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Abstracts from The Journal of the American Geriatrics Society - July 2006
Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium: A Randomized Placebo-Controlled Study
Kees J. Kalisvaart, MD, Jos F. M. de Jonghe, PhD, Marja J. Bogaards, PharmD, Ralph Vreeswijk, RN, MSc, Toine C. G. Egberts, PhD, Bart J. Burger, MD, PhD, Piet Eikelenboom, MD, PhD, and Willem A. van Gool, MD, PhD
Objectives: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium.
Design: Randomized, double-blind, placebo-controlled trial.
Setting: Large medical school–affiliated general hospital in Alkmaar, the Netherlands.
Participants: A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium.
Intervention: Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients.
Measurements: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay.
Results: The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk=0.91, 95% confidence interval (CI)=0.6–1.3); the mean highest DRS-R-98 score±standard deviation was 14.4±3.4 and 18.4±4.3, respectively (mean difference 4.0, 95% CI=2.0–5.8; P<.001); delirium duration was 5.4 versus 11.8 days, respectively (mean difference 6.4 days, 95% CI= 4.0–8.0; P<.001); and the mean number of days in the hospital was 17.1±11.1 and 22.6±16.7, respectively (mean difference 5.5 days, 95% CI= 1.4–2.3; P<.001). No haloperidol-related side effects were noted.
Conclusion: Low-dose haloperidol prophylactic treatment demonstrated no efficacy in reducing the incidence of postoperative delirium. It did have a positive effect on the severity and duration of delirium. Moreover, haloperidol reduced the number of days patients stayed in the hospital, and the therapy was well tolerated. J Am Geriatr Soc 2005;53(10):1658-1666.
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Long-Term Care Liability for Pressure Ulcers
Anne Coble Voss, PhD, RD, LD, Stacy A. Bender, MS, RD, LD, Maree L. Ferguson, PhD, RD, LD, Abby C. Sauer, MPH, RD, LD, Richard G. Bennett, MD, and Peter W. Hahn, JD
More than 20% of residents who have been in long-term care (LTC) facilities for 2 or more years will develop at least one pressure ulcer (PU). Residents suffer pain, disfigurement, and decreased quality of life, and their risk of illness and death increases. LTC facilities face censure from residents, their families, and surveyors and the threat of expensive lawsuits. Lawsuits are typically based on contentions of residents with a PU—or their advocates—that the LTC facility was negligent and failed to provide the care that, by industry standards, it must provide to prevent or manage such wounds (managing pressure, incontinence, and nutrition). In this article, data from 1999 and 2002 are presented, showing that lawsuits related to PUs are increasingly common and costly for LTC owners and care providers. Residents realized some type of recovery against the facility in 87% of the cases (verdicts for the resident plus settlements) and were awarded amounts as high as $312 million in damages. Even LTC administrators who believe that care in their facility equals or exceeds industry standards often settle lawsuits out of court to avoid jury verdicts. The data also show that jury awards were highest for PUs caused by multiple factors and that the highest awards for PUs caused by a single factor were seen when that factor was inadequate nutrition. LTC providers can help improve the health and quality of life of their residents, improve survey results, and minimize their risk of expensive lawsuits by developing, implementing, and documenting a plan of basic measures to prevent PUs. J Am Geriatr Soc 2005;53(9):1587-1592.
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Effect of Acetaminophen on Behavior, Well-Being, and Psychotropic Medication Use in Nursing Home Residents with Moderate-to-Severe Dementia
John T. Chibnall, PhD, Raymond C. Tait, PhD, Bonnie Harman, PhD, and Rebecca A. Luebbert, MSN
Objectives: To evaluate the effect of regularly scheduled administration of analgesic medication on behavior, emotional well-being, and use of as-needed psychotropic medications in nursing home residents with moderate-to-severe dementia.
Design: Randomized, double-blind, placebo-controlled, crossover trial.
Setting: Nursing-home based.
Participants: Twenty-five nursing home residents with moderate-to-severe dementia.
Intervention: Participants received 4 weeks of acetaminophen (3,000 mg/d) and 4 weeks of placebo.
Measurements: Behavior and emotional well-being were assessed using Dementia Care Mapping, an observational method that quantifies time spent in behaviors across 26 domains (e.g., social interaction, unattended distress) and assesses emotional state while behaviors are being observed. Agitation was measured using the Cohen-Mansfield Agitation Inventory. As-needed psychotropic medication use was aggregated from medication logs.
Results: Participants spent more time in social interaction, engaged with media, talking to themselves, engaged in work-like activity, and experiencing unattended distress when they received acetaminophen than they did when they received placebo. Participants also spent less time in their rooms, less time removed from the nursing home unit, and less time performing personal care activities when they received acetaminophen. There were no effects on agitation, emotional well-being, or as-needed psychotropic medication use.
