NURSING HOME MEDICINE UPDATE

Transcription

1 NURSING HOME MEDICINE UPDATE Bryan Primary Care Conference, Spring 2018 DISCLOSURES No financial disclosures I will mention non-fda approved use of medications

2 OBJECTIVES 1. Review the new CMS rules for Nursing Homes as they affect prescribers 2. Follow evidence-based prescribing practices in the nursing home setting 3. Identify common polypharmacy pitfalls in elders 4. Understand the continuum of care in nursing facilities TABITHA JANUARY 2015

3 CMS FINAL RULE / MEGA RULE New nursing home regulations Published in 2016 Phase 2 in November 2017 stricter rules on antibiotic stewardship and psychotropic prescribing Phase 3 in November 2018 PHONE CALL AT 1:00 AM Betty s urine has been really dark and foul smelling for the last couple days. Tonight she can t sleep and she s really agitated, pacing the floor talking loudly. What will you order? A. Urinalysis with reflex culture B. Seroquel (quetiapine) 25mg prn agitation C. Both of the above D. Neither of the above

4 CHOOSING WISELY

5 ANTIBIOTIC STEWARDSHIP 2018 Most common medications prescribed in the nursing home for inappropriate indications UNMC/DHHS tools and templates Antibiotic Starts and Infection Surveillance (McGeer/Loeb criteria) UTI Respiratory infections Skin and soft tissue GI infections (diarrhea) SBAR templates for physician communication INFLUENZA High risk Elders Immunocompromised Infants Chronic illnesses Please encourage everyone who is in contact with any high risk person to get a flu shot even if the effectiveness turns out to be suboptimal** ** ( season)

6 YOU RECEIVE A NOTICE FROM THE NURSING HOME WHERE YOUR PATIENT RESIDES INDICATING THAT TWO RESIDENTS LIVING DOWN THE HALL FROM HIM HAVE ACTIVE INFLUENZA INFECTION. WHAT DO YOU ORDER? A. Careful observation for symptoms B. Rapid influenza testing; treat if positive C. Oseltamivir (Tamiflu) 75mg po BID for 5 days* D. Oseltamivir (Tamiflu) 75mg po once daily for 14 days or longer* * adjusted if GFR is <60 C. DIFFICILE COLITIS Among NH patients receiving antibiotics, 8-33% will get c. difficile colitis 10-30% NH patients are colonized but asymptomatic Isolation is recommended for active infections Incubation period is 7 days from infection to symptomatic colitis

7 THE MOST IMPORTANT ASPECT OF A C.DIFFICILE PREVENTION PROGRAM IS: A. Washing hands with soap instead of using alcohol sanitizer B. Wearing protective gloves/gown when patients have active infections C. Appropriate antibiotic prescribing WHICH OF THESE SKIN ISSUES NEEDS AN ANTIBIOTIC? A B C D

8 SALLY IS A 70-YEAR-OLD FEMALE WITH SEVERE DEMENTIA AT THE NURSING HOME. THE STAFF TELLS YOU THAT SHE HAS RECENTLY DEVELOPED SERIOUS AGGRESSIVE BEHAVIORS THAT INCLUDE LASHING OUT PHYSICALLY AT CAREGIVERS ON A REGULAR BASIS. WHAT IS THE BEST PLAN OF ACTION? A. Check a UA with C&S B. 1:1 sitter in the room to keep her calm C. Risperidone 1mg IM now D. Lorazepam 1mg PO now E. Investigate the cause of her symptoms BPSD Behavioral and Psychological Symptoms of Dementia Another focus of CMS 2018 Mega Rule Very common Difficult for demented patients to voice discomforts Unmet Needs Overstimulated/Understimulated Decreased inhibitions (FTD) Pain Medical illness/exacerbation

