improvement in their knowledge of pain management and confidence in their ability to recognize and manage residents' pain. To measure the effectiveness of the QI initiative, the authors performed a chart review at baseline and at 3 and 8 months after the workshop and evaluated relevant indicators of adequate pain assessment and management. The post-workshop chart reviews showed significant improvement in how consistently employees documented pain characteristics (ie, location, intensity, duration) in resident charts and in their use of targeted pain assessments for residents with cognitive dysfunction. The proportion of charts that included a documented plan for pain assessment was high at baseline and remained stable throughout the study. Overall, the findings suggest a QI initiative is an effective way to improve pain care practices in the LTC setting.

The purpose of this study is to describe nursing home staff knowledge regarding delirium detection and the most common causes of delirium. Specific aims that guided this study include identifying the rate of nurse recognition of delirium and delirium superimposed on dementia (DSD), including different motoric subtypes of delirium, using standardized case vignettes, and exploring what nursing home staff describe as the potential causes of delirium. The study showed overall poor recognition of delirium and DSD, which did not improve over time. Interventions have the potential to increase the early detection of delirium and DSD by the staff and warrant development.

Little information about suicidal ideation and behavior in long-term care (LTC) facilities is available. Nonetheless, the implementation of the Minimum Data Set 3.0 requires that LTC facilities screen their residents for suicide risk and have protocols in place to effectively manage residents' responses. In this article, the authors briefly discuss the risk factors of suicide in the elderly and the problems that suicidal ideation and behavior pose in the LTC environment. The authors explain issues that arise when trying to manage suicide risk in the elderly LTC population with general, traditional approaches. These inherent issues make it difficult to develop an effective protocol for managing suicide risk in LTC facilities, leading the authors to propose their own framework for assessing and managing suicide risk in the LTC setting.

Urinary tract infections (UTIs) are commonly suspected in residents of long-term care (LTC) facilities, and it has been common practice to prescribe antibiotics to these patients, even when they are asymptomatic. This approach, however, often does more harm than good, leading to increased rates of adverse drug effects and more recurrent infections with drug-resistant bacteria. It also does not improve genitourinary symptoms (eg, polyuria or malodorous urine) or lead to improved mortality rates; thus, distinguishing UTIs from asymptomatic bacteriuria is imperative in the LTC setting. This article provides a comprehensive overview of UTI in the LTC setting, outlining the epidemiology, risk factors and pathophysiology, microbiology, diagnosis, laboratory assessment, and management of symptomatic UTI.

A substantial reduction in hospitalization rates has been associated with the implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement intervention using the accompanying paper-based clinical practice tools (INTERACT II). There is significant potential to further increase the impact of INTERACT by integrating INTERACT II tools into nursing home (NH) health information technology (HIT) via standalone or integrated clinical decision support (CDS) systems. This article highlights the process of translating INTERACT II tools from paper to NH HIT. The authors believe that widespread dissemination and integration of INTERACT II CDS tools into various NH HIT products could lead to sustainable improvement in resident and clinician process and outcome measures, including enhanced interclinician communication and a reduction in potentially avoidable hospitalizations.

Older adults commonly take nonsteroidal anti-inflammatory drugs (NSAIDs) chronically. Studies of older adults show that chronic NSAID use increases the risk of peptic ulcer disease, acute renal failure, and stroke/myocardial infarction. Moreover, chronic NSAID use can exacerbate a number of chronic diseases including heart failure and hypertension, and can interact with a number of drugs (eg, warfarin, corticosteroids). Preferred analgesics in older adults that may have a lower risk of these adverse drug reactions include acetaminophen, a nonacetylated salicylate (eg, salsalate), a short half-life NSAID (eg, ibuprofen), or low-dose opioid/opioid-like agents in combination with acetaminophen (in appropriate patients).