Assessment of constipation management in long-term care patients.

OBJECTIVES: To determine the prevalence of diagnosed constipation among nursing home patients; to assess the prevalence of routine (at least one time per week for 4 consecutive weeks) laxative use; and to investigate prescribing practices. DESIGN: A retrospective multi-center medical record evaluation. SETTING: Any one of 25 nursing facilities representative of a long-term care pharmaceutical provider's geographical coverage. PARTICIPANTS: All patients under the age of 65, and/or who had resided in the facility for less than 4 weeks, and/or who were placed in a specialty care bed (eg, Alzheimer's disease, hospice, HIV/AIDS) were excluded. RESULTS: A total of 712 resident charts meeting initial inclusion criteria were screened, 392 (55%) of which had a documented diagnosis of constipation and/or routine laxative use. Approximately 28% (CI +/- 3.3) of residents had a documented diagnosis of constipation. The rate of laxative use within the same sample population of 712 patients was 53.8% (CI +/- 3.7). Of the 392 patients with a diagnosis of constipation and/or routine laxative use, over 72% had at least one diagnosis or medication known to precipitate constipation. The most commonly prescribed laxatives were stool softeners (26.2%), saline laxatives (18.4%) and stimulant/irritant laxatives (15.6%). Almost half of the laxative users were prescribed more than one agent. CONCLUSION: This study supports the concern that there is often a gap between documentation of symptoms and constipation treatment decisions. No correlation was found between the specific laxative prescribed and the presence or absence of a documented diagnosis of constipation. Treatment decisions should be based on thorough examination and individualized patient needs. Furthermore, there is a need to increase monitoring for drug effectiveness.

Collaborative partnership for optimizing heart failure outcomes in the long-term care environment: a clinical experience.

RATIONALE: Heart failure (HF) is a devastating cardiovascular syndrome affecting more than 4.6 million Americans and resulting in a substantial economic burden. It is the number one cause of hospitalization in the older population. Because there is no cure for this costly disease, goals of therapy include; slowing progression, increasing patient survival, minimizing symptoms, improving patient functional capacity, and decreasing ER visits, hospital admissions, and readmissions. Studies have shown ACE inhibitors (ACEIs) to be extremely beneficial in reaching these goals. However, data nationwide indicate that less than half of HF patients are prescribed an ACEI. Therefore, a national long-term care pharmaceutical provider has committed to the development of a HF disease management program, which has been implemented through a collaborative partnership between medicine, nursing, and pharmacy. This report describes the experience and results of implementing this program in a large group of nursing homes. METHODS: With help from an independent health outcomes consulting firm and an expert panel, a multifaceted program was developed. The AMDA heart failure guidelines were used as a foundation to design program interventions, which included educational programs for the long-term care facility staff, implementation of a HF treatment algorithm, and an outcomes measurement program. The primary goals of this program were to increase awareness of HF and treatment options available and to decrease morbidity and mortality associated with HF through the optimization of pharmacologic management in a long-term care setting. OUTCOMES: A retrospective evaluation was conducted to assess changes in ACEI utilization, ACEI targeted dosing and HF-related hospitalizations 1 year after program implementation. A total of 510 patients followed by 23 consultants, representing 152 facilities met the inclusion criteria for the analysis. Data indicated an increase of 36% in newly enrolled HF patients utilizing ACEI after 1 year. A decreasing trend in HF hospitalizations was also noted from the first quarter, (2.2/100 patients) to the fourth (1.0/100 patients). The results of the Heart Failure-Health Outcomes Management Program (HF-HOMP) program demonstrate the opportunity existing for long-term care providers to improve patient health while minimizing expenditures. It also provides additional evidence that such programs should be implemented more broadly within this population.

Spirometry--acceptability and reproducibility in spinal cord injured subjects.

The American Thoracic Society (ATS) has formulated guidelines for spirometry. We hypothesized that individuals with SCI (SCI), as a result of weak respiratory muscles, would exhibit poor test acceptability and reproducibility. Seventy-eight SCI subjects (39 with complete SCI) answered a respiratory questionnaire and performed spirometry. Of those with complete SCI, the proportion of subjects which met ATS criteria decreased with higher levels of injury. Poor test performance was not associated with age, respiratory symptoms or muscle fatigue. The most common reason for failing to meet ATS criteria for acceptability was excessive back extrapolated volumes (EBEV). Individuals with efforts that were acceptable except for EBEV and/or for exhalation of less than six seconds had values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) that were reproducible. If ATS criteria for acceptable spirometry were used in studying subjects with SCI, individuals producing otherwise reproducible values for FVC and FEV1 would be excluded. We found reproducibility similar to what has been reported in other cohorts and conclude that longitudinal study of respiratory function in SCI is feasible.

Neuropsychological test patterns in men for Alzheimer's and multi-infarct dementia.

This paper examined three patterns of test performance on the Halstead Reitan Battery (HRB) and the Wechsler Adult Intelligence Scale-Revised (WAIS-R), including Fuld's formula, that differentiated Alzheimer's Disease (AD) from cerebrovascular disease, especially Multi-Infarct Dementia (MID). Study 1 and 2 utilized 12 AD subjects and 13 subjects who had transient ischemic attacks (TIAs). All of the subjects in this study were male. The severity of impairment was equated. A WAIS-R deterioration pattern was found for the AD subjects, from which a formula was derived that correctly identified 84% of the subjects. The Fuld formula identified 76%. In regard to the HRB, Motor tests especially were less impaired for AD subjects and the HRB formulas correctly identified about 92% of the subjects. A third study, using an entirely new sample, applied these formulas to 11 AD and 28 MID subjects. The same rate of separation for the HRB formulas was found. Neither the WAIS formula, with the original cutting points, nor did the Fuld formula quite reach significance.

Tension band wiring of displaced tibial tuberosity fractures in adolescents.

Twelve adolescent boys with avulsion fractures of the tibial tuberosity were treated with open reduction and tension band wire fixation. Fasciotomies were required in two cases for associated compartmental syndromes. All fractures healed in anatomic position. The tension band wire assisted both in neutralizing tensile (distracting) forces and compressing comminuted fragments. Early functional motion was started within four weeks. Osgood-Schlatter disease was diagnosed in five of the 12 patients. The apparent high incidence of this fracture pattern in the community prompted the recommendation to restrict jumping sports for adolescent boys with active Osgood-Schlatter disease.

The orthotic treatment of stable ankle fractures.

Fifteen limbs with stable lateral malleolar fractures treated with an adjustable, functional orthosis were compared to 12 limbs managed with short leg walking casts. The limbs managed with the adjustable orthosis were clinically healed at an average of 3.3 weeks with no fracture tenderness and with the ability to bear full weight without pain. Range of motion in the orthotic group at the end of treatment was significantly better than the casted group. Patient compliance was excellent. The advantages of the orthotic treatment include a more physiologic gait pattern due to the rocker bottom sole, ease of application, lighter weight, removability for range of motion exercises and bathing, and adjustability to maintain a good fit as posttraumatic swelling resolves.