Year in Review 2018 Fellows from Duke Wake

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Year in Review 2018 Fellows from Duke, Wake Forest, and Blue Ridge

Year in Review 2018 Fellows from Duke, Wake Forest, and Blue Ridge

Reduction of Viral Respiratory Transmission in Long-Term Care Serena Wong, DO

Reduction of Viral Respiratory Transmission in Long-Term Care Serena Wong, DO

Background • Healthcare personnel (HCP) have a higher risk of contracting influenza than other

Background • Healthcare personnel (HCP) have a higher risk of contracting influenza than other adults, and are at high risk of transmitting infection in LTC • Vaccination of HCP can prevent transmission and outbreaks, and many facilities have instituted policies for annual vaccination • However, rates are suboptimal: • 2015 2016: 79% overall but only 69% for HCP in LTC facilities • Goal of study: survey HCP to assess knowledge, attitudes, and practices regarding infection prevention policies and influenza vaccination

Methods • 120 bed LTC facility in St. Louis, MO – long term residential

Methods • 120 bed LTC facility in St. Louis, MO – long term residential care and shorter term skilled care • Mandatory influenza vaccination policy in place since 2008 • Survey administered to all staff, voluntary participation, anonymous • October – December 2015 • Assessed several domains • Knowledge and attitudes of prevention – Likert scale • Prevention practices – always/usually/sometimes/never performed • Knowledge of facility infection prevention policies – multiple choice

Demographics of respondents • 67. 1% female, 10. 9% did not answer • 42.

Demographics of respondents • 67. 1% female, 10. 9% did not answer • 42. 9% response rate (73 of 170 full and part time staff) • 57. 5% had more direct patient contact, 28. 8% had less (10% did not answer) • 61. 6% had >10 years of experience, and 24. 7% had >30 years

Results – knowledge and attitudes • Knowledge • 20% did not agree that respiratory

Results – knowledge and attitudes • Knowledge • 20% did not agree that respiratory infections are a major problem in LTC • 23% did not agree that hand hygiene helps protect patients • Attitudes • 76% thought they had enough training to recognize respiratory infections • 71% thought the facility had a good way of identifying patients on precautions • 35. 4% of women thought the facility makes it easy for them to stay home when they are sick, compared to 75% of men

Results – infection prevention practices • Hand hygiene • 96. 9% reported practicing hand

Results – infection prevention practices • Hand hygiene • 96. 9% reported practicing hand hygiene before entering a patient’s room, and 100% reported doing so upon leaving a room • 76. 5% reported that their coworkers performed hand hygiene before entering a patient’s room, and 85. 7% upon leaving • Staying home when sick • Only 58. 5% reported staying home when sick • 43. 8% reported that their coworkers stayed home when sick • 52. 9% with less patient contact reported staying home when sick, compared to 37. 5% with more patient contact

Results – knowledge of facility practices • 47. 5% correctly identified standard and droplet

Results – knowledge of facility practices • 47. 5% correctly identified standard and droplet precautions for flu • 59% with more patient contact vs 35. 3% with less patient contact • 85. 2% knew this included gown and gloves • Only 71. 7% knew that droplet precautions require face mask

Results – attitudes • Most (73 85%) HCP agreed that the influenza vaccine helps

Results – attitudes • Most (73 85%) HCP agreed that the influenza vaccine helps prevent the flu and is safe • 71. 8% would get the influenza vaccine even if it wasn’t mandated • Mostly to protect themselves and their families • Reasons given by those who would not get the vaccine: • 35% don’t like shots • 25% don’t want to put chemicals into their body • 20% do not believe the vaccine works well enough

Take-home points • Although compliance with influenza vaccination at this LTC was good, there

Take-home points • Although compliance with influenza vaccination at this LTC was good, there was room for improvement • There were still gaps in knowledge and understanding, even among HCPs with > 10 years of experience • Processes that can be improved: • Availability and accessibility of hand hygiene supplies, gloves, and masks • Improved infection prevention signage • Improvements in sick leave practices

Background • The Healthy People 2020 goal for influenza vaccination is 90% • In

Background • The Healthy People 2020 goal for influenza vaccination is 90% • In the 2014 2015 season, reported rates in LTC were 38 55% • Misconceptions: vaccine “causes” flu, lack of effectiveness, fear of side effects • Organizational: no formal policy, poor record keeping, staff turnover, lack of incentives, lack of communication of rates of vaccination to staff • Goal of study: increase influenza vaccination rates of HCP in LTC by designing and implementing evidence based interventions tailored to the LTC setting

Methods – baseline • 4 LTCFs in Illinois, Indiana, Minnesota, and Wisconsin • Baseline

Methods – baseline • 4 LTCFs in Illinois, Indiana, Minnesota, and Wisconsin • Baseline assessments: • Interviews with administrators • Determine policies, goals, and tracking mechanisms already in place • Identify problems the LTCFs would like to solve • Survey for nursing staff (CNAs, LPNs, RNs) • Demographics, including whether they had health insurance, children • Reasons for getting vaccine: free, avoid contracting and transmitting flu, concern for missing work due to illness • 59% of unvaccinated HCPs believed influenza vaccine can transmit influenza

Methods – Intervention • Customized based on baseline results • Educational programming • LTC

Methods – Intervention • Customized based on baseline results • Educational programming • LTC specific posters • In service emphasizing risk of disease and the safety and efficacy of the vaccine • Tracking mechanisms • Electronic roster • Four foot tall gauge to help communicate progress to staff • Worksheets to assist with program implementation

