Management of Orthostatic Hypotension in the Hospitalized Patient: A Narrative Review.

Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of hospitalizations, which exponentially increases in the geriatric population. We present a management plan based on a systematic literature review and understanding of the underlying pathophysiology and relevant clinical pharmacology. Initial treatment measures include removing offending medications and avoiding large meals. Clinical assessment of the patients' residual sympathetic tone can aid in the selection of initial therapy between norepinephrine "enhancers" or "replacers." Role of splanchnic venous pooling is overlooked, and applying abdominal binders to improve venous return may be effective. The treatment goal is not normalizing upright blood pressure but increasing it above the cerebral autoregulation threshold required to improve symptoms. Hypertension is the most common associated comorbidity, and confining patients to bed while using pressor agents only increases supine blood pressure, leading to worsening pressure diuresis and orthostatic hypotension. Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program are crucial in reducing hospital stay.

Local Passive Heat for the Treatment of Hypertension in Autonomic Failure.

Background Supine hypertension affects a majority of patients with autonomic failure; it is associated with end-organ damage and can worsen daytime orthostatic hypotension by inducing pressure diuresis and volume loss during the night. Because sympathetic activation prevents blood pressure (BP) from falling in healthy subjects exposed to heat, we hypothesized that passive heat had a BP-lowering effect in patients with autonomic failure and could be used to treat their supine hypertension. Methods and Results In Protocol 1 (n=22), the acute effects of local heat (40-42°C applied with a heating pad placed over the abdomen for 2 hours) versus sham control were assessed in a randomized crossover fashion. Heat acutely decreased systolic BP by -19±4 mm Hg (versus 3±4 with sham, P<0.001) owing to decreases in stroke volume (-18±5% versus -4±4%, P=0.013 ) and cardiac output (-15±5% versus -2±4%, P=0.013). In Protocol 2 (proof-of-concept overnight study; n=12), we compared the effects of local heat (38°C applied with a water-perfused heating pad placed under the torso from 10 pm to 6 am) versus placebo pill. Heat decreased nighttime systolic BP (maximal change -28±6 versus -2±6 mm Hg, P<0.001). BP returned to baseline by 8 am. The nocturnal systolic BP decrease correlated with a decrease in urinary volume (r=0.57, P=0.072) and an improvement in the morning upright systolic BP (r=-0.76, P=0.007). Conclusions Local heat therapy effectively lowered overnight BP in patients with autonomic failure and supine hypertension and offers a novel approach to treat this condition. Future studies are needed to assess the long-term safety and efficacy in improving nighttime fluid loss and daytime orthostatic hypotension. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02417415 and NCT03042988.

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly.

BACKGROUND: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions. METHODS: This is a quality improvement report, the geriatric patient-aligned care team (GeriPACT) at Tennessee Valley Healthcare System (TVHS) participated in ongoing quality improvement (Plan, Do, Study, Act (PDSA)) cycles during teamlet meetings. Post home discharge follow-up for GeriPACT patients was provided by proactive telehealth communication by the Registered Nurse (RN) care manager and nurse practitioner. Periodic operations data obtained from the Data and Statistical Services (DSS) coordinator informed the PDSA cycles and teamlet meetings. RESULTS: at baseline (July 2018-June 2019) the 30-day all-cause readmission for GeriPACT was 21%. From July to December 2019, 30-day all-cause readmissions were 13%. From January to June 2020, 30-day all-cause readmissions were 15%. CONCLUSION: PDSA cycles with sharing of operations data during GeriPACT teamlet meetings and fostering a shared responsibility for managing high-risk patients contributes to improved outcomes in 30-day all-cause readmissions.

Prevalence of Spasticity in Nursing Home Residents.

OBJECTIVES: To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services. METHODS: Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency. RESULTS: Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ2 = 51.72, P < .001), which was driven by lower limb spasticity (χ2 = 14.56, P = .006). CONCLUSIONS AND IMPLICATIONS: These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities.

