The Medical Management of Geriatric Patients in Skilled Nursing Facilities
Authors: Keith Doram, MD, FACP, MBA, CMD, Chief, Division of General Internal Medicine, Lehigh Valley Hospital, Allentown, PA; Assistant Professor of Medicine, Loma Linda University School of Medicine; Associate Clinical Professor of Medicine, Penn State University School of Medicine; Soheni Channah, MD; and Jae Lee, MD.
Peer Reviewer: Daniel Swagerty, Jr., MD, MPH, Assistant Professor, Departments of Family Medicine and Internal Medicine, Associate Director, Center on Aging, University of Kansas Medical Center.
Editor’s Note—There is a real need for efficient and efficacious medical management of geriatric patients in skilled nursing facilities (SNFs). The number of geriatric patients in SNFs is increasing primarily due to the overall increase in the population of the aged in our society. These patients consume the largest and most disproportionate amount of our healthcare dollars and resources. The government is concerned about the future solvency of Medicare as it is projected that the geriatric population (those > 65 years) will increase from 13% to 20% of the U.S. population by the year 2020.1 The U.S. Bureau of the Census estimates that the geriatric population 80 years of age and older is expected to increase to 6.1 million by 2010 and more than double to 12.3 million by 2040 (a rate 2.5 times that of the rest of the U.S. population). The Census data also show that 90% of all SNF patients are older than the age of 65 and of those, 45% are older than 85.2 Currently, almost 2 million people live in the nation’s 20,000 SNFs, and this is expected to reach 3.4 million by the year 2030.3
More and more practitioners find themselves caring for the frail, elderly, and often high-risk complicated patients in the unique and challenging environment of the SNF.4 These practitioners are under increasing pressures to deliver cost-effective quality medical care. This article is intended to provide the SNF healthcare provider with relevant and practical clinical information and practice guidelines that will better enable the medical staff to provide for the special needs of the geriatric patient. Physicians will be encouraged to develop their assessment/ plans being mindful of the useful information contained in the nationally standardized and mandated minimum data set (MDS) and resident assessment protocols (RAPs).
Across the continuum of acute care hospitals (ACHs), transitional/subacute care facilities, and nursing homes (NHs), all use skilled nursing personnel. Functionally, the main differences between the types of SNFs have related to the severity of illness and intensity of service(s) required. Subacute care facilities generally are capable of providing more intensive services than traditional SNFs or NHs but less than ACHs. Subacute care units are often found within ACHs and the typical patient is elderly (> 75% older than 65), less likely to be cognitively impaired, on more medications, and more likely to be rehospitalized.5 The focus will primarily be on traditional SNFs (i.e., NHs). Table 1 displays some of the major differences between ACHs and SNFs.
Key issues in the management of geriatric patients in SNFs:
• Governmental regulations
•
Functional status
• Medication usage
• Agitation and dementia
• Nutrition
• Preventive measures
• Special treatment considerations
| Table 1. Differences Between Acute Care Hospitals and Skilled Nursing Facilities | ||
| Characteristic | Acute Care Hospital | Skilled Nursing Facility |
| Patient care | Physician-driven | Nurse-driven |
| Progress notes | Daily | Every 30-60 days and PRN |
| Patient length of stay | Days | Weeks to years |
| Severity of illness | Acute and unstable | Chronic and stable |
| Facility surveys | Every three years using JCAHO standards | Every year using government regulation standards |
| Patient care updates | Done daily at bedside | Done mostly over the telephone PRN |
| __________________________________________________________ |
SNF Regulations
Prior to the institution of Medicare and Medicaid legislation in 1965, each state had oversight of SNFs. However, most states had few, if any, mechanisms in place to ensure that a minimally acceptable quality of care was being provided to the patients admitted to SNFs. The resultant public health concerns led to the development of federal-government-issued regulations for SNFs involved in Medicare and Medicaid in 1974.6
These regulations, however, did little to improve the quality of care for SNF patients. The regulations were not well received and the states often knowingly allowed their SNFs to remain out of compliance with the regulations. Therefore, in 1983, the Health Care Financing Administration (HCFA) contracted with the Institute of Medicine (IOM) to make recommendations that would "serve as a basis for adjusting federal (and state) policies and regulation governing the certification of nursing homes to make those policies and regulations as appropriate and effective as possible."7 Congress used the recommendations resulting from the HCFA-IOM alliance report as a basis for the regulatory changes incorporated into the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), Public law 100-203. Federal and state surveyors use interpretive guidelines based on OBRA 1987 for their inspection surveys of SNFs. States may also have other specific requirements (e.g., California’s Title 22 Regulations), that directly affect SNFs.
