Providing Appropriate Care

For clinicians in long-term care (LTC) facilities, providing appropriate care to residents must be a primary aim. However, insufficent understanding of specific resident populations and their care needs can present a barrier to providing appropriate care. In this issue, residents with unique medical and care needs, as well as the appropriate ways of addressing these needs, are discussed. 

US rates of suicide in LTC facilities can range anywhere from 16.5% to 34.8%. It has been suggested that inclusion of indirect self-destructive behaviors, such as refusals to eat or drink and medication non-compliance, increases the suicide rate substantially. Close observation remains a central approach to caring for acutely suicidal patients. Yet, up to 18% of those under close observation in psychiatric units commit suicide. Therefore, better strategies for managing LTC residents at risk for suicide are needed.

Julie Pullen, DNP, GNP, NP-C, identified in the literature regarding suicide in LTC that problematic attitudes, lack of knowledge, and insufficient skill among clinicians in identification and management of suicidal patients present a major barrier to appropriate suicide prevention. To address this problem, Pullen implemented a quality improvement project to improve suicide prevention in LTC.

The quality improvement project included two elements: an evidence-based suicide prevention gatekeeper training program for personnel, and a depression and suicide risk screening instrument for newly admitted residents. A pilot study to test the quality improvement strategy was done at one LTC facility in Montana, a state with a suicide rate that is among the highest in the United States.

Overall, outcomes suggested that the pilot quality improvement project mirrored previous positive results with the gatekeeper training program, but in an LTC setting. The project serves as an example of the benefits that can be gained by encouraging clinicians to improve their understanding of residents’ needs.

Atrial fibrillation (AF) is a common condition among older adults residing in LTC facilities. AF is a major risk factor for stroke, resulting in an overall 5-fold increase in the incidence of stroke in the absence of anticoagulation therapy. Therefore, it is common practice to prescribe oral anticoagulants for the prevention of stroke or systemic embolism in patients with AF.

The risk for stroke in AF is not homogenous but rather a continuum that includes a multitude of factors. Thus, the decision to initiate oral anticoagulant therapy, and the choice of treatment, should be driven by the patient’s individual risk assessment and the net clinical benefit, balancing stroke risk reduction against the risk of serious bleeding.

Candice L Garwood, PharmD, FCCP, BCPS, and Alex C Chaben make this point, discussing the limitations of warfarin and direct oral anticoagulant therapies and reviewing the individual patient characteristics that must be considered when selecting appropriate therapy for stroke prevention in older adults with AF. They also present a comprehensive overview of the use of antiplatelet therapies for stroke prevention in older patients with AF for whom oral anticoagulants are not appropriate. The authors place an emphasis on considering each patient’s need individually in order to make the best care decisions for each patient.

Because most foods are now vitamin-enriched, beriberi, a disease caused by a nutritional deficit in thiamine, is rare in the United States. But older adults, who have a high prevalence of chronic marginal nourishment and who are often taking diuretics, are at higher risk for thiamine deficiency.

Gregory Hill, MD, FACP, CMD, and colleagues present a case report of beriberi in a 59-year-old woman with prior bariatric surgery who was malnourished from recurring nausea and vomiting. Treating this patient with thiamine supplementation successfully reversed the severe cognitive and physical deficits with which she had presented.

Because simple replacement with thiamine can yield remarkable results when there is a deficient state, the authors stress the importance of considering this diagnosis when evaluating older adult patients with symptoms consistent with beriberi.

This case report serves as an example of the benefits that can be provided to residents in LTC by taking the time to consider their specific history, presentation, and care needs in order to determine the care that is most appropriate for them.