Reducing Antipsychotic Medication Use in Nursing Homes: A Qualitative Study of Nursing Staff Perceptions.

Background and Objectives: The purpose of this study was to use qualitative methods to explore nursing home staff perceptions of antipsychotic medication use and identify both benefits and barriers to reducing inappropriate use from their perspective. Research Design and Methods: Focus groups were conducted with a total of 29 staff in three community nursing homes that served both short and long-stay resident populations. Results: The majority (69%) of the staff participants were licensed nurses. Participants expressed many potential benefits of antipsychotic medication reduction with four primary themes: (a) Improvement in quality of life, (b) Improvement in family satisfaction, (c) Reduction in falls, and (d) Improvement in the facility Quality Indicator score (regulatory compliance). Participants also highlighted important barriers they face when attempting to reduce or withdraw antipsychotic medications including: (a) Family resistance, (b) Potential for worsening or return of symptoms or behaviors, (c) Lack of effectiveness and/or lack of staff resources to consistently implement nonpharmacological management strategies, and (d) Risk aversion of staff and environmental safety concerns. Discussion and Implications: Nursing home staff recognize the value of reducing antipsychotic medications; however, they also experience multiple barriers to reduction in routine clinical practice. Achievement of further reductions in antipsychotic medication use will require significant additional efforts and adequate clinical personnel to address these barriers.

Specific Physician Orders Improve Pain Detection and Pain Reports in Nursing Home Residents: Preliminary Data.

Despite evidence that many nursing home residents' pain is poorly managed, reasons for this poor management remain unanswered. The aim of this study was to determine if specific order sets related to pain assessment would improve pain management in nursing home (NH) residents. Outcomes included observed nurse pain assessment queries and resident reports of pain. The pretest/post-test study was performed in a 240-bed for-profit nursing home in the mid-southern region of the United States and participants were 43 nursing home residents capable of self-consent. Medical chart abstraction was performed during a 2-week (14-day) period before the implementation of specific order sets for pain assessment (intervention) and a 2-week (14-day) period after the intervention. Trained research assistants observed medication administration passes and performed participant interviews after each medication pass. One month after intervention implementation, 1 additional day of observations was conducted to determine data reliability. Nurses were observed to ask residents about pain more frequently, and nurses continued to ask about pain at higher rates 1 month after the intervention was discontinued. The proportion of residents who reported pain also significantly increased in response to increased nurse queries (e.g., "Do you have any pain right now?"), which underscores the importance of nurses directly asking residents about pain. Notably 70% of this long-stay NH population only told the nurses about their pain symptoms when asked directly. Findings uncover that using specific pain order sets seems to improve the detection of pain, which should be a routine part of nursing assessment.

Pain reports and pain medication treatment in nursing home residents with and without dementia.

AIM: The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self-reports and pain medication use in a group of verbally communicative nursing home (NH) residents. METHODS: The study design was a between groups, cross-sectional chart audit and a seven-question structured pain interview comparing outcomes in residents with and without a diagnosis of dementia. The study was carried out at a large metropolitan NH in the southern USA. The participants consisted of 52 long-stay NH residents capable of self-consent with at least one order for pain medication (opioid or non-narcotic) either pro re nata, scheduled or both. Approximately 40% (n = 20) had a diagnosis of dementia. RESULTS: Although each group had similar pain-related diagnoses, residents without a dementia diagnosis were significantly more likely to have a medication order for an opioid (OR 4.37,95% CI 1.29-14.73, P = 0.018). Based on self-reported pain interview responses, no statistically significant differences were identified between the groups for chronic pain symptoms. However, among residents who reported current pain, those with a dementia diagnosis reported greater pain intensity (based on a 0-10 numeric rating scale) than did those without dementia (median 8.0 vs 6.0, respectively; P = 0.010). CONCLUSIONS: Verbally communicative NH residents with mild and moderate cognitive impairment can report their pain symptoms and pain intensity. Nurses in long-term care might assume that residents with dementia cannot reliably self-report their pain; however, suffering from untreated severe pain could exacerbate cognitive impairment, worsen functional impairment and severely impair sleep. A brief, focused pain interview might be one method for increasing the detection of moderate to severe pain in verbally communicative NH residents with dementia.

