Comparison Between Medical Residents and Nursing Home Staff and End of Life Attitudes

Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Choline-esterase inhibitor and NMDA-antagonist use in long term care facilities Presenting Author(s): Bassem Morad Mostafa Elsawy, MD, CMD, Methodist Health Systems Author(s): Bassem M. Mostafa Elsawy, MD, CMD; Jennifer Arnouville, DO; Lorie Belitere-Blessing, MD Introduction/Objective: Dementia is and will continue to be one of the most common diagnoses in long term care facilities. Underuse and overuse of ‘dementia drugs’ continue to be debated. Is there a time to start and a time to stop these drugs? Do they really help? Are they cost-effective? Are there strong unbiased studies out there to help us make the ‘right’ decision? Design/Methodology: Literature Review. Results: Results will focus on displaying both sides of the argument, backed up by the most current unbiased literature review. Conclusion/Discussion: Choline-esterase inhibitor and NMDA antagonist use in long term care facilities is a controversial topic of discussion amongst long term care providers. The poster will provide guidance based on reliable, recently published articles. Disclosures: Bassem Morad Mostafa Elsawy, MD, CMD has no disclosures to be made that are pertinent to this abstract. As of submission, Lorie BelitereBlessing, MD and Jennifer Arnouville, DO have not provided disclosures.

Comparative safety and tolerability of alzheimer’s disease treatments Presenting Author(s): Gustavo Alva, MD, ATP Clinical Research Author(s): Gustavo Alva, MD; Jeffrey L. Cummings, MD; Malca Resnick, PhD; Michael Tocco, PhD; Stephen M. Graham, PhD Introduction/Objective: In the U.S., mild to moderate Alzheimer’s disease (AD) is treated with cholinesterase inhibitors (ChEIs), while moderate to severe AD is treated with the NMDA receptor antagonist memantine and the ChEI donepezil. This study reviews the safety and tolerability of the ChEIs and memantine, based upon manufacturers’ data found in prescribing information (PI) documents. Design/Methodology: U.S. prescribing information documents for donepezil, galantamine, rivastigmine, and memantine were obtained from American manufacturers’ websites, accessed in July 2007. Quantitative data about adverse events (AEs) from each PI document were reviewed. In addition, the odds of each AE occurring in the active vs. placebo group for each drug were compared by means of odds ratios. Descriptive safety data are presented without statistical analysis. Results: A review of prescribing information data indicated that the ChEIs donepezil, rivastigmine, and galantamine are associated with cholinomimetic effects. Nausea and vomiting were consistently reported across all ChEI trials as the most common reasons for trial discontinuation. Dizziness, anorexia, and diarrhea were also commonly reported AEs in all ChEI trials. The most frequently reported AEs in memantine trials were dizziness, headache, and confusion. No AEs led to trial discontinuation in ⬎1% of memantine-treated patients and at a frequency greater than that observed in placebo-treated patients. Odds ratio analysis of AEs occurring in more than 5% of patients (rounded to the closest integer) in the active treatment group suggests that, donepezil treatment - compared to placebo - was associated with significantly higher odds of experiencing diarrhea, muscle cramps, and nausea compared to placebo treatment in patients with mild to moderate AD, and of experiencing anorexia, diarrhea, ecchymosis, nausea, and vomiting in patients with severe AD. Galantamine treatment was associated with significantly higher odds of experiencing anorexia, dizziness, headache, nausea, vomiting, and weight decrease compared to placebo treatment. Patients treated with orally delivered rivastigmine had significantly higher odds of experiencing abdominal pain, accident, anorexia, asthenia, depression, diarrhea, dizziness, fatigue, headache, nausea, and vomiting, compared to control; however, a recent study suggests greatly improved tolerability with transdermal administration of rivastigmine. For memantine treatment, significantly higher odds ratios compared to placebo were found for headache. POSTER ABSTRACTS

Conclusion/Discussion: All FDA-approved AD treatments are safe and tolerable, including the co-administration of memantine and donepezil. It is difficult to make comparisons between drugs studied in different trials, but available data suggest that gastrointestinal AEs, typical of the ChEI drug class, may be greatly reduced by transdermal administration. Memantine provides a distinct tolerability profile that may be of use to prescribing physicians. Disclosures: Michael Tocco, PhD is a salaried employee of Forest Laboratories, Inc. Product(s) made by this company related to this topic: Memantine. Malca Resnick, PhD and Stephen M. Graham, PhD are salaried employee of Forest Research Institute. Product(s) made by this company related to this topic: Memantine. Gustavo Alva, MD received clinical research support from Saegis Pharmaceuticals, Inc., Myriad Genetics, Inc., Corcept Therapeutics, Forest Pharmaceuticals, Inc., Janssen, Bristol-Myers Squibb, Novartis, Pfizer Inc., and Eli Lilly and Company. Product(s) made by these companies related to this topic: Flurizam, Mifepristone, Memantine, Galantamine, paliperdone, Exelon, Aricept. Jeffrey L. Cummings, MD received speaker honoraria from Janssen, Novartis, Pfizer Inc., and Forest Pharmaceuticals, Inc. Product(s) made by these companies related to this topic: Cholinesterase Inhibitors and Memantine.

