Ensuring Appropriate Treatment

Deciding upon appropriate treatment for elders is a challenge, as there are numerous variables to consider, particularly for persons in long-term care (LTC), who tend to be frail, have many comorbidities, and are taking multiple medications. Further, because older adults, particularly those with pronounced health issues, are generally excluded from clinical trials, there is also a paucity of data that specifically relates to the use of various treatments in these persons. With all of these factors to contend with, overtreatment and inappropriate treatment can easily result, regardless of care setting, but particularly when there is a care transition. In this issue of Annals of Long-Term Care: Clinical Care and Aging^®, we include several articles that shed light on how to ensure LTC residents receive appropriate treatments. 

In “Palliative Care of Pressure Ulcers in Long-Term Care”, Torrie Burt, MSN, CRNP, provides a comprehensive review of the assessment and management of pressure ulcers for patients receiving palliative care, including how to address the distressing symptoms and complications caused by these wounds. Although pressure ulcers are common in LTC settings, with reports indicating that up to 23% of residents have them, information on how to optimally manage them when a person is receiving palliative care is limited. Burt’s article reviews the currently available body of literature, which, while limited, indicates that a change in treatment approach may be warranted when addressing pressure ulcers in patients receiving palliative care. For example, repositioning to prevent pressure ulcers or worsening of existing pressure ulcers is generally regarded as essential to pressure ulcer protocols, but discontinuing frequent turning of these patients may be desirable if it causes patients to have pain, distress, or sleep disturbances. In these patients, less aggressive treatments are generally desirable, particularly if this approach can improve quality of life and considers patients’ and their families’ preferences and values.  

In “Care Coordination Today: What, Why, Who, Where, and How?”, Richard G. Stefanacci, DO, examines the many issues surrounding care coordination, which has been noted by the Institute of Medicine and other medical organizations to be a critical  strategy for optimizing care. When care is not coordinated, particularly between settings, miscommunication and misunderstandings may cause patients to receive inappropriate care. As Stefanacci notes, although care coordination can protect patients from the harms of inappropriate care and reduce healthcare costs, there are hurdles with implementing care-coordination models. Practices will have to decide who oversees care coordination, which setting should handle care coordination, how to finance care coordination, and which methods to use in care-coordination efforts. The article proceeds to provide insights on the characteristics shared by some of today’s best care-coordination models. Not surprisingly, having patients and their families at the center of care planning and delivery is essential.

In “Involuntary Weight Loss After Switching Acetylcholinesterase Inhibitors” and its associated commentary, the authors review the case of a patient who lost almost 50 lb after his acetylcholinesterase inhibitor was switched from donepezil to galantamine because of a change in formulary at the outpatient clinic where he was being treated. Because of his weight loss and an increase in falls, the patient was subsequently admitted to a nursing home. In accordance with the Minimum Data Set 3.0, his weight loss was promptly addressed, which included switching him back to donepezil. The patient’s appetite improved shortly thereafter and he regained most of his weight. As this case shows, even a seemingly insignificant swap in medications can have a profound impact on a patient; thus, all medication changes need to be carefully considered, even if substituting an agent in the same medication class.

Finally, I encourage you to read this month’s AGS Viewpoint (page 14), which outlines five treatment approaches that should be used with caution in LTC settings and includes a summary of the evidence-based rationales for each recommendation. We’d like to know if you agree with these approaches and if you have any rules of thumb of your own for fostering safe and appropriate treatment of LTC residents. Send your thoughts to Allison Musante, Associate Editor, at
amusante@hmpcommunications.com. Your response may be published in an upcoming issue of the journal.

Thank you for reading!