Results • Overall vaccination rate of HCPs increased from 50% to 85% • HCP

Results • Overall vaccination rate of HCPs increased from 50% to 85% • HCP family members’ rates also increased (variable rate across sites) • Absenteeism due to respiratory illness decreased (variable rate across sites) • Administration interview highlights: • • Using the vaccination roster to track employee status was useful Kick off events helped them vaccinate large numbers of employees Incentives helped engage staff Continued use of rosters and incentives helped contribute to high vaccination rates even in the setting of high staff turnover

Results • Staff survey result highlights: • 60% reported encouraging others to receive the

Results • Staff survey result highlights: • 60% reported encouraging others to receive the vaccine • 43% discussed vaccination with residents • Those who received the educational intervention: • Were more likely to have discussed vaccination with others • Encouraged others to get the vaccine • Intended to receive the vaccine in the coming year • The facility with more HCP with English as a second language and diversity in their staff had the least improvement in vaccination rate

Take-home points • Engage stakeholders in increasing vaccination through multimodal approach • Stronger policies

Take-home points • Engage stakeholders in increasing vaccination through multimodal approach • Stronger policies • Clear communication with HCPs • Public accountability • High turnover may limit the sustainability of these interventions, which have to be repeated in subsequent seasons (and even within the same season)

Anticoagulation Navin Ramlal, MD Geriatrics Fellow Duke University

Anticoagulation Navin Ramlal, MD Geriatrics Fellow Duke University

Background • Risk of Atrial Fibrillation increases with age and is estimated to be

Background • Risk of Atrial Fibrillation increases with age and is estimated to be over 10% in those 80 and over. • Those with NAVF have a 4 5 X increased risk of thromboembolic stroke than those without NAVF • Only 35% of those over 85 with NAVF receive VKA (Vitamin K antagonists) with the main limitation to treatment being fear of bleeding • Safety of DOACs in NAVF has not been determined in a prospective study and this trial seeks to do that

Methods • Prospective Cohort trail • Eligibility: • 74+ years old • Atrial fibrillation

Methods • Prospective Cohort trail • Eligibility: • 74+ years old • Atrial fibrillation dx by EKG and NAVF confirmed by ECHO • On anticoagulation over the last three months Study Outcomes • Vital Status • Bleeding episodes • Thrombotic events

Methods • 2 Regression models were created • Crude model • Adjusted Model: Variables

Methods • 2 Regression models were created • Crude model • Adjusted Model: Variables related to anticoagulation Treatment and Bleeding risk

Results • Patients administered Dicumarol and the following DOACs: Rivoraxaban, Dabigatran and Apixiban •

Results • Patients administered Dicumarol and the following DOACs: Rivoraxaban, Dabigatran and Apixiban • Patients on DOACs had higher frequency of smoking, comorbidities , disabilities in ADLs and IADLs, mobility limitations and higher mortality at follow up • Incidence of bleeding: • 19. 2/100 years on DOACs • 13. 7 on Dicumarol

Results • Bleeding and Major Bleeding Events • HR of 1. 60 (Dicumarol) vs

Results • Bleeding and Major Bleeding Events • HR of 1. 60 (Dicumarol) vs 2. 22 ( DOACs) ( non statistically significant) • Disappeared after adjustment for Clinical characteristics • Non Major Bleeding Events • DOACs vs Dicumarol ( Crude 1. 56, Adjusted 1. 46) (non statistically significant)

Conclusion • Risk of bleeding was higher on DOACs vs VKA, however, these results

Conclusion • Risk of bleeding was higher on DOACs vs VKA, however, these results were statistically insignificant • Rates of GI bleed was higher with DOACs vs VKAs , however, other causes of bleeding were similar • Treatment with DOACs vs VKAs requires consideration of patient factors and should be done in a shared decision model

2 nd Article

2 nd Article

Background • AF common in elderly adults and warfarin is a very common choice

Background • AF common in elderly adults and warfarin is a very common choice for AC, however, studies have shown residents spend a significant portion of time outside therapeutic window TTR in one study was 54% with 35% below and 11% above TTR respectively • Aim of this study was to describe quality of warfarin use in LTCs and investigate potential predictors of oral anticoagulant use

Methods • Cross sectional study of 13 LTCs in Ontario • Primary Endpoint :

Methods • Cross sectional study of 13 LTCs in Ontario • Primary Endpoint : time in therapeutic INR range • Secondary Outcomes: a. ) Quality of warfarin use , b. )prevalence of DOAC use , c. ) Predictors or warfarin or DOAC use • Residents were classified into High risk for bleeding and bleeding events were ascertained by review of medical records for major or minor bleed

Methods • Target INR range was 2. 0 to 3. 0 • Those above

Methods • Target INR range was 2. 0 to 3. 0 • Those above 3. 0 and those who were not taking warfarin or absent from the facility were excluded from the study

Results • Characteristics of study population: 70% women, mean age 85 ± 8 yrs

Results • Characteristics of study population: 70% women, mean age 85 ± 8 yrs and majority was Caucasian.

Results • Most Common risk factors for bleeding were decreased Hematocrit, Hospitalization, ER visit,

Results • Most Common risk factors for bleeding were decreased Hematocrit, Hospitalization, ER visit, Hx of major bleeding and INR >4. 5 • TTR at the 13 facilities studied ranged from 51. 7% to 71. 3% • Average portion of days within TTR was 64% and Average portion of tests within TTR was 59. 6%

Discussion • Warfarin does not offers no benefit over antiplatelet therapy for patients with

Discussion • Warfarin does not offers no benefit over antiplatelet therapy for patients with AF at TTR ranging from 58 65% • 1 in 3 residents with clear indication for Anticoagulation were not receiving anticoagulation • Small improvements in TTR have been seen in comparison to other studies, however, there is still a very far divide to bridge

Take Home Points • Oral anticoagulants continue to be used sub optimally in the

Take Home Points • Oral anticoagulants continue to be used sub optimally in the LTC setting • 7% and 12% increase in TTR can reduce chance of major hemorrhage by 1 event every 100 patient years and reduce chance of thromboembolic event by 1 event every 100 patient years respectively • Those with good TTR control (> 75%) vs those with poor TTR control (<60%) has statistically significant decreases in MI, All cause death, stroke or systemic thromboembolism and major bleed

Thank you • Questions?

