The Year in Review: Hot Topics and Timely Articles

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1 The Year in Review: Hot Topics and Timely Articles Kendra D. Sheppard, MD, MSPH, CMD University of Alabama at Birmingham Fairhaven Retirement Center, Birmingham, AL Lecture Objective To present a brief review of recent geriatric literature that pertains to post-acute and long-term care The Details. Adapted from Session 229: This Year in Review for Long-Term Care (Encore 4-5 articles) Article selection arbitrary Dr. Greg Hill (case report) Future Presentation Disclaimer CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 Deborah Dowell, MD, MPH; Tamara M. Haegerich, PhD; Roger Chou, MD Importance Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. Objective To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. JAMA. 2016;315(15): doi: /jama

2 Methods 2014 Systematic Review Update (AHRQ)? articles Grading of Recommendations Assessment (GRADE) methodology Stakeholder Input Clinical Evidence Review Contexual Evidence Review Benefits and Harms Clinical Evidence Review Contextual Evidence Review 2

3 Conclusions/Recommendations The guideline includes 12 recommendations (Box 5). GRADE recommendation categories were based on the following assessment: No evidence shows a long-term benefit of opioids in pain and function vs. no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized clinical trials 6 weeks in duration). Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury). Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacology, with less harm. Recommendations 3

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6 Criticisms Several Editorials Lack of primary/continuing education Substance Abuse/Addiction Disorders Lack of Reimbursement Addiction Treatment Innovation Gap Lack of Research Pharmacological Management of Persistent Pain in Older Persons American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons Journal of the American Geriatrics Society (J AM GERIATR SOC), Aug2009; 57(8): (16p) Risk of dementia in elderly patients with the use of proton pump inhibitors Britta Haenisch Klaus von Holt Birgitt Wiese Jana Prokein Carolin Lange Annette Ernst Christian Brettschneider Hans-Helmut Ko nig Jochen Werle Siegfried Weyerer Melanie Luppa Steffi G. Riedel- Heller Angela Fuchs Michael Pentzek Dagmar Weeg Horst Bickel Karl Broich Frank Jessen Wolfgang Maier Martin Scherer Eur Arch Psychiatry Clin Neurosci (2015) 265: DOI /s Background: Observational studies detect inappropriate use of PPI without adequate documentation for a GI diagnosis (40-60%). Previous study showed a significant association of previous and current PPI use with the presence of B12 deficiency in a population-based sample. B12 deficiency is associated with cognitive decline. Hypothesis: The use of PPIs in elderly patients will be associated with an increased risk of dementia. 6

7 Methods Study Design --German Study on Aging --Inclusion: Age >75, absence of dementia at recruitment, regular contact with GP (at least once per year) Exclusion: NH residents; home visits Baseline and follow-up assessments (18 month interval); 4 visits Neuropsychological testing; MMSE, SIDAM ADL SCAle; Hachinski-Rosen scale, GDS scale, apoe4 genene Statistical analysis; Time-dependent cox-regression model Dependent variable--incident dementia Covariates: age, sex, education, polypharmacy, depression, diabetes, ischemic heart disease, stroke, ApoE4 allele Results Results 7

8 Results Conclusion --First epidemiological investigation showing evidence that PPI use might have an impact on dementia risk. (correlation does not equal causation) Limitations: drug information available at 2 time points; underlying mechanisms unknown Implications for practice: --difficult to wean off --H2 blockers not necessarily better for older adults Case Report: Dr. Greg Hill 8

9 Comparison of Posthospitalization Function and Community Mobility in Hospital Mobility Program and Usual Care Patients A Randomized Clinical Trial Cynthia J. Brown, MD, MSPH; Kathleen T. Foley, PhD, OTR/L; John D. Lowman Jr, PhD, PT; Paul A. MacLennan, PhD; Javad Razjouyan, PhD; Bijan Najafi, PhD; Julie Locher, PhD; Richard M. Allman, MD JAMA Intern Med. 2016;176(7): doi: /jamainternmed Published online May 31, IMPORTANCE Low mobility is common during hospitalization and associated with loss or declines in ability to perform activities of daily living (ADL) and limitations in community mobility. QUESTION What is the effect of an in-hospital mobility program on posthospitalization function and community mobility among a cohort of hospitalized older adults? OBJECTIVE To examine the effect of an in-hospital mobility program (MP) on posthospitalization function and community mobility. Methods Single blind randomized trial; MP vs. UC 100 hospitalized patients >65 (Jan.2010-June 2011; Birmingham VAMC wards Inclusion: cognitively intact; walking 2 wks Intervention: masked assessors assisted pt with walking; behavioral strategy to encourage mobility UC received twice daily visit Statistical Analysis: Change in self-reported Results 9

10 Conclusion No change in ADL function MP group maintained community mobility UC showed clinically significant declines Lower life-space mobility associated with increased risk of death, nursing home admission, and functional decline Limitations Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff Joseph G. Ouslander MD, Ilkin Naharci MD, Gabriella Engstrom PhD, RN, Jill Shutes GNP, David G. Wolf PhD, CNHA, CALA, CAS, Graig Alpert BS, Carolina Rojido MD, Ruth Tappen EdD, RN, FAAN, David Newman PhD JAMDA 17 (2016) 596e601 Background Determining if a transfer of a skilled nursing facility (SNF) patient/resident to an acute hospital is potentially avoidable or preventable is challenging. Most previous research on potentially avoidable or preventable hospitalizations is based on diagnoses without in-depth root cause analysis (RCA), and few studies have examined SNF staff perspective on preventability of transfers. Objectives To examine factors associated with hospital transfers rated as potentially preventable versus nonpreventable by SNF staff. Methods Randomized Clinical Trial of the INTERACT quality improvement program over 12 months Staff 64 US SNFs Intervention: implementation of the INTERACT QI program Measures: Extraction of data from the INTERACT QI tool, a structured, retrospectie RCA on hospital transfers 10

11 RESULTS Significant Transfer Reasons: Fall, fever, decreased intake, functional decline, shortness of breath, new urinary incontinence, leukocytosis, pulse oximetry, Primary care clinician decision, resident/family insistence Results <= 2 days, <30 days Weekend On-site evaluation before transfer Oxygen Other intervention PCP Admitted as inpatient Results No differences 11

12 Conclusion CONCLUSION: SNF staff rated a substantial proportion of transfers as potentially preventable on retrospective RCAs. Factors associated with ratings of preventability, as well as illustrative case examples, provide important insights that can assist SNFs in focusing education and care process improvements in order to reduce unnecessary hospital transfers and their associated morbidity and costs. Limitations Encore Presentations Dr. Milta Little 12

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20 Dr.Debra Bakerjian 20

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23 Dr. Julie Gammack 23

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