When Acute and Chronic Conditions Threaten Life

Although many long-term care (LTC) patients have several chronic conditions, these conditions and their symptoms can generally be managed successfully with medications and other interventions. Deciding on the best management approach in patients with multiple comorbidities can be challenging, but these challenges become amplified when an acute condition develops or a chronic illness progresses to a critical stage. This issue of ALTC examines identification of and intervention for three life-threatening conditions commonly encountered in LTC.
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Patients in long-term care (LTC) have cognitive and/or physical impairments that impede their ability to live independently. Although these patients may have several chronic conditions, these conditions and their symptoms can generally be managed successfully with medications and other interventions. Deciding on the best management approach in patients with multiple comorbidities can be challenging, but these challenges become amplified when an acute condition develops or a chronic illness progresses to a critical stage. In such cases, prompt identification and treatment of these problems is essential. In this issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC), we examine the identification of and interventions for three life-threatening conditions commonly encountered in LTC facilities: aortic stenosis (AS), venous thromboembolism (VTE), and delirium.

In the first article, “Aortic Stenosis: What Long-Term Care Providers Need to Know”, the authors review the presentation and diagnosis of AS and its current management options. No medications are available to treat AS, and until recently, surgical aortic valve replacement was the only treatment option. But many patients were not candidates for this treatment due to its substantial operative risks. However, the advent of transthoracic aortic valve replacement (TAVR) has changed the therapeutic landscape, enabling many more patients, including older adults, to become candidates for AS treatment. Because residents in LTC tend to have many chronic conditions, they may be overlooked for this potentially life-extending treatment that can also significantly improve their AS symptoms (eg, syncope, angina). Although LTC providers cannot determine their residents’ ultimate candidacy for TAVR, they will be expected to play a greater role in appropriately referring patients to the specialists who can make that determination.

In the second article, “Venous Thromboembolism Prophylaxis for Chronically Immobilized Long-Term Care Residents”, the authors review chronic immobility as a risk factor for VTE and discuss when prophylaxis is warranted. As the authors note, the current medical literature does not recommend prophylaxis for chronic immobility as a single risk factor for VTE; however, many residents in LTC have VTE risk factors beyond chronic immobility. Therefore, LTC providers need to carefully weigh the risks (eg, of bleeding) and benefits of prophylaxis on an individualized basis until studies are available to better define VTE risks and recommendations for LTC residents.

In the third article, “Using Standardized Case Vignettes to Evaluate Nursing Home Staff Recognition of Delirium and Delirium Superimposed on Dementia”, the authors report the results of their study, which was undertaken to assess nursing home staff knowledge regarding delirium detection and the most common causes of delirium. The authors found overall poor recognition of delirium and delirium superimposed on dementia, which did not improve over the course of their 12-month study. Previous studies using vignettes to assess delirium recognition among acute and home care providers showed similar results. However, compared with acute care providers, LTC staff are more likely to know what kind of behaviors are normal for their patients. Therefore, the authors stress the importance of educating all levels of nursing home staff, including nursing assistants and certified nursing assistants, about the signs and symptoms of delirium. As they note, prompt recognition can be both life-saving and prevent unnecessary suffering and hospitalizations.

We welcome your thoughts on the articles in this issue of ALTC. Responses can be sent to our associate editor, Amanda DelSignore, at adelsignore@hmpcommunications.com.

Thank you for reading!