Automated Assessment of Medical Students' Clinical Exposures according to AAMC Geriatric Competencies.

Competence is essential for health care professionals. Current methods to assess competency, however, do not efficiently capture medical students' experience. In this preliminary study, we used machine learning and natural language processing (NLP) to identify geriatric competency exposures from students' clinical notes. The system applied NLP to generate the concepts and related features from notes. We extracted a refined list of concepts associated with corresponding competencies. This system was evaluated through 10-fold cross validation for six geriatric competency domains: "medication management (MedMgmt)", "cognitive and behavioral disorders (CBD)", "falls, balance, gait disorders (Falls)", "self-care capacity (SCC)", "palliative care (PC)", "hospital care for elders (HCE)" - each an American Association of Medical Colleges competency for medical students. The systems could accurately assess MedMgmt, SCC, HCE, and Falls competencies with F-measures of 0.94, 0.86, 0.85, and 0.84, respectively, but did not attain good performance for PC and CBD (0.69 and 0.62 in F-measure, respectively).

Incorporating evidence into clinical teaching: enhanced geriatrics specialty case-based residency presentations.

INTRODUCTION: Case-based presentations are widely used in medical education and are a preferred education modality to teach about the care of geriatric patients across a range of medical specialties. METHODS: We incorporated evidence-based materials from topical literature syntheses into case-based presentations on the care of geriatric patients for use by specialty residents. These enhanced case-based presentations were used to augment learning and to facilitate detection of additional educational needs for future resident training sessions. RESULTS: Forty case-based presentations were presented to 11 specialty programs during a 4-year period. The program was popular, and program directors and residents requested additional presentations. Geriatric evidence-based summaries were viewed online 375 times during the course of the project. Geriatric clinical consults increased from an average of 10 consults a year to 141 from 64 different providers during the first year. DISCUSSION: Case-based presentation, enhanced with evidence-based summaries of research literature generated by information specialists, is a feasible and effective approach to teaching clinical content. These presentations can be used to target geriatrics educational competencies for resident trainees in nongeriatric specialties.

Documentation and management of words associated with delirium among elderly patients in postacute care: a pilot investigation.

OBJECTIVE: To describe in a pilot investigation the frequency that keywords associated with delirium were documented by providers and to study the effect of reporting such observations on physician orders. DESIGN: Retrospective investigation. SETTINGS AND PARTICIPANTS: Eighty elderly patients identified from 895 admitted to 2 postacute care (PAC) facilities. MEASUREMENTS: Keywords associated with delirium were confusion, disorientation, altered mental status, delirium, agitation, inappropriate behavior, mental status change, inattention, hallucination, and lethargy. The source of the words and actions taken were recorded. RESULTS: Keywords associated with delirium were identified in 80 (9%) of 883 patients who met inclusion criteria, with the term "confusion" most frequently noted (95%). Nurses and physicians recorded keywords in 79 (99%) and 55 (69%) patient charts. The actual term "delirium" was used in only 6 (7%) of 80 cases. In 55 (69%) cases when physicians were notified, treatments or evaluations were performed: pharmacological 55 (100%), nonpharmacological 11 (20%), assessments 38 (69%), transfer to the emergency department 19 (34%). Nurses did not alert physicians in 25 (31%) cases where keywords were found and thus no action was taken in these cases. CONCLUSIONS: In this pilot investigation in the postacute setting, nurses and physicians documented words associated with delirium in 9% of the patient charts. When nurses notified physicians of patients with charted keywords suggesting delirium, physicians responded with orders for further assessments or pharmacological interventions. However, nurses did not refer patients with keywords in 1 of 3 cases and no actions were documented in the charts for these patients.

Delirium in the nursing home patients seen in the emergency department.

