- Email: [email protected]
Discontinuation of Statins in Elderly Patients with Advanced Dementia and Limited Life Expectancy
Quality Improvement / JAMDA 18 (2017) B11eB20
NH, both short term and long term residents. As the program expanded we added the first NP in July of 2013 and the second in July of 2014. We felt that a Hospitalist group in tight collaboration with onsite nurse practitioners could help decrease our 30 day readmission rate from the hospital. Results: Within the first few months of starting the program we assumed care for almost 80% of the residents at the NH. We noticed that our readmission rate did drop significantly to below 10% within 6 months and has continued to stay consistently low, below the 10% mark. NH care has shifted vastly over the last few years from taking care of primarily cognitively impaired and functionally dependent older adults to include post-acute care. Hospitals are discharging a more medically complex patient population and NH’s are faced with caring for this challenging patient population. Success of such a program has been achieved by managing more acute problems in the NH setting and not using the ER unless it is a true emergency. At our facility we do have the ability to obtain labs, certain x-rays, administer IVF and antibiotics. Success can also be contributed to adopting a proactive approach and seeing complex patients that were admitted from the hospital 24-48hrs after arrival; and following up with them as medically indicated, usually about a week after arrival. By utilizing Hospitalists, transition of care from the hospital was much easier, specifically medication management. We also implemented a palliative approach to care for residents who are failing or those with end stage disease. Conclusions: This type of program did prove to be successful in significantly reducing the 30 day readmission rate from the NH. And we believe it is easily transferrable. Disclosures: All authors have stated there are no financial Disclosures to be made that are pertinent to this abstract.
Deprescribing in the Nursing Home: Phase 1 - PRN Medications Presenting Author: Paula Lueras, MD, Middleton VA Medical Center and University of Wisconsin Author(s): Paula Lueras, MD
Background: Deprescribing is a relatively new concept in medicine and particularly important for older adults. While new recommendations for deprescribing of certain scheduled medication classes have been emerging, there is still a lack of deprescribing guidelines or best practices to assist providers in managing complex medication regimens for nursing home (NH) patients. At least 50% of NH patients receive greater than one unnecessary or potentially inappropriate medication (PIM). The longer the medication list (ML), the greater the potential for adverse drug reactions. Barriers to NH deprescribing include multiple prescribers, unclear duration of treatment, and lack of continuous ML review. Objective/Aim: The aim is to suggest a practical NH deprescribing approach that begins with a comprehensive review and discontinuation of unnecessary or PIM PRN meds with the goals to clean up the ML and optimize individualized PRN medications. Quality Improvement Methods: Badger Prairie Health Care Center (BPHCC) is a 120-bed, non-profit NH that serves Dane County residents with psychiatric disorders. A phase-system was devised by Associate Medical Director (AMD) after meetings with NH leadership and pharmacist to establish deprescribing priorities. This quality improvement (QI) initiative involves 8 Phases, with Phase 1 being focused on PRN meds. Individual MLs were reviewed by AMD for all patients (N¼111) during a 3month period. Systematic review was initiated by first looking at advance directives followed by careful review of each patient’s full ML by AMD, generation of preliminary PRNs to discontinue, RN-AMD review of previous 4-week period of each PRN frequency of use, indication, and patient patterns prior to discontinuation. Average number of PRNs per patient at BPHCC is 7 (range 1-19). Multiple classes of PRNs were ordered for discontinuation on same day for all patients in order to track outcomes which included subsequent requests for PRNs and start-stop dates for newly prescribed PRNs during a post-intervention period of 3 months. Staff training was via in-services, Q&A sessions, and email. Results: A total of 470 PRNs were discontinued for all patients after 3-month review. Top five discontinued PRNs included milk of magnesia (73/470¼ 15.5%), Bisacodyl suppository (62/470¼ 13%), Fleets enema (43/470¼9%), APAP suppository and tablet (16/470¼3.4% each). Average number of PRNs
B13
discontinued per patient was 4. PRN anticholinergics accounted for 68% (19/ 28) of PIMs and PRN bowel meds accounted for 22% (12/54) of unnecessary meds. Start-stop dates for newly prescribed PRNs occurred 92% of the time (48/52). Most PRN requests were related to bowel regimen (31/52 ¼59%). Conclusions: It is feasible to start a deprescribing initiative at a NH with a focus on PRN meds as Phase 1 of the process. A team-based approach to identify PRNs for discontinuation as well as ongoing staff training to obtain start-stop dates are crucial for optimization and maintenance of individualized PRN MLs that are appropriate for each patient. Disclosures: All authors have stated there are no financial Disclosures to be made that are pertinent to this abstract. Discontinuation of Statins in Elderly Patients with Advanced Dementia and Limited Life Expectancy Presenting Author: Swetha Addagatla, MD, University of Alabama, Birmingham Author(s): Swetha Addagatla, MD