Thank you • Questions?

Antibiotic Stewardship David Schlientz, MD Geriatrics Fellow Duke University

Antibiotic Stewardship David Schlientz, MD Geriatrics Fellow Duke University

Background – The Numbers • 15, 600 LTCFs in the United States providing daily

Background – The Numbers • 15, 600 LTCFs in the United States providing daily medical and residential care for 1, 400, 000 persons. • 3, 200, 000 persons per year reside in one of these facilities for some period of time. • Approximately 75% of residents who stay in a LTCF for 6 months or longer will receive at least one course of antibiotics. • More than half of the antibiotic courses in LTCFs are unnecessary, and even when necessary, are often excessively broad spectrum or administered for longer than necessary.

The Solution - ASPs

The Solution - ASPs

Hospital ASP vs. LTCF ASP • ASPs in LTCFs are not as robust as

Hospital ASP vs. LTCF ASP • ASPs in LTCFs are not as robust as those in the hospital for a variety of reasons. • Important is to designate a leader of the program; this will often be the infection preventionist or director of nursing. Pharmacist may be appropriate for this role if available.

Pearls • A decision support tool, or a list of formulary preferred antibiotics for

Pearls • A decision support tool, or a list of formulary preferred antibiotics for the variety of infectious indications can be helpful. • Foster a prescribing etiquette which requires the length of therapy, indication, drug, and dose with every antibiotic order, as well as clinical indications for antibiotic testing. • Facility protocol on UTI testing/prescribing, for instance, can yield large dividends in reduction of prescribing.

Infections • Skin and soft tissue: third most common in LTCF residents. Surveys of

Infections • Skin and soft tissue: third most common in LTCF residents. Surveys of European and U. S. VA’s report about 22% of infections are SSTIs. Tables to follow. • C. diff: clinical criteria are 3 or more unformed stools within 24 hours and a stool test positive for toxigenic C. diff. Oral vancomycin is first line. Clindamycin, fluoroquinolones, cephalosporins (et al) are high risk for C. diff. • Norovirus: 90% of norovirus associated deaths occur in adults 65 or older. Majority of outbreaks occur in LTCFs. As few as 100 virions can lead to disease. LTCFs will recognize a norovirus outbreak when 2 or more cases fulfill the Kaplan Criteria: vomiting in more than half of affected persons, mean (or median) incubation period of 24 to 48 hours, mean (or median) duration of illness of 12 to 60 hours, and no bacterial pathogen identified in stool culture.

Infections (continued) • Pneumonia; A retrospective review of nearly 300 LTCF residents admitted through

Infections (continued) • Pneumonia; A retrospective review of nearly 300 LTCF residents admitted through the emergency department with a diagnosis of pneumonia described dyspnea as the most common presenting symptom (67%), followed by mental status change (51%), cough (49%), and fever (45%). • Diagnostic approach: pulse oximetry, chest radiography.

Best for Last: UTIs

Best for Last: UTIs

Background • Antibiogram development for a LTCF is challenging due to the low number

Background • Antibiogram development for a LTCF is challenging due to the low number of cultured isolates. Possible approaches: • • 1. extending the isolate data beyond 1 year 2. combining isolate data geographically 3. using a nearby acute care facility’s antibiogram as a proxy 4. collapsing isolate data

The Motivation • The Centers for Medicare and Medicaid Services “proposed that the facility’s

The Motivation • The Centers for Medicare and Medicaid Services “proposed that the facility’s infection prevention and control program must also include an antibiotic stewardship program that includes antibiotic use protocols and systems for monitoring antibiotic use and recording incidents” under Reform of Requirements for Long Term Care facilities. • CDC encourages nursing homes to start implementing at least 1 AMS activity and then gradually incoporating additional strategies. • So, a facility specific antibiogram would be in support of this.

 • Clinical and Laboratory Standards Institute (CLSI) publishes the M 39 Analysis and

• Clinical and Laboratory Standards Institute (CLSI) publishes the M 39 Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data; Approved Guideline, which is a good baseline for creation of antibiograms. • Cut off of 30 isolates to generate data is often recommended (think back to statistics and generating the normal curve), but in practice this is extremely difficult for any given LTCF to achieve.

Approach 1: Extending the Antibiogram Data Beyond 1 Year • May be the easiest

Approach 1: Extending the Antibiogram Data Beyond 1 Year • May be the easiest approach. CLSI M 39 promotes this approach to overcome the specific problem of a low number of isolates. • Pitfall is that changing bacterial resistance patterns can alter the interpretation of the data. However, depending on the rate of change here, it may still be practical to go back a few years with isolate data. • Approach may work best with a stable resident population.

Approach 2: Creating a Regional/Geographic Antibiogram • Combine data from several facilities within the

Approach 2: Creating a Regional/Geographic Antibiogram • Combine data from several facilities within the geographic area. • Practically, residents transfer often to and from nearby hospitals. Can think of this as them being microbiologically, “in communication. ” • Thus, transmission of bacteria and MDROs is a two way street. • LTCF residents acquire MDRO infections in LTCFs 60% of the time, and in hospitals 40% of the time (roughly speaking). • This approach relies on the assumption of regional susceptibility patterns (and that resistances emerge within a region consistently), which for a variety of factors may not necessarily be the case. • Also relies on good communication/stakeholdership between the parent hospitals and the LTCFs.