OBRA Regulations for Medical Director (Section 483.75)
Prior to OBRA 87, most SNF medical directors were just clinicians who cared for the majority of patients in the SNF and were in essence the "de facto physicians" for any and all clinical questions or issues that would arise. OBRA 87 stipulates that all SNFs have a medical director. However, there are more reported medical directors positively associated with hospital-based SNFs and with having a high proportion of Medicare residents.8 The physician who serves as the medical director must assume specific interactive and proactive administrative responsibilities for the design, measurement, assessment, and improvement of the quality of care. The medical director should meet regularly with the administrator and the director of nursing (DON) and should organize and monitor the medical staff.
OBRA Regulations for Attending Physicians (Section 483.40)
The attending physician should personally approve of the patient’s admission and admission orders. A complete history, physical, assessment, and plan should be completed by the attending physician within 72 hours of each patient’s admission. Generally, each patient requires a progress note every 30 days, although more or less frequent evaluations are allowed (and are billable). The physician should review the patient’s total program, including the minimum data set (MDS) and resident assessment protocols (RAPs).
Patient Rights (Section 483.10) and Physical Restraints (483.13[a])
The patient has the right to choose and contact his/her own personal physician, receive medical care in privacy, be informed of his/her medical condition, and refuse treatment.
There are many potential harms associated with the use of physical restraints (e.g., strangulation, skin and musculoskeletal injury, loss of personal dignity, etc.). Therefore, OBRA 87 requires that there should not be any undue use of chemical or physical restraints unless they are medically indicated to treat the resident’s symptoms. Restraints are not to be used for "discipline or convenience." After one year of implementation of this regulation, the use of restraints in the United States decreased by approximately 33%.9
Medication Usage (Section 483.25[1])
One of the main objectives of the Nursing Home Reform Amendments (included in OBRA 87) was the reduction of antipsychotic drug use in SNFs.10 The IOM committee stated in 1986 that excessive use of psychoactive medication is an indicator of poor-quality care.11 The regulations make the SNF directly responsible for physician prescribing patterns regarding psychoactive medication. SNFs are subject to potential financial penalties if physicians fail to comply with the OBRA interpretive usage guidelines.12 Essentially, physicians need to have clear and documented medical indications for use of psychoactive medications in SNF residents. Psychoactive drugs with shorter half-lives and fewer associated side effects are preferred.
Patient Assessment (Section 483.20)—Minimum Data Set and Resident Assessment Protocols
The MDS/RAPs are a comprehensive, standardized, and reproducible nursing generated functional assessment instrument mandated by OBRA in 1991 to be used by all SNFs certified by Medicare and Medicaid (or Medical).13 The MDS must be completed no later than 14 days after admission, annually, quarterly, and after any significant change in the patient’s physical or mental condition. All SNFs are required to send the MDS/RAPs report via modem to HCFA. (It is anticipated that in the future HCFA will correlate physicians’ billings with the MDS report and any significant discrepancies found may result in Medicare audits.)
Most physicians who manage patients in SNFs are still unfamiliar with the MDS and RAPs. The MDS assessment includes the medical history, medical status, physical and mental functional status, sensory and physical impairments, nutritional status and requirements, special treatments or procedures, psychosocial status, discharge potential, dental condition, activities, potential, rehabilitation potential, cognitive status, and drug therapy. The scored responses on the MDS trigger the use of RAPs, which involve 18 common clinical syndromes that occur in SNFs, especially the geriatric patients (see Table 2.)