Background: Statins play a major role in primary and secondary prevention of stroke and coronary artery disease. In the elderly populations, there is limited evidence regarding their efficacy and benefits. Statins can increase the risk of falls; myopathy and interact with numerous medications. The elderly population is particularly vulnerable to these side effects. In patients with advanced dementia and limited life expectancy, these risks could potentially outweigh the benefits of statins. Objective/Aim: To study the effects of statin discontinuation in geriatric population in the nursing home with particular attention to cardiovascular comorbidities and adverse effects. Quality Improvement Methods: Study was conducted at Park Place Nursing and Rehabilitation Center, Selma AL, an average sized nursing home with 103 beds. A chart review was conducted to determine the number of patients on a statin that had advanced dementia and or limited life expectancy less than five years. A total of ten patients met these criteria. After discussion with either the patient or their medical power of attorney, the statin was discontinued. Patients were then followed over a period of six months and evaluated for the following: 1. Cardiovascular events 2. Falls 3. Pre and Post Manual Muscle Testing 4. Pre and Post Grip Strength 5. Pre and Post Mobility Results: In our study, none of the patients had a cardiovascular event upon discontinuing the statin. There was no significant difference in muscle strength, grip strength, mobility status and falls after stopping the statin. Conclusions: In our limited study, discontinuation of the statin in this population did not improve muscle strength, mobility, grip strength or decrease falls. Further high quality studies are needed to determine the benefits of statins in elderly population, especially in patients with advanced dementia and limited life expectancy. Disclosures: All authors have stated there are no financial Disclosures to be made that are pertinent to this abstract. Fluoroquinolones, You’re Fired! Presenting Author: Christina Bungo, DO, UPMC Author(s): Christina Bungo, DO, David Nace, MD, John Naumovski, MD, Karen Scandrett, MD; and Keisha Ward, MD
Background: Efforts to improve antibiotic prescribing have become essential due to increased bacterial resistance and decreased antibiotic formulation. Long term care (LTC) facilities play a unique role in antibiotic overuse, as studies have found that 47-79% of LTC residents receive antibiotics at these facilities per year. UTIs are the most common reason for antibiotics in LTC, and fluoroquinolones are among the most commonly prescribed. In antibiograms taken from the two largest hospital systems in Pittsburgh, resistance rates to ciprofloxacin were as high as 31%. In addition to rising resistance, the side effects of quinolones, including risk of tendon rupture and QTc prolongation, creates further risk for the elderly. An assessment of prescriptions from our LTC facility revealed that a high percentage of UTIs are treated with quinolones as first line therapy, despite CDC recommendations to use other agents. Therefore, to improve
NH, both short term and long term residents. As the program expanded we added the first NP in July of 2013 and the second in July of 2014. We felt that a Hospitalist group in tight collaboration with onsite nurse practitioners could help decrease our 30 day readmission rate from the hospital. Results: Within the first few months of starting the program we assumed care for almost 80% of the residents at the NH. We noticed that our readmission rate did drop significantly to below 10% within 6 months and has continued to stay consistently low, below the 10% mark. NH care has shifted vastly over the last few years from taking care of primarily cognitively impaired and functionally dependent older adults to include post-acute care. Hospitals are discharging a more medically complex patient population and NH’s are faced with caring for this challenging patient population. Success of such a program has been achieved by managing more acute problems in the NH setting and not using the ER unless it is a true emergency. At our facility we do have the ability to obtain labs, certain x-rays, administer IVF and antibiotics. Success can also be contributed to adopting a proactive approach and seeing complex patients that were admitted from the hospital 24-48hrs after arrival; and following up with them as medically indicated, usually about a week after arrival. By utilizing Hospitalists, transition of care from the hospital was much easier, specifically medication management. We also implemented a palliative approach to care for residents who are failing or those with end stage disease. Conclusions: This type of program did prove to be successful in significantly reducing the 30 day readmission rate from the NH. And we believe it is easily transferrable. Disclosures: All authors have stated there are no financial Disclosures to be made that are pertinent to this abstract.