Approach 3: Using Antibiograms of Nearby Hospitals • “The apple doesn’t fall far from

Approach 3: Using Antibiograms of Nearby Hospitals • “The apple doesn’t fall far from the tree. ” • Assume the parent hospitals’ antibiograms. • Certainly convenient, as many hospitals will generate antibiograms annually already. • Again, relies in the assumption of similarity between the parent and child facilities.

Approach 4: Collapsed Antibiograms • Approach based on grouping similar organisms. • For example,

Approach 4: Collapsed Antibiograms • Approach based on grouping similar organisms. • For example, collect data by specimen site (i. e. urine, skin, sputum, etc. ) • In this approach, number of total isolates can be used instead of bacterial species. • Thus the interpreter selects and antibiotic with activity against several similar species most likely to be causative in an infection. • As an antibiogram is a tool for empiric decision making, this may be the most functionally useful approach. • i. e. , a collapsed urinary antibiogram would allow selection of an antibiotic most likely to be effective against the aggregate pool of urinary pathogens collected from a single LTCF.

 • Sorry for writing the phrase, “pool of urinary pathogens. ”

• Sorry for writing the phrase, “pool of urinary pathogens. ”

Comparison of Approaches • As there is no agreed upon standard for the development

Comparison of Approaches • As there is no agreed upon standard for the development of an LTCF antibiogram, which of the above strategies to pursue is facility dependent.

Thank you for your time.

Thank you for your time.

Advanced Care Planning Elspeth Clark, DO Geriatrics Fellow Duke University

Advanced Care Planning Elspeth Clark, DO Geriatrics Fellow Duke University

Background • Patients with advanced dementia often receive treatments that may be of little

Background • Patients with advanced dementia often receive treatments that may be of little clinical benefit and inconsistent with care preferences. • Traditional advanced care planning discussions are limited by: • Challenges of patients with dementia envisioning complex scenarios • Inconsistent physician counseling • Limitations of literacy and language • Solution: Video advanced care planning?

Methods • Cluster randomized control trial in 64 Boston area Nursing Homes • Eligibility:

Methods • Cluster randomized control trial in 64 Boston area Nursing Homes • Eligibility: • Nursing home with more than 45 beds • Patients >65 yo • Dementia with GDS score of 7 • Length of stay >90 days • English speaking proxy

Methods • Intervention: • In person interview, proxy asked initial level of care preference

Methods • Intervention: • In person interview, proxy asked initial level of care preference • 12 minute ACP (advanced care planning) video was shown to proxies • Describes typical features of advanced dementia • Discusses 3 levels of care • Intensive, basic, and comfort care • The proxy’s preferred level of care after viewing the video was documented and then sent to the resident's clinician. • Every 3 months proxies were asked the level of care preference (for 12 months) • Control: • Proxies were read descriptions of the levels of care and asked their preferences • Usual ACP practices

Results Primary outcome: No difference between the groups.

Results Primary outcome: No difference between the groups.

Results Primary Outcome – no difference within groups Secondary Outcome – More likely to

Results Primary Outcome – no difference within groups Secondary Outcome – More likely to forgo tube feeding when shown the video.

Results No change in do not hospitalize orders. More proxies decided to forgo tube

Results No change in do not hospitalize orders. More proxies decided to forgo tube feeding. No change in plans for IV hydration No change in documented goals of care discussions.

Conclusion • GOC video intervention • Did not change decisions regarding level of care

Conclusion • GOC video intervention • Did not change decisions regarding level of care • Did decrease plans regarding tube feeding • 97. 1% of proxies stated the would definitely or probably recommend the video to others.

Review of 26 publications Aim: To identify factors that motivate or restrain engagement among

Review of 26 publications Aim: To identify factors that motivate or restrain engagement among ethnic minorities in ACP in order to promote ACP. Four categories of factors that either facilitated or impeded ACP access • Socio demographic factors • Health status, literacy, and experiences • Cultural values • Spirituality

Socio-demographic Factors • Age, gender, education, income, socio economic status are predictors of awareness/engagement

Socio-demographic Factors • Age, gender, education, income, socio economic status are predictors of awareness/engagement in ACP. • A qualitative study with Puerto Ricans and Dominicans suggested being younger as a barrier to engagement in ACP. • Another qualitative study with Mexican and Puerto Rican women with cancer identified a lower level of education and less income as barriers to completing an advanced directive • A cross sectional survey with Latino older adults found a positive relationship between income, education, and completion of advanced directives.

Health Status, Literacy, and Experiences • Worse health status is associated with higher completion

Health Status, Literacy, and Experiences • Worse health status is associated with higher completion of advanced directives among Latino older adults, Asians, and Native Hawaiians. • Ethnic minorities consistently reported low health literacy regarding ACP. (awareness, knowledge, how to complete such documents) • No differences between ethnic minorities and non Hispanic Whites in informal discussions regarding ACP Educational intervention studies • Significant differences found in formal ACP were effective in improving • Designating a durable power of attorney • Completing a living will attitudes (in Latino older adults) and completion of ACP (in Blacks and Asian Americans).