Comparison between medical residents and nursing home staff and end of life attitudes Presenting Author(s): Yasier Awad Basheer-Gowi, MD, University of Louisville Author(s): Yasier A. Basheer-Gowi, MD; Christian D. Furman, MD, MSPH, CMD; Toni P. Miles, MD, PhD Introduction/Objective: The purpose of this project is to compare the attitude towards dying patients among medical residents and nursing home staff. This research designed to assess the attitudes about geriatric and palliative medicine patients at the end of their life. We also compare these two groups of nursing home staff and their understanding of dying patients. This analysis is an extension of prior studies in our group evaluating only nursing home staff attitude towards dying patients (Rhudravarum, AMDA 2006). Design/Methodology: The study sample consisted of 44 medical residents from family and internal medicine (Group A) who have had minimal training in palliative medicine and 38 persons (Group B) from nursing home staff who routinely have direct nursing home patient contact. We used a survey containing 35 items (Frommelt, 2000). We picked one item and used it as a basis to compare the response among the medical residents with the nursing home staff. Results: To illustrate the purpose of this survey consider the single item: ‘I would rather be anywhere else.” The following table shows the difference between the two groups, the young doctors and the nursing home staff:

Agree Disagree No opinion

Medical residents

Nursing home Staff

11.6% 65.1% 23.3%

6.3% 84.2% 9.5%

In our sample, 6% of participants from the nursing home staff indicated agreement with this statement while 9.5% had ‘no opinion’. The majority (84.2%) disagreed with this sentiment. On the other hand, among the medical residents 11.6% agreed, 23.3% had no opinion, and 65.1% disagree with the statement. Young doctors are twice more likely to agree with the statement than the nursing home staff, and two times more likely than the nursing home staff to have no opinion. Also they are less likely to disagree with the statement that the nursing home staff. Conclusion/Discussion: These data suggest that nursing home staff attitudes towards dying patients is different than the physicians in training although the pattern is not uniform. This suggests differences between the two groups in the comfort level with dying patients. We noticed a similar pattern of differences of opinions between nursing home staff and young doctors in all of our 35 items survey. These attitudes may form a barrier to the discussion of goals of care between the two groups, especially if young doctors are expected to lead the discussion. Our surveys are designed to look at this association, and the data will be used to try to improve communication B9

between these two groups. Limitations: These results are based on data from 38 participants from the nursing home staff and 44 from the medical residents. The current work is ongoing to increase the sample for both groups. Disclosures: Christian D. Furman, MD, MSPH, CMD and Yasier Awad Basheer-Gowi, MD have no disclosures to be made that are pertinent to this abstract. As of submission, Toni P. Miles, MD, PhD has not provided disclosures.

Comprehensive geriatric assessment in assisted living setting Presenting Author(s): Robert P. Chen, MD, CentraState Family Medicine Residency Program, Robert Wood Johnson Medical School Author(s): Robert P. Chen, MD; Joshua J. Raymond, MD, MPH; Anshia Bhalla, MD Introduction/Objective: The current trend in long-term care is that elderly residents are entering assisted living facilities later in life but their average of stay in assisted living is shorter in duration. Why? There are higher expectations of the functional capabilities for the elderly population. The vulnerable elderly population often present with complaints that are multi-factorial and chronic. Many times, even after the acute medical conditions are stabilized, the elderly patient is not ready nor is it safe for them to return to his or her baseline home environment. Unfortunately, the option of entering assisted living is most often not contemplated by patients and family until there is a crisis. In addition, there is often no realistic comprehensive plan of care set because of poor ’hand-off’ leading to increased risk for adverse outcomes as well as avoidable readmissions to the hospital. I believe that a comprehensive evaluation tool could be developed that would be used universally by providers and assisted living facilities to facilitate quality and efficient care for the patient utilizing a multidisciplinary approach. Design/Methodology: Design a Geriatric Assessment Form as part of a pilot trial to identify appropriate candidates for AL admission: A) Medical status 1) Diagnosis associated with poor long-term prognosis: a) End stage diseases (ex. NYH IV CHF, severe COPD). b) History of recent CVA, MI. c)⬎ 2 major cardiovascular risk factors. d) Poorly controlled active conditions (Cancer undergoing chemotherapy, DM or HgA1c ⬎9) 2) Non-compliance to medical treatment. B) Cognitive status 1) History of brain injury 2) Mental Status: MMSE, Global deterioration scale 3) Behavior issues C) Functional Status 1) Disabilities 2) ADLs, IDLs D) Environmental status 1) Current 2) Recommended to ensure quality of life and safety E) Communication status: 1) Living Will/POA/Health Proxy 2) Capability to make decisions for self Results: Chart review at an Assisted Living Facility in Freehold, NJ was done. 9 charts were reviewed in order to assess if 5 domains mentioned above were matched prior to admission to the AL facility. Only 3 of 9 patients were considered to be ’appropriate’ AL placement based on the five domains identified. 9 of 9 patients required some level of assistance with medication administration. 4 of 9 patients had more than 9 daily medication usage. MMSE scores ranged from 16/30 to 30/30. 1 of 9 patients did not have advance directive. Only 2 of 9 patients ambulated independently. Conclusion/Discussion: Utilizing this geriatric assessment tool in assisted living admission process will improve the selection process of appropriate assisted living patients and educate the patients and family on realistic environment of care. Further and larger scale studies need to be conducted to test the validity of the tool. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. B10