OBJECTIVES: To determine whether nursing home patients are more likely than non-nursing home patients to present to the emergency department (ED) with delirium and to explore how variations in their delirium risk factor profiles contribute to this relationship. DESIGN: Prospective cross-sectional study. SETTING: Tertiary care academic ED. PARTICIPANTS: Three hundred forty-one English-speaking patients aged 65 and older. MEASUREMENTS: Delirium status was determined using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants. Multivariable logistic regression was used to determine whether nursing home residence was independently associated with delirium. Adjusted odds ratios (ORs) with their 95% confidence intervals (95% CIs) were reported. RESULTS: Of the 341 patients enrolled, 58 (17.0%) resided in a nursing home and 38 (11.1%) were considered to have delirium in the ED. Of the 58, (22 (37.9%) nursing home patients and 16 of 283 (5.7%) non-nursing home patients had delirium; unadjusted OR=10.2, 95% CI=4.9-21.2). After adjusting for dementia, a Katz activity of daily living score less than or equal to 4, hearing impairment, and the presence of systemic inflammatory response syndrome, nursing home residence was independently associated with delirium in the ED (adjusted OR=4.2, 95% CI=1.8-9.7). CONCLUSION: In the ED setting, nursing home patients were more likely to present with delirium, and this relationship persisted after adjusting for delirium risk factors.

Prevalence of constipation symptoms in fecally incontinent nursing home residents.

OBJECTIVES: To determine the prevalence of constipation symptoms and the effects of a brief toileting assistance trial on constipation in a sample of fecally incontinent nursing home (NH) residents. DESIGN: Observational study. SETTING: Five NHs. PARTICIPANTS: One hundred eleven fecally incontinent NH residents. MEASURES: Research staff measured bowel movement frequency every 2 hours for 10 days. The following week, residents were offered toileting assistance every 2 hours for 2 days to determine resident straining, time required for a bowel movement, and resident perceptions of feeling empty after a bowel movement. Constipation data were abstracted from the medical record. RESULTS: The frequency of bowel movements during usual NH care was low (mean=0.32 per person per day), and most episodes were incontinent. The frequency of bowel movements increased significantly, to 0.82 per person per day, and most episodes were continent during the 2 days that research staff provided toileting assistance. Eleven percent of residents showed evidence of straining, and 21% of the time after a continent bowel movement, residents reported not feeling empty. Five percent of participants had medical record or Minimum Data Set documentation indicative of constipation symptoms. CONCLUSION: Low rates of bowel movements during the day that are potentially indicative of constipation were immediately improved during a 2-day trial of toileting assistance in approximately 68% of the residents, although other symptoms of constipation remained in a subset of residents who increased toileting frequency.

Physicians' response to guided geriatric dosing: initial results from a randomized trial.

Guided dosing within a computerized provider order entry (CPOE) system is an effective method of individualizing therapy for patients. Physicians' responses to guided dosing decision support have not been extensively studied. As part of a randomized trial evaluating efficacy of dosing advice on reducing falls in the elderly, CPOE prompts to physicians for 88 drugs included tailored messages and guided dose lists with recommended initial doses and frequencies. The study captured all prescribing activity electronically. The primary outcome was the ratio between prescribed dose and recommended dose. Over 9 months, 778 providers entered 9111 study-related medication orders on 2981 patients. Physicians using guided orders chose recommended doses more often than controls(28.6% vs. 24.1%, p<0.001). Selected doses were significantly lower in the intervention group (median ratio of actual to recommended 2.5, interquartile range [1.0,4.0]) than the control group (median 3.0 interquartile range [1.5,5.0], p<0.001). While physicians selected the recommended dose less than a third of the time, guided geriatric dosing modestly improved compliance with guidelines.

A pilot study of CME on risk management in long-term care.