Cultural Values • Decision making about ACP is typically a family centered collective process

Cultural Values • Decision making about ACP is typically a family centered collective process for ethnic/racial minorities – especially in Asians and Latinos. • Family member’s opinions and thoughts are valued or even prioritized over patient preferences in regards to ACP • Role of acculturation is also a factor in ACP among Asian Americans and Latinos

Spirituality • Particularly important factor in Latinos and Blacks. • Blacks who believed in

Spirituality • Particularly important factor in Latinos and Blacks. • Blacks who believed in God expressed reluctance towards ACP because of the view that such directives may lead to death happening sooner. • A qualitative study found that Dominicans and Puerto Ricans believed that ACP is about planning in advance for things beyond their control so ACP may be unnecessary.

Take-home points • In ACP with proxies of patients with advanced dementia a video

Take-home points • In ACP with proxies of patients with advanced dementia a video based support tool did not change goals of care. • However, it did decrease tube feeding plans of care • Four categories of factors identified that either facilitated or impeded ACP access among ethnic or racial minorities: • • Socio demographic factors Health status, literacy, and experiences Cultural values Spirituality • More research is needed to find interventions to overcome barriers to promote ACP for ethnic minorities

Antipsychotic Deprescribing Monica Stout, MD Geriatrics Fellow Duke University

Antipsychotic Deprescribing Monica Stout, MD Geriatrics Fellow Duke University

Antipsychotic Deprescribing A novel approach to deprescribing in long term care settings: The SMART

Antipsychotic Deprescribing A novel approach to deprescribing in long term care settings: The SMART campaign. • The Indiana Safer Medication Administration Regimens and Treatment (SMART) campaign is a collaborative effort funded by the Indiana State Department of Health. • Collaboration between the Indiana State Department of Health, Purdue University, Indiana University, the Indiana Society for Post Acute and Long Term Care, Industry Association leaders, and Signature Health. CARE corporation

Antipsychotic Deprescribing A novel approach to deprescribing in long term care settings: The SMART

Antipsychotic Deprescribing A novel approach to deprescribing in long term care settings: The SMART campaign. • A team of consulting geriatricians and geriatric pharmacists will use direct physician to prescriber communication • Facilities will train with Purdue QI engineers: • They will select their project parameters, focus, and process improvement area

Antipsychotic Deprescribing Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study.

Antipsychotic Deprescribing Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study. Longitudinal cohort study of long term care residents with behavioral and psychological symptoms of dementia initially on antipsychotics.

Antipsychotic Deprescribing Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study.

Antipsychotic Deprescribing Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study. Participants: 139 residents taking regular antipsychotic medication for ≥ 3 months without primary psychotic illness Intervention: Education/training of health care staff and a deprescribing protocol.

Antipsychotic Deprescribing Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study.

Antipsychotic Deprescribing Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study. Outcomes Measured: Number of participants on antipsychotics, medication substitutions, changes in BPSD, social engagement, falls, and hospitalizations. Results: • Number of participants on regular antipsychotics over 12 months reduced by 81. 7% • No change in antidepressant use or PRN antipsychotic use. There was in increase in PRN benzodiazepines, but this was not statistically significant. • No changes in BPSD. • Decrease in falls and hospitalizations, but not statistically significant.

References • Abrahamson, et al. “A novel approach to deprescribing in long term care

References • Abrahamson, et al. “A novel approach to deprescribing in long term care settings: The SMART campaign. ” Research in Social and Administrative Pharmacy. 13(2017) 1202 1203. • Brodaty, et al. “Antipsychotic Deprescription for Older Adults in Long term Care: The HALT Study. ” JAMDA. 19 (2018) 592 600.

Depression Tyler Mc. Queen, MD Geriatrics Fellow Wake Forest University

Depression Tyler Mc. Queen, MD Geriatrics Fellow Wake Forest University

Background • Depression commonly occurs in older adults cared for in institutional settings •

Background • Depression commonly occurs in older adults cared for in institutional settings • “Attentively Embracing Story” theory • Application of story theory to address health challenges and reduce stress • Care receivers share their stories with caregivers who sensitively and attentively listen • Three steps: • Intentional dialogue • Connecting with self in relation • Creating ease • Can a story centered care intervention based on this theory reduce depressive symptoms, improve cognitive function, and improve heart rate variability?

Methods • Parallel design, single blind (outcome evaluator), random assignment study enrolling older adults

Methods • Parallel design, single blind (outcome evaluator), random assignment study enrolling older adults in two Taiwanese long term care facilities • Eligibility • Older than 65 years old • Clear consciousness, normal hearing, conversant • Not on antidepressants • Without diagnosis of dementia • Without loss of loved one in past 3 months

 • Intervention • IG received story centered care intervention program once a week

• Intervention • IG received story centered care intervention program once a week for 4 weeks • CG received a health consultation once a week for 4 weeks • Measures • Geriatric Depression Scale (primary) • Short Portable Mental Status Questionnaire • 5 min heart rate variability • Outcomes measured at baseline, post intervention, 1 month, and 3 months

Results • Reduction of depressive symptoms • Significant decrease in GDS 15 scores for

Results • Reduction of depressive symptoms • Significant decrease in GDS 15 scores for the IG compared with the CG: • Post intervention (regression coefficient 1. 612, p <0. 001, 95%CI 0. 08 0. 48) • 1 month follow up (regression coefficient 1. 621, p=0. 001, 95%CI 0. 08 0. 50) • 3 month follow up (regression coefficient 1. 816, p=0. 006, 95%CI 0. 05 0. 59) • Improvement in cognitive function • No significant difference in decrease in SPMSQ post intervention • SPMSQ scores significantly reduced for IG compared to CG at 1 and 3 months (respectively, regression coefficient 0. 409, p=0. 009, 95%CI 0. 49 0. 91 and regression coefficient 0. 345, p=0. 025, 95%CI 0. 53 0. 96) • No significant difference between groups in terms of heart rate variability measures