| Table 2. Resident Assessment Protocols (RAPs) |
1. Delirium_________________________________________________ |
The medical staff should make greater use of the information contained in the MDS and RAPs algorithms. The nurses are responsible for completing the MDS/RAPs and they rely on the physicians’ comprehensive assessment of the patient—especially diagnoses and conditions that affect function. Primary examples of these types of diagnoses and health conditions are contained in various sections of the MDS (see Table 3).14
| Table 3. Diagnoses and Health Conditions of the MDS | |
| Disease Diagnoses Heart/Circulation a. Arteriosclerotic heart disease (ASHD) b. Cardiac dysrhythmias c. Congestive heart failure (CHF) d. Hypertension (HTN) e. Hypotension f. Peripheral vascular disease g. Other cardiovascular disease Neurological h. Alzheimer’s disease i. Dementia other than Alzheimer’s j. Aphasia k. Cerebrovascular accident (stroke) l. Multiple sclerosis m. Parkinson’s disease Pulmonary n. Emphysema/asthma/COPD o. Pneumonia Psychiatric/Mood p. Anxiety disorder q. Depression r. Manic depressive (bipolar disease) Sensory s. Cataracts t. Glaucoma Other u. Allergies v. Anemia w. Arthritis x. Cancer | y. Diabetes mellitus z. Explicit terminal prognosis aa. Hypothyroidism bb. Osteoporosis cc. Seizure disorder dd. Septicemia ee. Urinary tract infection in last 30 days ff. None of the above Health Conditions Problem Conditions a. Constipation b. Diarrhea c. Dizziness/vertigo d. Edema e. Fecal impaction f. Fever g. Hallucination/delusions h. Internal bleeding i. Joint pain j. Pain—resident complains or shows evidence of pain daily or almost daily k. Recurrent lung aspirations in last 90 days l. Shortness of breath m. Syncope (fainting) n. Vomiting o. None of the above Accidents a. Fell in the past 30 days b. Fell in the past 31-180 days c. Hip fracture in the last 180 days d. None of the above |
| ____________________________________________________________ |
SNFs are nurse-orientated and the physician or practitioner must rely on timely telephone (or other) communication with the SNF nurses in order to adequately care for their elderly patients. The nurses are required to notify the physician to verify admission orders and to notify him/her of any significant changes in the patient’s status. The number and complexity of patients a physician has will determine the frequency of communication required. Ouslander and colleagues published useful guidelines for notification of physicians or mid-level practitioners concerning changes in the patient’s status.15 The symptoms, signs, laboratory, and other prompters of immediate versus nonimmediate notification as outlined in these guidelines are summarized in Table 4. These guidelines are not meant to be all inclusive.
| Table 4. Immediate and Nonimmediate Notification Problems |
Immediate Notification (Acute) Problems—Physician is notified directly or by beeper right away Nursing staff should call 911 (for full code status patients) in situations requiring immediate action (e.g., respiratory/cardiac arrest or rapid deterioration of signs and symptoms prior to physician response) Nonimmediate Notification (Subacute) Problems Persistent symptoms or complaints by patient or family member (e.g., constipation, anorexia, urinary incontinence, recurrent falls, weakness, ataxia, itching, etc.)____________________________________________________________________________________________ |
Functional Status
Geriatric patients will usually have two or more chronic illnesses that can affect function (e.g., osteoarthritis, ASHD, etc.). Elderly patients admitted to SNFs are usually higher risk (higher acuity) patients who have significant impairment of function due to more advanced chronic illnesses (e.g., moderate to severe dementia, stroke, osteoporosis-related hip fractures, etc.). However, often a lower acuity patient has to be admitted to a SNF simply because there are insufficient family and/or social support persons available at home.
Healthcare outcomes are better predicted by functional status than medical diagnoses.16 Two reliable and validated standardized tests of functional status are the instrumental activities of daily living (IADL) and activities for daily living (ADL)—these are also found in the MDS.17,18 Inability to perform one or more ADL is more likely to cause an elderly person to be admitted to a SNF than one or more losses of IADL functions (see Table 5).
| Table 5. Functional Assessment Tests | |
| Activities of Daily Living (ADL)* | |
| 1. Continence 2. Transferring 3. Toileting | 4. Bathing 5. Dressing 6. Feeding |
* Arranged in logical order patterned after the usual functions a person would perform after arising from bed in the morning.Instrumental Activities of Daily Living (IADL) | |
| Managing finances Taking medications Using transportation Laundry | Housekeeping Food preparation Shopping Telephone |
| _________________________________________________________________ |
Podsiadio and Richardson have shown that geriatric patients were independent for basic transfers if they could complete "up & go" tasks (such as chair transfers, toilet transfers, walk 50 yards, etc.) in time scores of less than 20 seconds.19 In addition to assessing IADL and ADL, the physician should focus on aspects of the history and physical exam that can affect function (see Table 6).