Deprescribing in the Nursing Home: Phase 1 - PRN Medications Presenting Author: Paula Lueras, MD, Middleton VA Medical Center and University of Wisconsin Author(s): Paula Lueras, MD
Background: Deprescribing is a relatively new concept in medicine and particularly important for older adults. While new recommendations for deprescribing of certain scheduled medication classes have been emerging, there is still a lack of deprescribing guidelines or best practices to assist providers in managing complex medication regimens for nursing home (NH) patients. At least 50% of NH patients receive greater than one unnecessary or potentially inappropriate medication (PIM). The longer the medication list (ML), the greater the potential for adverse drug reactions. Barriers to NH deprescribing include multiple prescribers, unclear duration of treatment, and lack of continuous ML review. Objective/Aim: The aim is to suggest a practical NH deprescribing approach that begins with a comprehensive review and discontinuation of unnecessary or PIM PRN meds with the goals to clean up the ML and optimize individualized PRN medications. Quality Improvement Methods: Badger Prairie Health Care Center (BPHCC) is a 120-bed, non-profit NH that serves Dane County residents with psychiatric disorders. A phase-system was devised by Associate Medical Director (AMD) after meetings with NH leadership and pharmacist to establish deprescribing priorities. This quality improvement (QI) initiative involves 8 Phases, with Phase 1 being focused on PRN meds. Individual MLs were reviewed by AMD for all patients (N¼111) during a 3month period. Systematic review was initiated by first looking at advance directives followed by careful review of each patient’s full ML by AMD, generation of preliminary PRNs to discontinue, RN-AMD review of previous 4-week period of each PRN frequency of use, indication, and patient patterns prior to discontinuation. Average number of PRNs per patient at BPHCC is 7 (range 1-19). Multiple classes of PRNs were ordered for discontinuation on same day for all patients in order to track outcomes which included subsequent requests for PRNs and start-stop dates for newly prescribed PRNs during a post-intervention period of 3 months. Staff training was via in-services, Q&A sessions, and email. Results: A total of 470 PRNs were discontinued for all patients after 3-month review. Top five discontinued PRNs included milk of magnesia (73/470¼ 15.5%), Bisacodyl suppository (62/470¼ 13%), Fleets enema (43/470¼9%), APAP suppository and tablet (16/470¼3.4% each). Average number of PRNs
B13
discontinued per patient was 4. PRN anticholinergics accounted for 68% (19/ 28) of PIMs and PRN bowel meds accounted for 22% (12/54) of unnecessary meds. Start-stop dates for newly prescribed PRNs occurred 92% of the time (48/52). Most PRN requests were related to bowel regimen (31/52 ¼59%). Conclusions: It is feasible to start a deprescribing initiative at a NH with a focus on PRN meds as Phase 1 of the process. A team-based approach to identify PRNs for discontinuation as well as ongoing staff training to obtain start-stop dates are crucial for optimization and maintenance of individualized PRN MLs that are appropriate for each patient. Disclosures: All authors have stated there are no financial Disclosures to be made that are pertinent to this abstract. Discontinuation of Statins in Elderly Patients with Advanced Dementia and Limited Life Expectancy Presenting Author: Swetha Addagatla, MD, University of Alabama, Birmingham Author(s): Swetha Addagatla, MD
Background: Statins play a major role in primary and secondary prevention of stroke and coronary artery disease. In the elderly populations, there is limited evidence regarding their efficacy and benefits. Statins can increase the risk of falls; myopathy and interact with numerous medications. The elderly population is particularly vulnerable to these side effects. In patients with advanced dementia and limited life expectancy, these risks could potentially outweigh the benefits of statins. Objective/Aim: To study the effects of statin discontinuation in geriatric population in the nursing home with particular attention to cardiovascular comorbidities and adverse effects. Quality Improvement Methods: Study was conducted at Park Place Nursing and Rehabilitation Center, Selma AL, an average sized nursing home with 103 beds. A chart review was conducted to determine the number of patients on a statin that had advanced dementia and or limited life expectancy less than five years. A total of ten patients met these criteria. After discussion with either the patient or their medical power of attorney, the statin was discontinued. Patients were then followed over a period of six months and evaluated for the following: 1. Cardiovascular events 2. Falls 3. Pre and Post Manual Muscle Testing 4. Pre and Post Grip Strength 5. Pre and Post Mobility Results: In our study, none of the patients had a cardiovascular event upon discontinuing the statin. There was no significant difference in muscle strength, grip strength, mobility status and falls after stopping the statin. Conclusions: In our limited study, discontinuation of the statin in this population did not improve muscle strength, mobility, grip strength or decrease falls. Further high quality studies are needed to determine the benefits of statins in elderly population, especially in patients with advanced dementia and limited life expectancy. Disclosures: All authors have stated there are no financial Disclosures to be made that are pertinent to this abstract. Fluoroquinolones, You’re Fired! Presenting Author: Christina Bungo, DO, UPMC Author(s): Christina Bungo, DO, David Nace, MD, John Naumovski, MD, Karen Scandrett, MD; and Keisha Ward, MD
Background: Efforts to improve antibiotic prescribing have become essential due to increased bacterial resistance and decreased antibiotic formulation. Long term care (LTC) facilities play a unique role in antibiotic overuse, as studies have found that 47-79% of LTC residents receive antibiotics at these facilities per year. UTIs are the most common reason for antibiotics in LTC, and fluoroquinolones are among the most commonly prescribed. In antibiograms taken from the two largest hospital systems in Pittsburgh, resistance rates to ciprofloxacin were as high as 31%. In addition to rising resistance, the side effects of quinolones, including risk of tendon rupture and QTc prolongation, creates further risk for the elderly. An assessment of prescriptions from our LTC facility revealed that a high percentage of UTIs are treated with quinolones as first line therapy, despite CDC recommendations to use other agents. Therefore, to improve