Psychotropic Medication Reduction through Innovative Activity Programming

Disclosures: Dean Gianarkis, MS, PharmD is a salaried employee at Pfizer Inc. Robert Fusco, BScPh has stated there are no disclosures to be made that are pertinent to this abstract. Prevention of Venous Thrombo-Embolism in Long Term Care: MultiCenter Project to Study Practice Patterns and Implement Clinical Practice Guidelines Presenting Author: T. Dharmarajan, MD, Montefiore Medical Center North & NY Medical College Author(s): T. S. Dharmarajan, MD, Larry Lawhorne, MD, Aman Nanda, MD, Bikash Agarwal, MD, Parag Agnihotri, MD, Gaileen Doxsie, GNP, Murthy Gokula, MD, Ashkan Javaheri, MD, Madhusudhana Kanagala, MD, Anna Lebelt, MD, Prauna Madireddy, MD, Sourya Mahapatra, MD, Padmavathi Murakonda, MD, Ram Rao Muthavarapu, MD, Meenakshi Patel, MD, Christopher Patterson, MD, Kathleen Soch, MD, Anna Troncales, MD, Kamal Yaokim, MD, Robin Kroft, PhD; and Edward P. Norkus, PhD Introduction/Objective: Introduction: Implementation of preventive measures for Venous Thomboembolism (VTE) through risk assessment based on clinical practice guidelines (CPGs) are variably adopted in long-term care facilities (LTCF). Recent guidelines recommend that prophylactic measures be based on VTE risk assessment, individualized to patient status. In the LTC setting, patients have differing co-morbidity, life-expectancy and quality of life issues (from other environments) warranting an approach by providers that considers comorbidity, patient/caregiver wishes and advance directives. This report summarizes current practices to prevent VTE in 17 LTCF after phase 1 of a 3-phase educational project aimed at improving practice patterns consistent with CPGs. Design/Methodology: Methods: Phase 1 determined the current practice in implementing risk assessment and VTE prophylaxis in 17 geographically diverse LTCF (3260 total beds). Phase 2 provided intervention (education through current CPGs); Phase 3 (in progress) reexamines use of VTE prophylaxis in the same 17 centers following educational phase. Phase 1 results are presented here. Results: Individual sites reported on 377 recent admissions [20-26 cases/site, resident ages 78  12(sd) yrs, 67% female, 9 states represented (CA, IN, LA, NY, NH, OH, RI, SC, TX). Based on current CPGs, our examination revealed that assessment of risk/prophylaxis for VTE occurred in 42.2% of overall admissions; however 38.4% of those (11.7% of total) implemented were inadvertent (e.g. anticoagulated for atrial fibrillation). Another 5.3% were evaluated, but measures not implemented, based on caregiver wishes, life-expectancy or QOL, and 2.7% were contraindicated. Based on current CPGs, 37.6% were inadequately assessed, 2.3% not assessed as subjects were deemed ambulatory, 9.6% not evaluated respecting caregiver or life-expectancy issues, and 0.3% based on history of recurrent falls. We also observed no differences in age (P 5 .9174) or sex (P 5 .883) between those with or without VTE assessment. After submitting phase 1 data, the sub-investigators at the 17 sites received the Physician’s Tool Kit-Antithrombotic Therapy in the LTC Setting (AMDA 2006) & the ACCP (2008) guidelines on VTE prevention, completing Phase 2 of study, prior to implementing measures for VTE prophylaxis in phase 3. Conclusion/Discussion: Conclusions: 1) Phase 1 data suggest that 50.4% of the evaluated residents had risk assessments and prophylaxis for VTE, but that only 30.5% of those evaluated were consistent with current CPGs; 2) An opportunity to implement measures consistent with CPGs through education (Phase 2) exists; and 3) Phase 3 provides an opportunity to study this impact on practice patterns in preventing VTE in LTC (data to be presented, AMDA, March 2010). Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. Proton Pump Inhibitors and Clostridium Difficile Infection in Long Term Care Facility Residents Presenting Author: Andrew Rosenzweig, MD, Abington Memorial Hospital Author(s): Pranav Shah, MD, Joseph Hassey, MD, Doron Schneider, MD, Andrew B. Rosenzweig, MD, Mary Naglak, PhD; and Mary Hofmann, MD Introduction/Objective: Clostridium difficile (C diff) is a spore forming bacillus causing illness ranging from diarrhea to death. Risk factors associated POSTER ABSTRACTS

with C diff infection include antibiotic usage, advanced age, percutaneous endoscopic gastrostomy, increased number of comorbidities and hospitalization. It is more commonly seen in patients residing in long term care facilities (LTCF). Up to 20% of LTCF residents may be asymptomatic carriers of C diff, likely related to two emerging factors: the evolution of increasingly virulent and resistant strains and the increased use of gastric acid suppression medications, particularly proton pump inhibitors (PPIs). Current data indicates the adjusted rate ratio of acquired C diff infection with concurrent PPI use is at 2.9. We attempted to corroborate these findings at our institution. Design/Methodology: This was a retrospective chart review of patients with toxin assay confirmed C diff taking PPIs from January to June 2006 at a 600 bed community teaching hospital. Patients with recurrent C diff were excluded. End points were mortality, ICU admission and length of stay. Patients were grouped as having no comorbidities, 1 comorbidity and . 1 comorbidity. Patients taking and not taking PPIs were compared in each of these three groups in terms of mortality, length of stay and ICU admission using chi square analysis. Results: 82 C diff positive patients were included in the study of which 81% were on PPIs at admission. Of these patients, 40.2% (33/82) were admitted from a LTCF. The average age was 71  17 years. All 13 patients (78  9 years) who died were taking PPIs and were approximately 7 years older than the mean. 96% of the patients who required ICU care after diagnosis of C diff infection were on acid suppression. More than 80% of patients with evidence of colitis on computed tomography were taking PPIs. The average length of stay after a C diff diagnosis for patients with no comorbidities, 1 comorbidity and .1 comorbidities) was 6, 5 and 6 days more in those taking acid suppression therapy as compared to patients who were not (p . 