This pilot study's purpose was to evaluate behavioral changes among medical directors and physicians following CME on risk management in long-term care (LTC) facilities. The setting was a satellite conference at the AGS Meeting Symposium 2000. CME participants included 51 medical directors, attending physicians, and nurses. Evaluations were based on 20 LTC medical directors and physicians. Descriptive statistics were used for outcome measurements. Respondents (n = 15, 75%) "committed" to an average of 3 changes. Of the 45 commitments, no progress was reported on 8 (17.7%); another 8 commitments were reported as fully completed. The mean implementation rate was 60%. LTC physicians departed the course with intentions to alter their behaviors, but important obstacles such as "lack of time" and "staff not available or interested" interfered with implementation.

Pneumococcal vaccination in nursing homes: does policy change practice?

OBJECTIVE: To describe the impact of a Tennessee Department of Health regulation amendment requiring that all nursing home residents 65 years of age or older demonstrate documentation of pneumococcal vaccination, or documented medical contraindication, or patient refusal. DESIGN: Cross-sectional descriptive study of nursing homes using a mailed self-administered survey instrument. RESULTS: Of 354 Tennessee nursing homes, 304 homes were targeted for the survey, after excluding hospital-based rehabilitation and skilled care facilities, and facilities with fewer than 50 beds. Pneumococcal immunization rates improved from 32% to 42% from 1998 to 1999, coincident with the new policy. Homes reporting high immunization rates (>/=75%) increased from 21% to 28%. These facilities were more likely to be larger (>100 beds) and urban; to have a computerized or chart-based vaccine record; to have a standing order policy; and high influenza immunization rates. Overall, only 23% of homes reported that the policy was helpful in increasing immunization rates, and only 38% of facilities reported an increase in rates of at least 5%. However, 58% of facilities that found the policy useful improved pneumococcal vaccination rates at least 5% compared with 32% that did not find it useful. No other factors were strongly associated with improved vaccine rates. CONCLUSION: Pneumococcal immunization rates of at least 75% were associated with facility size, location, and record-keeping practices. Pneumococcal vaccination rates improved only modestly between 1998 and 1999, coincident with the health department amendment. Those who found the policy useful had the greatest improvement in rates.

Cultural models of long-term care.

Long-term care remains a formidable challenge in the spectrum of geriatric services, influenced by cultural attitudes, funding priorities, societal needs, and personal preferences. Many positive components exist in American models of long-term care, including medical directorships, mid-level practitioners, and regulatory control, however home and community-based services are relatively under-developed compared to the experiences in other countries.

Physician behavior changes following CME on the prospective payment system in long-term care: a pilot study.

INTRODUCTION: Physicians must understand regulatory changes in long-term care (LTC) and adhere to prospective payment system (PPS) guidelines for minimum data set (MDS), resource utilization groups (RUG) and resident assessment instrument (RAI) processes, documentation, and evaluation. We pilot-tested "Prospective Payment System in LTC," a 7.5 hour continuing medical education (CME) program designed to help participants make plans to implement and adhere to PPS guidelines and regulatory requirements. METHODS: Twelve medical directors or attending physicians participated. A "commitment to change" evaluation assessed whether participants' plans were reasonable and were implemented, and what barriers interfered. Participants identified 3-5 changes they intended to make. Three months later, participants estimated actual implementation of intended changes, identified obstacles to success, and rated PPS's impacts on patient care. RESULTS: Respondents "committed" to an average of 3.4 changes ranging from "better monitor transfers from LTC to acute care" to "train nurses re MDS and RUGs." Of 40 commitments, 0%100% progress were reported on 9 (23%) each. Mean implementation rate was 41%. Removing responses reporting 0% implementation, the rate was 53%. Common barriers were "lack of time," and "can't get attending MDs to meetings." MDs' ratings of PPSs' impacts were neutral (2.9 on a scale where 1 = "PPS causes great deterioration in quality of care," 3 = "...no change." and 5 = "...great improvement.") both immediately and 3 months post-course. CONCLUSIONS: Participants made reasonable plans consistent with course objectives and made progress implementing most intentions. LTC physicians who attended the CME course intended to alter their behaviors, but significant obstacles interfered, at least in the short term. Most thought PPS would not change the quality of care provided in their institutions. Future courses should address implementation barriers.