A review of the management of heart failure in long-term care residents.

OBJECTIVE: The objective of this study was to describe the characteristics of long-term care residents with heart failure (HF), to evaluate the management of HF, and to compare their management with nationally published American College of Cardiology/American Heart Association guidelines. DESIGN/SETTING: Residents in long-term care facilities were identified by diagnosis of HF within their electronic medical record. PARTICIPANTS: Data were collected on 302 residents in 19 long-term care facilities. The average age of the study population was 83.2 +/- 11.1 years and comprised 68.5% females. RESULTS: Diabetes, obesity, hypertension, coronary artery disease, dementia, and hypothyroidism were identified in greater than 30% of residents. A diuretic was prescribed in 76.8% of residents. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers were prescribed to 40.7% and 38.4% of residents, respectively; 16.2% of residents received both agents. Residents with diabetes or hypertension were not prescribed ACE inhibitors more often than residents without these comorbidities. Digoxin was prescribed more frequently in residents with atrial fibrillation (P = 0.028). Hospital admissions related to HF were documented in 30 (9.9%) residents within the past 12 months. CONCLUSIONS: According to guidelines, most patients with HF should be routinely managed with a combination of four types of drugs: a diuretic, an ACE inhibitor, a betablocker, and, often, digoxin. Improvement in HF outcomes resulting in reduced morbidity and mortality may be achieved through greater adherence to nationally recognized guidelines. Opportunities exist for health care professionals to improve the management of residents with HF through appropriate drug therapy management.

An assessment of the diagnosis and management of dementia in nursing homes.

OBJECTIVES: The purpose of this study was to evaluate the diagnosis and management of dementia in the nursing home setting through use of the Mini-Mental State Examination (MMSE) and monitoring of acetylcholinesterase-inhibitor (ACHEI) therapy. DESIGN: Longitudinal cross-sectional study. SETTING: Long-term care facilities in Indiana. PATIENTS: Residents in long-term care facilities were included. MAIN OUTCOME MEASURES: The number of residents with MMSE scores indicative of dementia, the presence of a dementia diagnosis, and receipt of ACHEI therapy. RESULTS: Data were collected on 782 residents. An MMSE score was available within the past 12 months in 456 (58.3%) of residents. The median MMSE score was 17 and ranged from 0 to 30 points. Out of the total population, ACHEI therapy was prescribed in 165 (21.1%) residents. Seventy-five (29.2%) of the residents with mild-moderate dementia (MMSE = 10-26) were prescribed ACHEI therapy. The most frequently prescribed ACHEI was donepezil 10 mg/day prescribed in 98 (59.4%) of the residents receiving ACHEI therapy. Average length of ACHEI therapy was 9.0 months. CONCLUSION: MMSE scores were not available in a large proportion of this nursing home population (41.7%). Of those residents with an available MMSE score, a significant number of them had scores indicative of dementia. Despite having scores indicative of dementia, 182 (70.8%) residents were not receiving AChEI therapy. An assessment to determine why residents were not receiving therapy is needed. Opportunities exist to improve the screening, diagnosis, and treatment of dementia in the nursing home setting.

Gastrointestinal-related complications in a long-term care population taking NSAIDs versus COX-2 inhibitor therapy.

OBJECTIVES: To determine the following in a long-term care population taking traditional nonsteroidal anti-inflammatory drug (NSAID) or cyclo-oxygenase-2 (COX-2) inhibitor therapy: (1) incidence of gastrointestinal (GI) adverse events and GI-related hospitalizations, (2) prevalence of GI-protective medication use, and (3) prevalence of GI risk factors as defined by Indiana Medicaid prior-authorization criteria. DESIGN: Longitudinal cross-sectional study. SETTING: Long-term care facilities in Indiana. PATIENTS: Residents in long-term care and assisted-living facilities were included if they were receiving either traditional NSAID or COX-2 inhibitor therapy. MAIN OUTCOME MEASURES: The number of residents experiencing GI intolerance or complications or GI-related hospitalizations associated with NSAID or COX-2 inhibitor use. RESULTS: Over this 14-month evaluation period, 1,198 long-term care and assisted living residents were identified as receiving NSAID or COX-2 inhibitor therapy. Celecoxib was the most frequently prescribed medication used in this population. Age >70 years and concomitant aspirin use were the most frequently noted risk factors for GI disease. Significantly fewer GI complications were observed in COX-2 recipients (4.0%) compared with NSAID users (8.4%) (P = 0.002). GI-related hospitalizations occurred significantly less with COX-2 use (2.0%) compared with traditional NSAID use (4.5%) (P = 0.014). A relatively low incidence of GI-related events also was associated with ibuprofen use. CONCLUSION: Individuals residing in assisted living or long-term care settings had lower rates of GI complications and hospitalizations related to COX-2 inhibitors compared with traditional NSAIDs.

The use of medications with known or potential anticholinergic activity in patients with dementia receiving cholinesterase inhibitors.

OBJECTIVES: To assess the prevalence of prescribed medications with anticholinergic activity given concurrently with acetylcholinesterase-inhibitor therapy in long-term care residents with dementia and to recommend dose adjustment or discontinuation of these medications with anticholinergic activity. DESIGN: Prospective case series. SETTING: Long-term care facilities in Indiana. PATIENTS: Geriatric residents in long-term care facilities were included if they were receiving both an agent with anticholinergic activity as determined by radioreceptor assay and an acetylcholinesterase inhibitor. INTERVENTIONS: Recommendations were made to the resident's physician suggesting substitution, dose reduction, or discontinuation of the agent with anticholinergic activity. MAIN OUTCOME MEASURES: The number of residents with a recommended change in their anticholinergic medication regimen as a result of the consultant pharmacist's recommendation. RESULTS: Of the 2,021 long-term care residents evaluated, 498 (25%) were receiving an acetylcholinesterase inhibitor. Of the 498 residents receiving acetylcholinesterase inhibitor therapy, 103 (20.7%) were receiving concurrent medications with anticholinergic activity. The most commonly prescribed medication with anticholinergic activity was furosemide, an agent with "possible" or low anticholinergic effects. One hundred forty-six medications with anticholinergic activity were used in these 103 residents. Overall, adjustments to the agents with anticholinergic activity were completed in 24 (16.4%) cases. The majority of medications prescribed had "possible" anticholinergic activity (62.3%) compared with those prescribed with "definite" anticholinergic activity (37.7%). No medication dose adjustments or discontinuations were frequent, regardless of whether the medication was deemed to have "definite" (29.1%) or "possible" (31.9%) anticholinergic activity. Medication changes or discontinuations occurred in 13 (23.6%) agents with "definite" and 11 (12.1%) agents with "possible" anticholinergic activity. CONCLUSIONS: Medications with anticholinergic activity may interfere with the beneficial effects of acetylcholinesterase inhibitors. Attention should be placed, however, on agents with moderate or strong anticholinergic activity or the use of multiple medications with anticholinergic activity. Health care providers should consider the risk versus benefit of using agents with anticholinergic activity in someone with cognitive impairment receiving an acetylcholinesterase inhibitor.