AMDA Long Term Care Medicine 2011

Tampa, FL; March 24-27, 2011

Use of Antimuscarinics Not Optimized in Long-Term Care

Tampa, FL—At the recent AMDA—Long Term Care Medicine 2011 meeting, a poster outlining a study evaluating the use of antimuscarinics to treat urinary incontinence in long-term care (LTC) residents showed that 16% of patients who were on antimuscarinics were receiving them inappropriately. In addition, 74% of untreated patients may have been candidates for this therapy. Based on these findings, the investigators note that “The decision to use antimuscarinics in this setting must be individualized with careful consideration and ongoing risk/benefit assessments.” The study was a retrospective review of the AnalytiCare LTC database, which included information on over 90,000 LTC residents in 20 states. Linked clinical assessments and prescription records between 2007 and 2009 were analyzed using the Minimum Data Set (MDS) to determine which LTC residents were more likely to receive antimuscarinics and whether these agents were being used appropriately in LTC residents with urinary incontinence. The investigators found that treated residents were more likely to be younger (≤84 years), white, women, and residing in facilities in the Midwest compared with other parts of the United States. They were also more likely to have depression, anxiety, and osteoporosis than their untreated counterparts. Based on MDS item H1b, a 5-item scale that ranges from 0 (continent) to 4 (incontinent), 63% of treated patients and 69% of untreated patients experienced incontinence more than once a week, as demonstrated by an H1b score of >2. Among the untreated residents, 74% were found to have adequate cognitive and physical function, and may have been candidates for antimuscarinic therapy. In addition, of the treated residents, 16% were deemed not to be appropriate candidates for this therapy. The investigators note several study limitations to their findings. First, the study was a retrospective review of MDS and prescription records. Because MDS assessments do not include a specific code to indicate a diagnosis of overactive bladder, patients were selected based on their H1b score; thus, individuals with urinary incontinence secondary to a condition other than overactive bladder may have been included in the analysis. MDS data are often subjective, as included information may be derived from residents’ and caregivers’ recollection of symptoms, and nurses’ notes and chart data may be misinterpreted by the person conducting the MDS assessment. In addition, urinary continence was measured only intermittently, and standards for defining adequate urinary function are currently lacking. Although the majority of patients (84%) were receiving antimuscarinics appropriately, the study demonstrates room for improvement. It also indicates that patients who need more toileting assistance may still be potential candidates for receiving antimuscarinics, as even individuals requiring extensive assistance with toileting were deemed to have adequate mobility in this study.

Financial support for this poster was provided in part by Astellas Pharma US Inc. and GlaxoSmithKline.

Therapy Eliciting the Senses Reduces Use of Psychotropic Medications in SNF Setting

Tampa, FL—Since the 1970s, controlled multisensory stimulation, also known as Snoezelen, has been used to calm patients with mental disabilities by exposing these individuals to a soothing and stimulating environment, which is created in a room dubbed the Snoezelen room. These rooms provide a serene atmosphere and a sensory experience through the use of equipment that stimulates the senses, including tactile, visual, auditory, olfactory, and taste. Although more common in Europe, Snoezelen rooms have been established in institutions worldwide. During a poster session at the recent AMDA—Long Term Care Medicine 2011 meeting, Scott M. Bolhack, MD, chief executive officer, TLC HealthCare Companies, Tucson, AZ, and colleagues presented their positive experience with the use of this treatment in a skilled nursing facility (SNF). At their SNF, Snoezelen therapy appears to have dramatically reduced the need to administer psychotropic medications to residents with agitation. “The staff at the facility has effectively learned to use the room for residents exhibiting behaviors that are escalating. The typical response in most facilities is to administer psychotropic medication. Our staff uses the room as a nonmedicine intervention very effectively,” Bolhack told Annals of Long-Term Care: Clinical Care and Aging. To assess the effects of Snoezelen therapy, Bolhack and colleagues established two simultaneous quality improvement projects. One project monitored the effect of Snoezelen therapy on patients and the second monitored the use of psychotropic medications, including antipsychotics, antidepressants, antianxiety, and hypnotics, in these patients. Snoezelen therapy was initiated if requested by a resident or if a staff member recommended this therapy for a resident whom he or she thought might benefit from it. Staff trained to use the equipment provided treatment, and these individuals were encouraged to use one or more available sensory therapy before administering an as-needed psychotropic medication. “Within the room are multiple modalities, including aromatherapy, color therapy, and a bubble machine for auditory therapy. In addition, there are several therapies that combine two sensory perceptions, such as soft eggs that constantly change color, eliciting both tactile and visual responses,” said Bolhack. To determine the effect of Snoezelen therapy on patients, Bolhack and colleagues monitored 16 behaviors: 9 negative (ie, restlessness, fidgety hands, wandering, moaning, crying, hollering/yelling out, grinding teeth, grimacing, physical aggression) and 7 positive (ie, calm, verbal response, eye tracking, smiling, sleeping, laughing, display of affection), both prior to initiating treatment and directly thereafter. They found that one-on-one interactions in the room resulted in a decrease in negative behaviors and an increase in positive behaviors; a total of 48 negative and 150 positive behaviors were recorded at baseline compared with a total of 12 negative and 191 positive behaviors following treatment. When examining the use of psychotropic medications, Bolhack and colleagues found that the use of these agents was considerably lower at their institution than state and national averages. For example, 1.7% of patients at their SNF received an antipsychotic versus 25.2% of SNF residents nationally and 23.9% of SNF residents in Arizona. “Snoezelen therapy has worked very well for the residents at our facility. There is a learning curve for the staff at the facility, but once you start seeing an impact, as we did with less use of psychotropic medications, the learning curve improves sharply,” said Bolhack. “In addition, when you look at the time to administer psychotropic medications, delays in obtaining the medication requested from the pharmacy, the time for documenting behaviors once the ordered medication is administered, and, ultimately, the known negative impact of the psychotropic medications on elderly residents, the benefit of Snoezelen therapy becomes quite evident,” he concluded.