| Table 6. Important Factors of Geriatric History and Physical Exam that can Affect Functional Status |
| • General—weight, height, body mass index (key indicator of nutritional status) • Eyes—check visual acuity; r/o presbyopia, cataracts, glaucoma, macular degeneration • Ears—check for presbycusis (high-frequency acuity loss)—use finger rub or whispered voice • Mouth—oral hygiene, dentition (loose dentures, missing teeth, malocclusion) • Lungs—quantify dyspnea or any chronic lung disorders • Cardiovascular—check for bruits, heart gallops, congestive heart failure, atrial fibrillation; check pulses and orthostatic changes • Gastrointestinal—rectal exam for occult blood, masses, or fecal impaction • Genitourinary—r/o atrophic vaginitis, urinary incontinence, prostate hypertrophy • Musculoskeletal—r/o osteoporosis, arthritis; check muscle strength • Neurological—check gait and balance by direct observation (consider using Tinnetti exam;20 r/o focal neurological deficits or peripheral neuropathy • Mental status—r/o cognitive impairment (mental status testing); can do quick short-term memory testing by asking patient to recall 3 unrelated words/objects after spelling "WORLD" backward—if patient is not completely accurate do a full Mini-Mental State Exam (MMSE);21 check for depression using the Geriatric Depression Scale,22,23 agitation, or thought disorders • Endocrine—r/o diabetes, hypothyroidism, or hyperlipidemia • Skin—check for decubitae (if present, is highly suggestive of impaired mobility) _______________________________________________________________________________ |
Whenever possible, every effort should be aimed at bringing the entire multidisciplinary team (social services, physical and occupational therapy, nursing, physician, etc.) together to maintain and improve the functional status of each elderly SNF resident. Doing this will help ensure their best possible healthcare outcome.
Medication Usage
The elderly consume more than 33% of our nation’s prescription medications, even though they currently represent only about 13% of the U.S. population.24 The reason for this statistic is obvious—the geriatric patients have more chronic symptomatic illnesses. Unfortunately, adverse drug reactions are more likely to occur in the elderly. This is due to several age-related pharmacokinetic changes that affect drug bioavailability, half-life, and the volume of distribution (see Table 7).25 For example, acidic drugs, such as salicylates, warfarin, phenytoin, and valproate, are bound primarily by albumin. Basic drugs, such as lidocaine, meperidine, propranolol, and carbamazepine, are mostly bound by alpha1-acid glycoprotein.26 Additional factors that can affect drug levels, such as inflammatory disorders, renal or hepatic diseases, and drug-drug interactions, are more likely to be present in the geriatric patient.
| Table 7. Age-Related Changes Affecting Medications |
| • Decrease in total body water weight (plasma volume remains essentially unchanged) • Decrease in glomerular filtration rate and renal clearance • Decrease in hepatic blood flow and hepatic clearance • Decrease in cell membrane receptors and sensitivity • Increase in relative body fat content • Albumin concentration decreases and alpha1-acid glycoprotein concentration increases _____________________________________________________________ |
The goals of drug therapy in the elderly must always be assessed and reassessed. For example, the therapeutic goals for a highly functional 68-year-old female diabetic will undoubtedly be different than for a bed-bound, severely demented 88-year-old female diabetic patient. Also, in Wallace and Verbeeck’s opinion, the use of insulin sliding scales or other more aggressive glucose-lowering therapies is strongly discouraged in the geriatric Type II diabetic SNF patient. Wallace and Verbeeck have found that writing the following standing orders for Type II diabetics is acceptable and helps prevent unnecessary telephone calls and the more acutely dangerous symptomatic hypoglycemia: capillary blood glucose (CBG) checks PRN (but usually not more than once per day) and the nurse is to call the physician for any CBG less than 55 mg/dL or for two or more CBG levels that are greater than 250 mg/dL. The guidelines recommended by the American Diabetic Association should be modified according to what is reasonable.
As a general rule, when antipsychotic and anxiolytic medications (e.g., haloperidol, resperidone, lorazepam, etc.) are indicated, they should be started at one-third to one-half the dose of that normally used in the younger adult patient.
The safest tricyclic antidepressents (TCAs) to use are nortriptyline or desipramine—and they should primarily be given (in low doses) to patients for pain syndromes (e.g., peripheral neuropathy, etc.).
The other TCAs should not be prescribed in the older SNF patient for either depression or pain syndromes given the many other safer therapeutic options that are now available (e.g., selective serotonin reuptake inhibitors).
We now know that the elderly can benefit from the same medical interventions of the younger or middle-age adult. Increasingly, based on landmark clinical trial data that included many elderly patients (e.g., West of Scotland Study—pravastatin; Scandinavian Simvastatin Survival Study; and the Cholesterol and Recurrent Events trial—pravastatin), expert consensus panels are recommending a more aggressive stance in the treatment of various acute and chronic disorders in the elderly (e.g., the National Cholesterol Expert Panel [NCEP] guidelines).27 For example, following these NCEP treatment guidelines in the appropriate patient can result in a significant reduction in heart attacks and strokes—leading causes of death and disability in the elderly patient.