Conclusions • A “Story Centered Care Intervention Program” reduced depression in older adults living

Conclusions • A “Story Centered Care Intervention Program” reduced depression in older adults living in long term care facilities with sustained effects for up to 3 months • A non pharmacological approach to addressing depression in this population • Decreases in SPMSQ scores demonstrate improved cognitive function with this intervention • Recollection of past events stimulates memory functions and improves orientation • Future studies could broaden observed population and could focus on more objective measures

Background • Prior research has shown non pharmacologic interventions including music therapy to be

Background • Prior research has shown non pharmacologic interventions including music therapy to be complementary modalities in reducing depression and delaying deterioration of cognitive function • Previously mixed findings on the effectiveness of animal assisted therapy or dog assisted therapy (DAT) with respect to depression, mood, and social interaction • What effect does DAT have on mood, affect, and illness perception among residents of long term care facilities?

Methods • Randomized allocation of residents from northern Italy long term care facility •

Methods • Randomized allocation of residents from northern Italy long term care facility • Eligibility • Age 65 90 years, in institution for at least 2 months • GDS 15 score of 5 or higher • MMSE score of 19 or higher • Exclusion: multisensory impairment

Methods • Intervention • IG received DAT, which involved a 30 min session once

Methods • Intervention • IG received DAT, which involved a 30 min session once weekly for 10 weeks (dog, handler, and observer) • CG did not participate in DAT (or other substitute) • Measures (upon completion of 10 weeks) • Geriatric Depression Scale (GDS 15) • Generalized Anxiety Disorder 7 (GAD 7) • Positive and Negative Affect Schedule (PANAS) • Illness Perception Questionnaire Revised (IPQ R) • Satisfaction Questionnaire • Numeric Pain Rating Scale (NPRS, scale 0 10)

Results • GDS 15 results were significant showing a mean decrease of 3. 10+/

Results • GDS 15 results were significant showing a mean decrease of 3. 10+/ 2. 18 (p=0. 0011) between IG and CG • Changes in anxiety and positive and negative affect were not significant • Reduction in reported pain was not significantly different between groups • Overall satisfaction for treatment group was 4. 89 on a 1 5 scale

Conclusions • DAT was effective in reducing depressive symptoms with a sizeable effect •

Conclusions • DAT was effective in reducing depressive symptoms with a sizeable effect • The treatment group had positive emotional responses towards encounters and reported high satisfaction • Further study could explore the effect of DAT on elderly individuals with more severe cognitive impairment

Pain Management Kathleen Marshall, MD Geriatric Fellow Carolinas Healthcare System Blue Ridge

Pain Management Kathleen Marshall, MD Geriatric Fellow Carolinas Healthcare System Blue Ridge

Can We Quickly and Thoroughly Assess Pain with the PACSLAC-II? A Convergent Validity Study

Can We Quickly and Thoroughly Assess Pain with the PACSLAC-II? A Convergent Validity Study in Long-Term Care Residents Suffering from Dementia Mélanie Ruest, Monique Bourque, Sarah Laroche, Marie-Philippe Harvey, Marylie Martel, Kayla Bergeron-Vézina, Catherine Apinis, Dominique Proulx, Thomas Hadjistavropoulos, Yannick Tousignant-Laflamme, Guillaume Léonard Research Centre on Aging, Faculty of Medicine and Health Sciences, University of Sherbrooke, Quebec Canada

Background • Both Dementia and Chronic pain are significant health problems among older adults

Background • Both Dementia and Chronic pain are significant health problems among older adults in LTC • The evaluation of pain in patients with dementia is challenging • This may lead to inadequate analgesic treatment of pain in this population • There are several pain assessment scales available to recognize and estimate pain in elderly patients with dementia • PACSLAC II (shorter version) • PAINAD

Background: Study Objectives • Assess the relationship between the PACSLAC II and the PACSLAC

Background: Study Objectives • Assess the relationship between the PACSLAC II and the PACSLAC • Assess the relationship between the PACSLAC II and the PAINAD • Hypothesis: The PACSLAC II would be highly correlated with both the PACSLAD and the PAINAD • Document and compare the time required to complete and score each assessment scale • Hypothesis: Scoring time would be longest for PACSLAC, then PACSLAC II, and shortest would be PAINAD

Methods Participant recruitment: LTC centers in southeastern Canada Chart Review Age 50+ Diagnosis of

Methods Participant recruitment: LTC centers in southeastern Canada Chart Review Age 50+ Diagnosis of Dementia Score of 2 or 3 on Communication section of Functional Autonomy Measurement System • Unable to answer yes/no 4. Able to be transferred safely by nursing staff • • • 1. 2. 3. 36 Women, 10 Men Mean age 83

Methods: Assessment tools • Domains of nonverbal behaviors recommended by the American Geriatric Society

Methods: Assessment tools • Domains of nonverbal behaviors recommended by the American Geriatric Society for assessment: • • • 1. Facial expressions 2. Verbalizations/vocalizations 3. Body Movements 4. Changes in interpersonal interactions 5. Changes in activity patterns 6. Mental status changes

Methods: Assessment Tools PACSLAC-II PAINAD Development 2004, Fuchs Lucelle 2014, Chan et al 2001,

Methods: Assessment Tools PACSLAC-II PAINAD Development 2004, Fuchs Lucelle 2014, Chan et al 2001, Warden et al Number of items 60 31 5 Scoring Absent or present Scale of 0 2 #of AGS Domains 6 6 3 Validated Yes Yes

Procedures • 3 independent, trained evaluators randomly assigned to an assessment scale (PACSLAC, PACSLAC