Study Shows Increase in AF Among LTC Residents From 1985 to 2004

Tampa, FL—A multiyear survey on atrial fibrillation (AF) in the long-term care (LTC) setting found that the number of residents recognized as having AF and the AF rate have increased almost 4-fold from 1985 to 2004. Furthermore, historical data estimated that the number of LTC residents with AF in 2030 could double to approximately 325,000, according to the results of a study presented at the recent AMDA—Long Term Care Medicine 2011 meeting. Previous studies have estimated the prevalence of AF—the most common sustained cardiac arrhythmia—in the LTC setting. The current study, however, is the first analysis to examine the change over time in AF prevalence among LTC residents. For the study, the researchers analyzed data from the 1985, 1995, 1997, 1999, and 2004 National Nursing Home Survey (NNHS)—the 5 most recent nationally representative NNHS surveys. All residents who had a diagnosis of AF at the time of the NNHS survey (all-cause AF, ICD-9 427.3x) were identified, and their demographics and current medical conditions were recorded. NNHS-provided sampling weights were used to extrapolate national estimates from the survey data, including AF and comorbidity prevalence rates and population estimates. The change in AF prevalence rate was estimated by logistic regressions of AF, using survey year as the sole covariate. The researchers also applied logistic regression using survey year to examine whether changes in AF prevalence over time were related to differences in case-mix, but this time adjusting for age, race, sex, and comorbidities (eg, diabetes, congestive heart failure, Alzheimer’s disease, anemia, cancer). The researchers based the study results on the total sample size of 43,154 residents by years 1985, 1995, 1997, 1999, and 2004 (5238, 8056, 8138, 8215, and 13,507 residents, respectively). The prevalence rate of AF rose steadily from 2.8% in 1985 to 10.9% in 2004. Of the 43,154 residents, the prevalence rates of AF by year were: 2.8% in 1985 (95% confidence interval [CI], 2.3-3.4); 5.1% in 1995 (95% CI, 4.6-5.6); 5.8% in 1997 (95% CI, 5.3-6.3); 6.9% in 1999 (95% CI, 6.3-7.4); and 10.9% in 2004 (95% CI, 10.2-11.5). The population of residents with AF progressively increased from 42,188 in 1985 to 162,061 in 2004, translating to a 184% increase over the entire period. The unadjusted logistic regression model and the model adjusted for case-mix indicated minimal difference in the increased odds of AF (8.2%, 95% CI, 7.1-9.3; 8.0%,m 95% CI, 6.8-9.3, respectively) per year between 1985 and 2004. Assuming (conservatively) that the AF prevalence rate were to remain at the 2004 rate of 10.9%, by applying a projected nursing home population of 3 million, approximately one-third of 1 million LTC residents would be expected to have AF in the year 2030. “Both the prevalence rate and the number of residents with AF have increased substantially in LTC facilities over these survey years. This increase appears to be independent of resident case-mix changes,” concluded the researchers. However, one study limitation noted by the investigators that could have affected the findings is that NNHS data coders could have made changes in the ICD-9 coding for AF and comorbidities across the study years.

Financial support for this poster was provided by Ortho-McNeil Janssen Scientific Affairs, LLC.