The main questions to ask regarding drug therapy in the SNF geriatric patient are:
1. What medications have been proven to best improve and/or maintain function?
2. What medications can be stopped?
3. What are the safest drugs and what are their lowest effective doses?
Agitation and Dementia
The most common psychiatric disorder in the elderly is dementia, especially in those older than 85 years (wherein an estimated 40-50% may have dementia—two-thirds of which are secondary to probable Alzheimer’s disease [AD]).28 In the SNF setting, 70-90% of residents have one or more of the psychiatric diagnoses found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the majority being AD.29
All patients with dementia should be evaluated for possible reversible causes such as hypothyroidism, vitamin B12 deficiency, pseudodementia (depression), and neurosyphilis. A history of stroke should raise suspicion for multiinfarct dementia—the second leading cause of dementia in the elderly. Aggressive implementation of proven stroke prevention measures should be done in all appropriate geriatric patients (e.g., treatment of hypertension, use of warfarin in patients with atrial fibrillation, reduction of LDL-cholesterol in patients with coronary artery disease, use of aspirin, etc.).
Although memory loss, decreasing ability to perform IADLs and ADLs, and progressive loss of higher cognitive function have a major effect on a person’s quality of life, it is often the behavioral problems that arise in patients with dementia that present the greatest challenges to caregivers and attending physicians.
There are many nonpharmacologic approaches to management of behavioral disturbances in dementia, including: behavioral ("time outs," distraction, choice, conditioning); environmental modification (feeding, increasing or decreasing stimulation, signs/pictures); group programs (music, exercise, planned activities); touch (reassuring and caring); routines (familiar possessions and clothing); use of family members for feeding and to be in their SNF environment; and improving communication between patients and caregivers.30
Cholinergic agents (e.g., tacrine and donepezil) are the first class of drugs that have been approved by the FDA for the treatment of AD, although other agents such as estrogen replacement therapy may also be beneficial.31 Tacrine and donepezil have approximately equal efficacy as shown by the Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), which measures memory, language, and praxis-heavily weighted toward memory.32 Donepezil has the best tolerability and safety profile of the two and 82% of patients either improved or had no further cognitive decline after 24 weeks of therapy—it is the preferred agent.33 The clinical trials were performed in mild to moderately severe AD as defined by the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRADA),34 as well as the Diagnositic and Statistical Manual of Mental Disorders, 3rd edition revised (DSM-III-R)35 criteria for the diagnosis of probable Alzheimer’s disease. The MMSE score of the individuals studied was between 10 and 26.
Donepezil has also been used in the treatment of advanced (severe) Alzheimer’s (i.e., those with MMSE scores of 0). These anecdotal case studies have shown improvements in the ADL functional abilities but not in the IADL.36 Family and caregiver satisfaction is especially related to improvement in ADLs. Although prospective clinical trial studies need to be performed in advanced AD patients, Shua-Haim and colleagues recommend that consideration for donepezil therapy be given to all AD patients.
Agitation and other behavioral problems encountered in patients with dementia are often difficult to manage in SNFs. Antipsychotic drugs can effectively reduce acute agitation and can have a role in the management of chronic behavioral disorders. However, many considerations have to be addressed, including OBRA 87 regulations on the use of antipsychotics, and the frequent and severe side effects associated with these medications.
There has been a significant decline in the short- and long-term use of antipsychotic drug usage in SNFs in the post-OBRA 87 era. This decrease in antipsychotic drug usage has resulted in an improvement in the quality of SNF care, but additional research is needed to determine the effects on patient outcomes.37 Table 8 displays preferred treatment guidelines as adapted from an Expert Consensus Panel for Agitation in Dementia.38
| Table 8. Agitation in Patients with Dementia: Expert Panel Treatment Guidelines |
| Environmental Intervention Options • Mild and severe agitation—education and support for family and caregivers • Mild agitation—structured routines, reassurance, socialization • Severe agitation—supervision and environmental safety Medications and Specific Presentations of Agitation IM Medication for Acute Interventions—haloperidol alone, consider lorazepam alone Safest Medications for Long-Term Use—SSRIs, buspirone Safest Medication Choices for Patients with High Medical Comorbidity Medication Least Likely to Cause Drug Interactions—buspirone |
Guiding principle: Always seek to know why the patient is agitated and initially try environmental (nondrug) interventions in the mildly agitated patient. The cause for delirium should always be determined and managed expeditiously.