Procedures • 3 independent, trained evaluators randomly assigned to an assessment scale (PACSLAC, PACSLAC II, or PAINAD) • Simultaneously observed pts during a transfer or mobilization • Immediately completed assessment forms and recorded time

Results: Correlations between Pain Assessment Tools • Correlational analyses (Pearson r) used to quantify

Results: Correlations between Pain Assessment Tools • Correlational analyses (Pearson r) used to quantify relationships between tools (0 negligible to 1 highly correlated) • PACSLAC to PACSLAC II: 0. 613 • PACSLAC II to PAINAD: 0. 645 • PACSLAC to PAINAD: 0. 625

Results: Scoring Times

Results: Scoring Times

Conclusions • The PACSLAC II is a valid and appropriate pain assessment scale for

Conclusions • The PACSLAC II is a valid and appropriate pain assessment scale for seniors with limited ability to communicate • The PACSLAC II is shorter to administer than the PACSLAC, but significantly longer than the PAINAD. • Finding a balance between too few and too many items to evaluate can be challenging • Standardized reporting of pain levels by nursing staff improves communication among providers, and may benefit LTC residents through improved recognition and treatment of pain

Long-acting opioid initiation in US nursing homes Jacob N. Hunnicutt, Anne L. Hume, Christine

Long-acting opioid initiation in US nursing homes Jacob N. Hunnicutt, Anne L. Hume, Christine M. Ulbricht, Jennifer Tjia, Kate L. Lapane Department of Quantitative Health Sciences, University of Massachusetts Medical School Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island 2018, 1 8

Background • CDC guidelines for nonmalignant chronic pain warn against initiating long acting opioids

Background • CDC guidelines for nonmalignant chronic pain warn against initiating long acting opioids in those without tolerance • Increased risk of respiratory depression and death • In US Nursing homes, 6% of all residents receive LA opioids (2012) • 17. 8% of residents on any opioids receive LA opioids • Prior studies have shown 9 39% of opioid naïve patients being started on opioid therapy were initially prescribed LA opioids • This study sought to examine the frequency of LA opioid initiation among all residents starting opioid therapy

Methods • Cross sectional study using national claims data from 2011 to 2013, including

Methods • Cross sectional study using national claims data from 2011 to 2013, including Minimum Data Set 3. 0 and Medicare Part D • 183, 735 fee for service Medicare beneficiaries, long stay nursing home residents (>90 days) initiated on long or short acting opioids • Excluded: ** • • 1. no MDS assessment within 120 days 2. skilled nursing care in past 90 days 3. provider based facilities, free standing skilled nursing facilities 4. <50 years of age 5. Pts with cancer or receiving hospice care 6. comatose 7. no data on resident characteristics

Methods • Opioid initiation: first Part D opioid prescription claim w/ no prior claims

Methods • Opioid initiation: first Part D opioid prescription claim w/ no prior claims in past 60 days. Opioids classified as short or long acting • Estimated average daily dose in oral morphine equivalents (OME) • Examined geographic variation by state and then by hospital referral regions • Examined variation in resident characteristics based on MDS 3. 0 assessment

Results Long acting opioids were prescribed to 2. 2% of residents initiating opioids. Of

Results Long acting opioids were prescribed to 2. 2% of residents initiating opioids. Of those: 82. 2% (!) initiated transdermal fentanyl For short acting opioids, hydrocodone (42. 5%) and tramadol (31%) were most commonly prescribed Doses < 50 OME/day were most common

Results: regional variation 0. 6% Lousiana 7. 5% South Dakota Northeast, northern Midwest and

Results: regional variation 0. 6% Lousiana 7. 5% South Dakota Northeast, northern Midwest and northern West

Results: Regional variation by HRR 0% in multiple HRRs 9. 5% in Great Falls,

Results: Regional variation by HRR 0% in multiple HRRs 9. 5% in Great Falls, MT

Results: Patient Characteristics Increased odds of LA opioid initiation • Older age (> 95

Results: Patient Characteristics Increased odds of LA opioid initiation • Older age (> 95 v 65 74, OR 1. 45) • Female sex (OR 1. 16) • Severe cognitive impairment (OR 1. 35) • Severe physical limitations (OR 2. 13) • Self reported pain (OR 1. 16) • Staff assessed pain (OR 1. 59) Decreased odds of LA opioid initiation • Non Hispanic Black v Non Hispanic White (OR 0. 70) • Hispanic/Latino v non Hispanic White (OR 0. 64)

Results • Rates of initiation of LA opioids is higher in nursing home residents

Results • Rates of initiation of LA opioids is higher in nursing home residents than in US veterans with chronic pain (1. 9%), commercially insured persons (0. 5%), older adults with Medicare Advantage (0. 9%), and disabled adults with Medicare (1. 9%) • Study strengths: large, national sample; evaluated geographic variation and resident characteristics • Study limitations: use of prescription claims (may overestimate use), no documentation of how meds were used (prn or scheduled), potential to have included pts receiving hospice care, study did not account for meds obtained from sources other than Medicare Part D

Conclusions • In the US, 2. 2% of long stay residents initiating opioids in

Conclusions • In the US, 2. 2% of long stay residents initiating opioids in 2011 2013 were prescribed long acting opioids • Proportion of people initiated on LA opioids varied geographically • Certain characteristics were associated with being initiated on LA opioids: older age, female sex, non Hispanic white, severe cognitive or physical impairment, staff or self reported pain • Long acting opioid initiation is lower than previously documented in nursing homes. • Improvement is possible, especially by region and pt characteristics.