Conclusion: Untreated pain inhibits activity in nursing home residents with moderate-to-severe dementia. Pain treatment in this group may facilitate engagement with the environment. J Am Geriatr Soc 2005;53(11):1921-1929.
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Physicians “Missing in Action”: Family Perspectives on Physician and Staffing Problems in End-of-Life Care in the Nursing Home
Renée R. Shield, PhD, Terrie Wetle, PhD, Joan Teno, MD, MS, Susan C. Miller, PhD, MBA, and Lisa Welch, PhD
Objectives: To understand the roles of physicians and staff in nursing homes in relation to end-of-life care through narrative interviews with family members close to a decedent.
Design: Qualitative follow-up interviews with 54 respondents who had participated in an earlier national survey of 1,578 informants.
Setting: Brown University interviewers conducted telephone interviews with participants throughout the United States.
Participants: The 54 participants agreed to a follow-up qualitative interview and were family members or close to the decedent.
Measurements: A five-member, multidisciplinary team to identify overarching themes taped, transcribed, and then coded interviews.
Results: Respondents report that healthcare professionals often insufficiently address the needs of dying patients in nursing homes and that “missing in action” physicians and insufficient staffing create extra burdens on dying nursing home residents and their families.
Conclusion: Sustained efforts to increase the presence of physicians and improve staffing in nursing homes are suggested to improve end-of-life care for dying residents in nursing homes. J Am Geriatr Soc 2005;53(10):1651-1657.
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A Clinical Trial of a Rehabilitation Expert Clinician Versus Usual Care for Providing Manual Wheelchairs
Helen Hoenig, MD, Lawrence R. Landerman, PhD, Kathy M. Shipp, PT, PhD, Carl Pieper, DPh, Carl Pieper, DPh, Margaret Richardson, OTR, Nancy Pahel, BS and Linda George, PhD
Objectives: To determine the effect of differing methods of dispensing wheelchairs.
Design: Quasi-experimental by day of week.
Setting: Department of Veterans Affairs Medical Center.
Participants: Eighty-four community-dwelling, cognitively intact patients prescribed a standard manual wheelchair.
Intervention: A multifactorial intervention consisting of an expert physical/occupational therapist who used a scripted evaluation that included an evaluation based on medical record review and self-reported and physical performance measures; individualization of the wheelchair and initiation of orders for additional occupational/physical therapy, equipment, or home modifications as needed; multimodal patient education; and telephone follow-up at 3 and 6 weeks.
Measurements: The primary outcome was amount of wheelchair use. Secondary outcomes were shoulder pain, wheelchair comfort and confidence, and home modifications.
Results: The intervention group had significantly greater wheelchair use than usual care at 2 weeks, 3 months, and 6 months (P=.01). Wheelchair use declined monotonically over time for the entire study sample (P<.001). There were no significant differences between the two groups in shoulder pain, wheelchair comfort or confidence, or home modifications.
Conclusion: New wheelchair owners used the wheelchair more often if they received it from an expert therapist using a multifactorial intervention. J Am Geriatr Soc 2005;53(10):1712-1720.
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Experts Recommend Strategies for Strengthening the Use of Advanced Practice Nurses in Nursing Homes
Mathy Mezey, EdD, RN, Sarah Greene Burger, MPH, RN, Harrison G. Bloom, MD, Alice Bonner, APRN-BC, GNP, Mary Bourbonniere, PhD, RN, Barbara Bowers, PhD, RN, Jeffrey B. Burl, MD, Elizabeth Capezuti, PhD, RN, Diane Carter, MSN, RN, Jacob Dimant, MD, Sarah A. Jerro, MA, RN, Susan C. Reinhard, PhD, RN, and Marilyn Ter Maat, MSN, RNC
In 2003, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University Division of Nursing, convened an expert panel to explore the potential for developing recommendations for the caseloads of advanced practice nurses (APNs) in nursing homes and to provide substantive and detailed strategies to strengthen the use of APNs in nursing homes. The panel, consisting of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care, developed six recommendations related to caseloads for APNs in nursing homes. The recommendations address educational preparation of APNs; average reimbursable APN visits per day; factors affecting APNs caseload parameters, including provider characteristics, practice models, resident acuity, and facility factors; changes in Medicare reimbursement to acknowledge nonbillable time spent in resident care; and technical assistance to promote a climate conducive to APN practice in nursing homes. Detailed research findings and clinical expertise underpin each recommendation. These recommendations provide practitioners, payers, regulators, and consumers with a rationale and details of current advanced practice nursing models and caseload parameters, preferred geriatric education, reimbursement strategies, and a range of technical assistance necessary to strengthen, enhance, and increase APNs’ participation in the care of nursing home residents. J Am Geriatr Soc 2005;53(10):1790-1797.