Nutrition
Nutritional problems are extremely common in the geriatric patient. The adequate assessment and treatment of nutritional deficiencies in SNF patients is a key quality-of-care issue and affects healthcare outcomes. There is a decline in food intake as one gets older in spite of the increase in weight that occurs during middle age.39 This finding suggests a change in the resting metabolic rate and physical activity that is associated with aging. Other factors that foster anorexia and the increased likelihood of nutritional deficiencies developing in the geriatric patient include: declines in olfaction and taste,40 increased levels of cholecystokinin (a gastrointestinal satiety hormone),41 gender differences in leptin (fat cell hormone that decreases food intake and increases metabolism) levels,42 and circulating cytokines (e.g., cachectin).43
A body mass index less than 19, the unintentional loss of 5% body weight in less than 30 days (or a loss of 10% in < 6 months), and an albumin less than 3.5 mg/dL all suggest the presence of malnutrition. Table 9 shows one instrument, "SCALE," that has been shown to aid in the identification of malnutrition44 and correlates well with the well-validated Mini Nutritional Assessment (MNA).45
| Table 9. SCALE: A Malnutrition Detection Instrument |
| S Sadness (Geriatric Depression Scale) C Cholesterol less than 160 mg/dL A Albumin less than 3.5 mg/dL L Loss of 5% of body weight E Eating problems (physical or cognitive) |
Once malnutrition is diagnosed it is important to attempt to correct the underlying problem and facilitate adequate nutritional intake. Review all medications closely; many drugs can cause gastrointestinal problems and anorexia (e.g., most SSRIs, antibiotics, digitalis, nonsteroidal anti-inflammatory agents, etc.). Delirium, dementia, depression, and other illnesses (e.g., febrile illnesses, infections, congestive heart failure, pain syndromes, neuromuscular disorders, terminal cancers, renal failure, etc.) can adversely affect nutritional update.46
Dietary supplements can be helpful in malnourished patients. Carbohydrate-rich liquid supplementation is less likely to cause satiation than more fat-rich liquid supplements.47 Frequent feeds, encouraging family to bring favorite snacks or meals, avoidance of restricted diets, and a supportive eating environment are all important measures that can be taken. If long-term enteral feeding tubes are required, gastrostomy tubes are preferred over nasogastric enteral feeding tubes, and continuous enteral feeding techniques are preferred over bolus feeding in the nonambulatory patient (due to an increased risk of aspiration associated with bolus feeding). It is important to note that there is no difference in survival between tube-fed and those who were not. Generally, most patients require 25-30 kcal/kg ideal body weight (IBW) per day for maintenance (20 kcal/kg/d to lose weight and 40 kcal/kg/d to gain weight).
Prevention
The U.S. Preventive Services task force has published preventive recommendations to be used in the asymptomatic elderly patient.48 However, evidence-based preventive measures with directly proven benefit in the asymptomatic elderly person include: tobacco use history, blood pressure measurements, blood glucose and cholesterol testing, evaluating vision and hearing, initiating estrogen replacement for women, and ensuring current tetanus, influenza, and pneumococcal immunizations.49 Mammography, pelvic exams, hemoccult stool testing, and prostate-specific antigen testing can also be useful in the appropriate SNF patient.
Approximately 25% of the tuberculosis (TB) cases in the United States occur in elderly persons and SNF patients are at an even higher risk.50 All SNF patients/residents should receive a two-step tuberculin skin test on admission or a screening chest radiograph. The established recommendations by the Centers for Disease Control should be followed regarding the surveillance, containment, assessment, and reporting of TB infection and TB disease.51
Prevention and treatment of decubitus ulcers primarily relate to increasing a patient’s functional status and mobility. Otherwise, frequent turning (at least every 2 hours) and a red-uction in skin moisture and friction are fundamental therapies.
More aggressive use of proven medical therapies that can help prevent stroke—the leading cause of chronic disability in the United States—should be considered in the appropriate patient. These therapies include: warfarin use in atrial fibrillation,52 HMG-Coenzyme A reductase inhibitor use in coronary artery disease,53 antihypertensive treatment,54 and other alternative treatments in patients with known atherosclerosis (e.g., aspirin, ticlodipine, clopidogrel).55
Special Treatment Considerations
Physical Restraints and Falls. Try to avoid their use if at all possible. The more functional SNF geriatric patients may be more likely to fall. However, if they are restrained they may be even more susceptible to serious injury.56 Look closely at reasons for repeat falls in any SNF geriatric resident.