05). Conclusion/Discussion: Acid suppression therapy and its effect on morbidity and mortality from C diff infection was not statistically significant in this study. Trends identified included longer hospitalization and increased ICU admissions in patients on acid suppression. Acid suppression medications have been shown to have multiple, potentially serious side effects in elderly patients and the risks and benefits of using these medications without absolute indications must be carefully considered. While these trends require further evaluation through larger, prospective studies, this study does emphasize the vigilance required of geriatricians taking care of patients in LTCFs where more virulent C diff strains are increasingly prevalent. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. Psychotropic Medication Reduction through Innovative Activity Programming Presenting Author: Dan Osterweil, MD, FACP, CMD, University of California, Los Angeles, Valley Geriatric Medical Group, Inc Author(s): Dan Osterweil, MD, CMD, Smadar D. Gal, RN, Limor Ness; and Kelly A. Hickey Introduction/Objective: Introduction: In August of 2008, a 72 bed nursing home in Los Angeles, California instituted an enhanced recreational activities program that aimed to increase participation among the facility’s residents regardless of their care and cognitive levels. This was accomplished through a variety of programs designed to stimulate the resident’s senses, promote well-being and inspire creativity. Objective: The objective of this exploratory study is to determine whether SNF residents undergoing psychotropic therapy who regularly participated in a high quality recreational program experienced a reduction of psychotropic medication use. Design/Methodology: Direct observation and medication data review. Resident participation levels were determined by conducting systematic observations of activities every 15 minutes across five discrete observation periods. A total of fifty-six ‘‘15 minute snapshots’’ were obtained. Medication data for those residents on psychotropic therapy as of August 2008 was abstracted from independent Pharmacy Consultant Reports. Results: Since the enhancement, the overall use of psychotropic medications among residents decreased 5.2%. Compared with baseline levels, hypnotic medication use was reduced by 5.8%. Anti-psychotic medications were reduced by 4.5%. There was an 8% reduction of antidepressants B19

and 2.5% reduction of anti-anxiety medication. Overall use of psychotropic medication at the SNF fell significantly below state and national norms. Conclusion/Discussion: An active and consistent activity program can produce tangible quality of care outcomes in addition to their impact on residents’ quality of life. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. Quality Improvement Issues: Weight Loss Presenting Author: Erin Cooper, MD, University of Nebraska Medical Center Author(s): Erin L. Cooper, MD; and Brenda Keller, MD Introduction/Objective: Unintentional weight loss in the nursing home is an important clinical problem that warrants early identification and intervention. The accurate identification of residents with true weight loss is imperative so that efforts and resources may be focused on those who need them the most. In our facility, we undertook a quality improvement project with the goals of improved accuracy of weight collection and documentation, reliable identification of residents with true weight loss, improved accuracy and documentation of meal and supplement intake, and to increase caloric intake from meals and snacks, rather than from liquid nutritional supplements. Design/Methodology: A multidisciplinary team, including physicians, nurses, a registered dietician, dietary staff, and restorative therapist, met in a series of focus group sessions to identify key factors contributing to weight loss. Areas identified include, inconsistent weight values, errors in documentation of weights, inconsistent recording of dietary intake, and unreliable delivery of snacks to residents with weight loss. Results: A weight tracking flow sheet was developed and implemented for all residents. The flow sheet included a protocol to trigger an immediate recheck of the weight if the value differed plus or minus three pounds compared to the previous weight. All bath aides attended an in-service training session reviewing the proper use of scales in the facility and use of the flow sheet. Using this system we were able to more accurately identify residents with true weight loss and its associated complications. This was reflected in the Minimum Data Set (MDS) indicator for nutrition and eating referred to as ‘‘residents who lose too much weight’’, where we observed a decrease from 17.7% of residents (98th percentile in the state) to 5.1% of residents (33rd percentile in the state) over a 30 day period after instituting the weight tracking flow sheet. Unanticipated results were the identification of multiple systems barriers to implementing a snack program and decreasing supplement use. Conclusion/Discussion: Improved accuracy of weight documentation increases the reliable identification of residents with true weight loss in the nursing home, and can be accomplished with a low cost intervention, requiring little time and training. Multiple systems barriers exist which may contribute to increased nutritional supplement use in place of caloric intake from meals and snacks. