Controversial, Underestimated, or Solutions Resisted

Long-term care (LTC) providers struggle with many dilemmas. This is not surprising considering the prevalence of chronic diseases and functional disabilities among LTC residents; regulatory, staffing, and billing issues; and a host of other hurdles. This issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC) includes three articles that examine patient and staff dilemmas that are frequently faced in LTC, but that may be controversial, underestimated, or have viable solutions resisted.

Prostate cancer, the most common malignancy among elderly men, is prevalent in LTC residents. In elders with a life-limiting comorbidity, the approach to screening and treatment is challenging and controversial. While many would argue for a conservative approach, the authors of “Managing Localized Prostate Cancer in a Septuagenarian With Dementia” (page 36) provide a compelling report of prostate cancer screening and treatment in a 77-year-old man with moderate dementia. Although the patient could no longer communicate his desires, his daughter requested that the care plan wishes he outlined before his cognitive impairment be honored. The authors explain how they used the American Urological Association’s Guideline for the Management of Clinically Localized Prostate Cancer to determine the optimal treatment for this patient, who had a good result with brachytherapy and was still alive more than 3 years after treatment.

A common yet likely underestimated problem in LTC is visual hallucinations. Although many nonpsychiatric conditions can lead to visual hallucinations, including visual deficits and medication side effects, they often result from a brain disease attributed to a dementing illness. When hallucinations occur in cognitively intact elders, they may fear that reporting the condition will result in their being considered mentally ill or being placed in a more restrictive environment. In “Visual Hallucinations in Long-Term Care” (page 25), the authors report a case of visual hallucinations from Charles Bonnet syndrome in an elderly man. They also provide a review of the differential diagnosis, diagnostic work-up, and various treatment options for patients experiencing visual hallucinations. The authors encourage physicians to educate staff on the prevalence of this symptom so that the staff are equipped to allay patients’ and families’ anxiety over visual hallucinations, which can expedite diagnosis and treatment, leading to better outcomes.

Resident and staff safety is a major concern in LTC. According to the US Bureau of Labor Statistics, nursing home staff are twice as likely as other workers to be injured on the job, with many of these injuries being serious. It is estimated that nursing home staff at the average facility lift a cumulative weight of 1.8 tons in a typical 8-hour day, making them prone to musculoskeletal and joint injuries. Despite the tremendous costs associated with such injuries—estimated to be $7.4 billion in 2008—safe resident-handling programs are not being implemented as rapidly as they should be, even though they can significantly reduce the risk of injuries to both staff and residents. There are certainly many reasons for these delays, including lack of education and staff resistance. In “Creating Safer Environments for Long-Term Care Staff and Residents” (page 42), the author describes a pilot study in one LTC facility that illustrates how nursing homes can develop and implement an effective safe resident-handling program. Although the nursing home staff in the pilot study were initially resistant to implementing the program, a postintervention survey showed a complete change in attitude, with most staff strongly agreeing that only mechanical lifts should be used to move patients. In addition, the unit that followed the safe resident-handling program reported no injuries to staff during resident handling over a 12-month period, whereas the injury experience in the control unit remained largely unchanged.

As for ALTC news, this month we are launching our first theme e-newsletter, with every month providing coverage of a different healthcare issue. March’s newsletter will focus on nutrition issues in LTC. If you do not already receive the ALTC e-news-letters, I encourage you to sign up at www.annalsoflongtermcare.com/e-news.

Thank you for reading!