Urinary Incontinence. Look for treatable causes (e.g., delirium/dementia, urinary tract infections, atrophic vaginitis, medications, diabetes, restricted mobility, and stool impaction) and categorize the incontinence as stress, urge, or overflow and treat accordingly. Avoid using indwelling or external catheters unless the patient has severe pressure sores, is in hospice care, or has expressed a preference for catheter use.
Pressure Ulcers. Good SNFs should be able to keep the incidence of pressure ulcers less than 5%. Adequate nursing protocols and SNF policies are essential. Try not to use topical agents containing povidone or hydrogen peroxide because they may delay the healing process. If wet-to-dry dressings are ordered, make sure they are changed frequently enough. The aim is to keep the inside of the wound/ulcer moist but the surrounding skin dry. Shallow stage II-III decubitae can often be managed conservatively and respond well to hydrocolloid, 1% silver sulfadiazine, transparent adhesive dressing, bacitracin zinc, and similar topical dressings.57 In Alvarez and associates’ opinion the single most important risk factor for pressure ulcer development is immobility.
Hospice. Judicious use of this valuable service is warranted. However, all patients who have less than six months to live do not have to be enrolled in a hospice program—even though they may technically qualify. Hospice is a healthcare resource that should be used appropriately. Hospice can be helpful especially in terminal patients with significant pain and suffering and in aiding families who are having difficulty coping with the death and dying process.
Diagnostic Testing/Hospitalization/Advanced Directives. Each SNF geriatric patient is different. Although many may carry the same diagnoses, the decision to do more advanced testing, hospitalize, etc., will depend on several factors particular for each individual. The primary guiding questions are: 1) "Will this test or treatment significantly improve this patient’s quality of life?" 2) "What is the patient’s (or surrogate decision-maker’s) informed decision as stated in his/her advanced directives?"
The attending physician should provide the patient (and family) with the treatment options accompanied with his/her recommendations. The physician can be helpful in providing guidance to the patient and their family. Most patients want to be assured of no undue pain or suffering and to maintain their personal dignity. Physicians and practitioners can be of great assistance in helping families cope with death and dying.
Summary
The number of geriatric patients in SNFs will continue to grow substantially. It is therefore essential that physicians become more knowledgeable about the aging process and maintain a sensitivity to the particular needs of the geriatric SNF resident. The attending physician should always seek to appropriately maximize the elderly SNF resident’s functional status and to prescribe proven therapies that improve outcomes and quality of life. In most patients, but especially in the elderly, concerns about the quality of life supercede longevity issues.
The attending physician should be aware of the unique environment of the SNF and the governing OBRA regulations. He/she should make use of the MDS and RAPs in developing the specific treatment goals of each patient and should communicate effectively with the nursing staff.
Physicians caring for geriatric patients in SNFs should also consider subscribing to relevant publications by the American Geriatrics Society and the American Medical Directors Association (AMDA).
References
1. Calkins E, Davis PJ, Ford AB: The Practice of Geriatrics. Philadelphia: W.B. Saunders;1986.
2. FIND/SVP: The Long Term Care Market: A Market Intelligence Report. New York; FIND/SVP, 1993.
3. Ouslander J, Osterweil D, Morley J. Medical Care in the Nursing Home. 2nd ed. New York, New York: McGraw-Hill;1997.
4. Shaughnessy PW, Dramer AM. N Engl J Med 1990;332(2):1-27.
5. Smith RL, Osterweil D. The medical director in hospital-based transitional care units. Clinics in Geriatric Medicine (Medical Direction in Long-term Care). Philadelphia: W.B. Saunders Co., Vol. 11(3), August 1995:375.
6. Institute of Medicine, Committee on Nursing Home Regulation. Improving the Quality of Care of Nursing Homes. Washington, DC: National Academy Press 1986.
7. Feldman J, Boulter C (eds.): Minimum Data Set Plus: Multistate Nursing Home case Mix and Quality Demonstration Training Manual. Natick, MA: Eliot Press, 1991.