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. Quality Improvement Project: Vitamin D Supplementation in the Nursing Home Residents Presenting Author: Mamata Yanamadala, MBBS, Duke University Author(s): Mamata Yanamadala, MBBS; and Gwendolen Buhr, MD Introduction/Objective: Elderly nursing home residents are at high risk for falls, which can lead to fractures. Several randomized controlled trials showed that vitamin D supplementation reduces falls in nursing home residents. For instance, one meta-analysis of vitamin D supplementation in elderly nursing home residents found a 22% fall reduction; a second meta-analysis found that 700-800IU vitamin D is needed for fracture reduction. In our nursing home, review of medication administration records of all patients (101) revealed that 27 (26.7%) patients received no vitamin D supplementation, 39 (31.3%) received inadequate vitamin D (\800IU per day), and the remaining 35 (42%) received adequate dosage (800IU a day). These data revealed a need for intervention. B20

Design/Methodology: We used several plan-do-study-act (PDSA) cycles to test and implement changes. Initially, we identified the patients who were not on adequate dose of vitamin D and made a recommendation to start these patients on supplementation totaling 800IU, using the principles of academic detailing. Next, we educated the nurses on the importance of adequate vitamin D supplementation, and asked them to identify patients who were not on adequate vitamin D supplementation and to notify the physicians. As a motivator, charts were displayed at each nurses’ station that graphically displayed the current number of patients on that unit who were taking at least 800IU of vitamin D. These charts were updated monthly. The staff was told that their floor would win a prize if they met 80% adherence rate. To raise awareness and serve as a reminder, pens with the saying ‘‘800 D a Day Keep Falls Away’’ printed on them were distributed. The admissions coordinator was requested to place a reminder for the physicians to start vitamin D on eligible new patients coming into the facility. Three months after the goal of 80% adherence was achieved, the residents who were experiencing falls were examined for the possibility of vitamin D deficiency. The falls committee was educated on importance of vitamin D in reducing falls. The falls committee was advised to contact the physicians of the patients who were vitamin D deficient while on 800IU of vitamin D to start them on 50,000IU of vitamin D. Results: The number of patients taking at least 800IU of vitamin D ranged from 11% to 55% (average 29.25%) for the four nursing units at the beginning of the project. After several PDSA cycles and 5 months the rate was between 81% and 93% (average 86%). Three months after achieving 80% adherence rate of Vitamin D there was no change in the rate of falls in the facility. Out of 10 patients that kept falling while on 800IU of vitamin D, 3 were found to be vitamin D deficient. Conclusion/Discussion: Multiple PDSA cycles were run to achieve the target adherence rate. A multidisciplinary approach helped to increase the adherence rate. There was no difference in the total number of falls in the facility but this study was not designed to prove the effect of vitamin D on falls reduction. The Quality Improvement interventions used in this study could be adopted by other nursing facilities. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. Recognizing the Impact of Obstructive Sleep Apnea Syndrome and Treatment on Activities of Daily Living in Nursing Home Residents Presenting Author: Pauline Daley, MD, Western Maryland Hospital Center Author(s): Pauline M. Daley, MD; and Kalim Ahmed, MD Introduction/Objective: Impairment in the activities of daily living (ADL) decreases quality of life, and has direct implications for long term care needs. The association between sleep disordered breathing (SDB) and functional impairment is well recognized, however studies are sparse on whether treatment of elderly patients with SDB improves ADL. Obstructive Sleep Apnea (OSA) syndrome is a treatable cause of disordered breathing in which the upper airway closes repeatedly during sleep (1). We present a case study of an elderly patient with OSA syndrome, and severe functional impairment who improved with treatment. Design/Methodology: CASE STUDY: A 69-year old black woman was admitted to a nearby hospital because of a change in mental status, right hemiparesis and slurred speech. She lived independently but has a history of recurrent hospitalizations and falls. Her comorbidities include diabetes mellitus, hypothyroidism and hypertension. Neuroimaging was negative. Other investigations were unrevealing. She was treated clinically as if she had a stroke. After a few days, she was transferred to the hospital’s acute rehabilitation program but soon did not meet the criteria to warrant that level of care. Repeat CAT scan of the head was negative. She was transferred to our nursing home. The patient was an obese black woman of short stature. Her vital signs were stable. She had a short thick neck. She had coarse tremors of the hands and mild weakness in the right lower extremity. Her ADL were significantly impaired with a Barthel ADL index (BI) of 10. BI is a 0-100 point scale often used in geriatric medicine to assess ADL; 0 meaning maximal impairment and 100 no impairment. For the first several weeks the patient failed to show progress in the physical medicine and rehabilitation program. Her stay was complicated by falls, obtundation and confusional states. The patient sustained multiple falls from her wheelchair. "Urgent" JAMDA – March 2010