- Transition of Care Review Sara Movaghar DO Geriatrics Fellow @ Blue Ridge Geriatrics

- Transition of Care Review Sara Movaghar DO Geriatrics Fellow @ Blue Ridge Geriatrics – Morganton, NC

Background • The elderly are subject to more transition of care complications than the

Background • The elderly are subject to more transition of care complications than the rest … why? For starters, older adults account for a larger % of transfers between health care sites Many have some form of cognitive impairment or are very frail making them less able to participate in said process • So what? Transition of care ‘complications’ can lead to adverse outcomes i. e. readmissions, longer rehab stay, increased costs, oh and then there’s death too!

Purpose • If using a videoconference program called Extension for Community Health Outcomes –

Purpose • If using a videoconference program called Extension for Community Health Outcomes – Care Transitions (ECHO-CT) that connects an interdisciplinary hospital based team with clinicians at SNF reduces: Patient mortality Hospital readmission SNF length of stay 30 day health care costs

Methods • Prospective cohort study • From January 2014 to December 2014*** • Comparing

Methods • Prospective cohort study • From January 2014 to December 2014*** • Comparing 1 year outcomes of SNF participating in ECHO CT program to those receiving standard of care • Eligibility Inclusion: all patients d/c from hospital to short term rehab (<100 days) Exclusion: patients with missing data, or not participating in comparable facility in terms of size, quality rating, or significant baseline differences in facility case mix

Intervention – ECHO-CT Video Conference • Sessions were discrete, secure • Conducted weekly for

Intervention – ECHO-CT Video Conference • Sessions were discrete, secure • Conducted weekly for 1. 5 hrs • 15 min face to face discussion between hospital and SNF teams Hospital team: hospitalist facilitator, pharmacist, SW, project manager SNF team: nurses, facility doctor/ACP, and occasionally PT • Discussed hospital course, update on patient’s condition, review of meds, and challenges/questions related to care plan

Results

Results

Results

Results

Limitations • Unable to assess root cause of rehospitalization or prolonged LOS • Not

Limitations • Unable to assess root cause of rehospitalization or prolonged LOS • Not randomized, room for cofounding bias • Unable to ascertain if any beds marked for short term were actually used for long term use (facilities matched per total bed size) • Misclassification of in patient’s designation of short term rehab or as long term care • Differences in care delivery and number of patients per provider as well as practice styles could not be standardized

Conclusion • Overall … Video communication platform improved interdisciplinary teamwork between discharging and receiving

Conclusion • Overall … Video communication platform improved interdisciplinary teamwork between discharging and receiving facilities is cost effective investment of resources for HCS and can improve patient outcomes.

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Background/Objective • Persons with dementia (Pw. D) account for large % of SNF utilizers

Background/Objective • Persons with dementia (Pw. D) account for large % of SNF utilizers • Understanding experience of hospital to SNF transitions for Pw. D is critical to identifying potentially modifiable RFs that may impact care quality and post hospital outcomes • SNF nurses play important role in this process • Objective: To examine SNF nurses’ perspectives regarding experiences and needs for Pw. D during hospital to SNF transitions To identify factors related to quality of these transitions

Methods • Grounded Dimensional Analysis (GDA) study • Using individual and focus group interviews

Methods • Grounded Dimensional Analysis (GDA) study • Using individual and focus group interviews with nurses from 11 SNFs • Open ended questions focusing exclusively on factors that are unique to Pw. D • Interviews/focus groups led by one or two members of study team – typically an RN and/or Geri NP • Both were Ph. D trained with extensive experience with GDA

Results • Experiences and needs of Pw. D during hospital to SNF transitions Preparing

Results • Experiences and needs of Pw. D during hospital to SNF transitions Preparing Pw. D for the transition Obtaining detailed personal/social history and developing tailored behavioral/social care plan Preparing individualized physical environment prior to transfer • Factors impacting quality of transitions for Pw. D Communication about dementia related behavioral symptoms Control over admission decisions Caregiver engagement during transition Role of timing in transitions for Pw. D • Perceived misalignment between hospital pressure and transitional care needs of Pw. D

In Prepping the Pw. D for Transition

In Prepping the Pw. D for Transition

Obtaining detailed personal/social history and developing tailored behavioral/social care plan

Obtaining detailed personal/social history and developing tailored behavioral/social care plan

Preparing individualized physical environment prior to transfer

Preparing individualized physical environment prior to transfer

Communication about dementiarelated behavioral problems

Communication about dementiarelated behavioral problems

Control over admission decisions

Control over admission decisions

Caregiver engagement during the transition

Caregiver engagement during the transition

Perceived misalignment between hospital pressure and transitional care needs of Pw. D • Most

Perceived misalignment between hospital pressure and transitional care needs of Pw. D • Most salient areas of conflict: • Hospital time pressures to d/c patients quickly • Differences in degree of emphasis on medical and social/behavioral needs • Differing views regarding impact of transparency about behavioral symptoms and associated care needs • Different perspectives regarding what defines a successful transition

Discussion …. Implications • SNF nurses perceive hospital to SNF transitions for Pw. D

Discussion …. Implications • SNF nurses perceive hospital to SNF transitions for Pw. D as challenging, resource intensive, and generally poor in quality • For more successful transitions, existing health systems must recognize specific needs and tailor transition process accordingly • Hospitals and SNFs must work hand in hand to optimize this with real time, bidirectional communication btw settings, ensuring planning time is adequate, and involving patient and caregivers • Hospitals should be held accountable for facilitating this communication • More studies needed to assess impact on unmet transitional care needs

Questions. Concerns. Criticisms. Thank You For Your Attention

Questions. Concerns. Criticisms. Thank You For Your Attention