Continuous positive airway pressure and sleep apnea in long-term care Presenting Author(s): Ashkan Javaheri, MD, Stanford University School of Medicine, VA Palo Alto Health Care Author(s): Ashkan Javaheri, MD; Priscilla Sarinas, MD Introduction/Objective: The prevalence of sleep-disordered breathing (SDB) has reported to be three times higher in patients over 70 compared to their middle-age counterparts. Nocturia, excessive daytime sleepiness, neurocognitive decline, GERD, HTN, diabetes, stroke, and cardiovascular disease are associated with SDB, particularly with obstructive sleep apnea (OSA). Despite different treatment options for OSA, continuous positive airway pressure (CPAP) remains the most reasonable option for older adults. In this poster, we will demonstrate the data available on the efficacy of CPAP treatment and how to implement it in long-term care facilities. Design/Methodology: Review of literature. Results: Nocturia: Although there is no randomized controlled trial, based on three prospective studies, nocturia was significantly reduced after using CPAP in elderly patients with OSA. Daytime Sleepiness and Quality of Life: Current data support the effectiveness of CPAP in reducing subjective daytime sleepiness (ESS) and quality of life (SF-36) in both nondemented patients and patients with Alzheimer disease. Cognition: Cognitive impairment in OSA correlates highly with the severity of breathing disturbance. Although numerous uncontrolled studies show improvement in cognitive function after initiation of CPAP, the results of placebo-controlled investigations do not provide unequivocal support for the hypothesis. GERD: Green et al concluded that treatment with high-pressure CPAP decreases the frequency of nocturnal GERD symptoms by 48%. Since elders require lower CPAP pressure, it is unclear that they get the same benefit. HTN: Data are inconsistent. While some studies have reported decrease in mean arterial blood pressure with CPAP treatment others found no change. Joint national committee (JNC) has recently added sleep apnea as an identifiable cause of HTN. Diabetes: The more severe OSA, the greater the insulin resistance regardless of obesity. The available studies on CPAP effectiveness are inconsistent. However, CPAP treatment in severe OSA may reduce the HgbA1C by 0.5%. Stroke: Severe OSA increases the risk of ischemic stroke, independent of known confounding factors. Additionally, stroke patients present a high prevalence of OSA and those with OSA have a higher mortality after 1 year and poorer functional outcome compared with others. Cardiovascular disease(CVD): OSA treatment is associated with a CV risk reduction of 64% independent from age and pre-existing comorbidities. Treatment should be considered for primary and secondary prevention, even in milder OSA. CPAP therapy may also increase the ejection fraction by 9% in patients with heart failure. Conclusion/Discussion: CPAP therapy should be encouraged in long-term care facilities and nursing staff should be familiar with commonly used CPAP machines. Medicare authorizes payment for CPAP machines and supplies. Regular follow-up with primary provider is important to determine compliance with treatment, improvement in symptoms, and need for pressure adjustments. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Correlation between blood pressure measurements and adjustment of hypertensive therapy in elderly nursing home residents Presenting Author(s): Shahin Ahmed, MD, Long Island Jewish Medical Center Author(s): Shahin Ahmed, MD; Hashim Nemat, MD; Stephen Hom, DO; Charles E. Cal, MBA; Barbara Tommasulo, MD; Roshan Hussain, MPH; Yosef Dlugacz, PhD; Gisele P. Wolf-Klein, MD Introduction/Objective: Almost half of the 1.5 million nursing home residents in the U.S. have hypertension. The seventh report of the Joint National Committee (JNC VII) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure emphasizes the importance of treatment efficacy in elderly hypertensives. Yet, current practice for blood pressure monitoring in the nursing home has not been standardized. Our aim is to study the correlation between blood pressure measurements and therapeutic interventions in the management of hypertensive nursing home residents. Design/Methodology: A retrospective chart review of the nursing home JAMDA – March 2008