8. McCarthy JF, et al. Annals of Long-Term Care 1999;7(2):35-43.
9. Kane RI, et al. Annual Review of Public Health 1993;14: 545-584.
10. Elon R, Pawlson LG. J Am Geriatr Soc 1992;2:394-398.
11. Institute of Medicine, Committee on Nursing Home Regulation. Improving the Quality of Care of Nursing Homes. Washington, DC: National Academy Press, 1986.
12. Elon RD. Omnibus Budget Reconciliation Act of 1987 and its implications for the medical director. Clinics in Geriatric Medicine (Medical Direction in Long-Term Care). Philadelphia: W.B. Saunders Co., Vol. 11(3), August 1995:426.
13. Zisselman MH, et al. Annals of Long-Term Care 1998;6(7):200.
14. State Operations Manual. Minimum Data Set 2.0. US Department of Health and Human Services. Health Care Finance Administration (HCFA). Washington, DC: 1997
15. Ouslander J, et al. J Am Geriatr Soc 1990;38:490-492.
16. Norain P, et al. J Am Geriatr Soc 1988;36:775-783.
17. Lawton MP, Brody EM. Gerontologist 1969;9:179-186.
18. Katz S. J Am Geriatr Soc 1983;31:721-727.
19. Podsiado D, Richardson S. J Am Geriatr Soc 1991;39:142.
20. Tinetti ME. J Am Geriatr Soc 1986;34:119.
21. Folstein MF, et al. J Psychiatr Res 1975;12:189-198.
22. Yesavage JA, et al. J Psychiatr Res 1983;17:37-49.
23. Burke WJ, et al. J Am Geriatr Soc 1992:40:922-935.
24. Stason WB, et al. J Am Coll Cardiol 1987;10:18A-22A.
25. Yuen GJ. Clin Geriatr Med 1990;6:257-267.
26. Wallace SM, Verbeeck RK. Clin Pharmacokinet 1987;12:41-72.
27. Summary of the Second Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 1993;269:3015.
28. Evans DA, et al. JAMA 1989;262:2551-2556.
29. Rovner BW, et al. Am J Psychiatry 1986;143:1446-1449.
30. Grossberg GT. Alzheimer's Disease—Management Today 1998; 1(1):4-7.
31. Yaffe K, et al. JAMA 1998;279:688-695.
32. Olin JT, Schneider LS. Int J Geriatr Psychiatry 1995;10:753-756.
33. Rogers SL, et al. Dementia 1996;7:293-303.
34. Mckhann G, et al. Neurology 1984;34:939-944.
35. American Psychiatric Association. Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed rev. Washington, DC: APA;1987:121.
36. Shua-Haim JR, et al. Annals of Long-Term Care 1999;7(2):67-71.
37. Shorr RI, et al. JAMA 1994;271:358-362.
38. Alexopoulos GS, et al. The Expert Consensus Guideline Series: Treatment of agitation in older persons with dementia. Postgraduate Medicine Special Report; April 1998.
39. MMWR Morb Mortal Wkly Rep 1994;43:116-125.
40. Morley JE. Am J Clin Nutr 1997;66:760-773.
41. Bertelemy P, et al. J Am Geriatr Soc 1992;40:R755-R761.
42. Sih R, et al. J Clin Endocrinol Metab 1997;82:1661-1667.
43. Merguid MM, et al. Nutrition 1996;12:557-562.
44. Morley JE, et al. Annals of Long-Term Care 1998;6(Supplement) E:1-12.
45. Guigoz Y, et al. Nutr Rev 1996;54:S59-S65.
46. Morley JE, Silver AJ. Ann Intern Med 1995;123:850.
47. Shafer RB, et al. Am J Physiol 1985;248:R479-R483.
48. U.S. Preventive Services Task Force. Guide to preventive services. 2nd ed. Baltimore: Williams Wilkins, 1996.
49. Frame PS. Am Fam Physician 1999;59(7):1747-1750.
50. Yoshikawa TT. Nursing Home Medicine 1995;3(9):207.
51. MMWR Morb Mortal Wkly Rep 1990;39(No. RR-10):1.
52. Atrial Fibrillation Investigators. Arch Intern Med 1994;154: 1449-1457.
53. Hebert PR, et al. JAMA 1997;278:313-321.
54. SHEP Coorperative Research Group. JAMA 1991;265:3255-3264.
55. Matchar DB, et al. Ann Intern Med 1994;121(1):41-53.
56. Capezuti E, et al. J Gerontol A Biol Sci Med Sci 1998;53(1): M47-M52.
57. Alvarez O, et al. Wounds. Wayne, PA: Health Management Publications Inc., 1989:35-51.