9 NON-PHARMACOLOGIC INTERVENTIONS HAVE NOT CURBED SALLY S VIOLENT OUTBURSTS. YOUR EVALUATION DOES NOT REVEAL ANY TREATABLE UNDERLYING CONDITIONS. AFTER A CONVERSATION ABOUT RISKS AND BENEFITS WITH HER FAMILY AND THE NURSING HOME STAFF, WHICH ONE OF THE FOLLOWING (NON-FDA APPROVED) TREATMENTS WOULD YOU RECOMMEND FOR THIS PATIENT? (**THIS QUESTION COMES FROM THE ABFM) A. Diphenhydramine (Benadryl) B. Aripiprazole (Abilify) C. Clonazepam (Klonopin) D. Mirtazapine (Remeron) E. Ziprasidone (Geodon) YOU ORDER ARIPIRAZOLE (ABILIFY) 10 MG PRN AGGRESSIVE BEHAVIORS RELATED TO DEMENTIA. HOW SOON DOES CMS REQUIRE YOUR NEXT FACE-TO-FACE EVALUATION WITH SALLY IN ORDER TO RENEW THIS PRESCRIPTION? A. 14 days B. 30 days C. 60 days D. 90 days E. At the discretion of the attending physician

10 WHICH OF THE FOLLOWING PRN MEDICATIONS REQUIRES A FACE-TO-FACE EVALUATION EVERY 14 DAYS IN ORDER TO USE AS NEEDED? A. Melatonin for sleep B. Morphine for pain C. Compazine for nausea D. Lorazepam for anxiety E. Senna for constipation PSYCHOTROPIC VS. ANTIPSYCHOTIC Antipsychotic (No exceptions to the 14 day evaluation period for PRNs) Other psychotropics (can be >14 days with prescriber rationale for PRNs) Antidepressant Anxiolytic Sedative/hypnotic Opioid pain medication Any other drug with similar CNS effects

11 WHICH INTERVENTION IS NOT RECOMMENDED TO PREVENT FALLS? A. Medication review to limit polypharmacy B. Bed/chair alarms C. Vitamin D supplementation D. Tai Chi POLYPHARMACY LONG TERM PROTON PUMP INHIBITOR USE HAS BEEN ASSOCIATED WITH WHICH OF THESE COMPLICATIONS? A. C. difficile infection B. Fractures C. Hypomagnesemia D. Poor B12 absorption E. All of the above

12 POLYPHARMACY-- RISK VS. BENEFITS Average NH resident has >10 medications Vitamins Beer s List medications PPI Statins for primary prevention Antihypertensives Etc. MY PATIENT CAN T GO HOME D/C TO REHAB!

13 REHAB VS. LONG TERM CARE 100 skilled days Medicare benefit Admission note justifies the need for rehab care What issue is likely to get worse without this level of monitoring / skilled care? Statement of goals for the short term stay Careful assessment of rehab potential. Return to previous functional status? ADLs due to physical or cognitive limitations Should we consider long term placement or hospice? CLARIFY GOALS OF CARE EARLY St. Louis Rapid Assessment _Geriatric_Assessment_2017.pdf FRAIL (physically weak/frail) SNAQ (nutrition assessment) SARC-F (sarcopenia) RCS (cognitive screen) E-prognosis calculator

14 YOUR 89 YEAR OLD PATIENT IS ADMITTED TO REHAB FOLLOWING HIS 3 RD FALL AT HOME. HE IS 121#, DOWN 20# IN 6 MONTHS. HE REQUIRES ASSISTANCE WITH DRESSING, BATHING, AND MEAL PREPARATION. HE IS ABLE TO FEED HIMSELF AS LONG AS SOMEONE IS THERE TO KEEP HIM ON TASK. WITH HIS WEIGHT LOSS >10% OF HIS BODY WEIGHT OVER THE PAST 6 MONTHS, WHAT IS YOUR RECOMMENDATION? A. Continue encouraging him to eat with assistance as needed B. Prescribe a high protein/calorie supplement C. Prescribe megestrol acetate (Megace) D. Prescribe mirtazapine (Remeron) E. Refer for feeding tube placement CHOOSING WISELY -- AGS

15 QUESTIONS?