Longterm Care

By Joel Doughten

DEFINITION OF ASYMPTOMATIC BACTERIURIA

• A positive urine culture does not prove that a patient has a urinary tract infection (UTI). • The term asymptomatic bacteriuria (ASB) is used to suggest that a patient has bacteria in the

urine but not a true infection• A true UTI is bacteriuria in association with specific symptoms arising from the urinary tract. • Women without urinary tract symptoms but with two consecutive urine cultures containing

100,000 colony-forming units per milliliter (cfu/mL) of a single isolate, obtained by clean catch of a voided specimen, have, by definition, ASB.

• ASB in men is defined in a similar way, except that only one urine culture with 100,000 cfu/mL of a single organism is needed to meet the definition.

• A catheter specimen from asymptomatic men or women that grows 100 cfu/mL also meets the definition of ASB.

• Patients without urinary tract symptoms but with significant bacteria in their urine have ASB and not a UTI.

• Asymptomatic Bacteriuria in the Nursing Home by• Timothy J. Benton, MD, Rodney B. Young, MD,• and Stephanie C. Leeper, MD, FACP

PREVALENCE OF ASB• The elderly, especially those residing in long-term-care facilities, more commonly have ASB than the general population.

• About 25-50% of women and 15-40% of men living in long-term-care facilities have ASB.

• The prevalence rates in elderly women and men outside of the nursing home are 10.8-16% and 3.6-19%, respectively.

• The high prevalence among nursing home residents presents a particular problem since ASB resembles UTI on paper, but treatment of ASB is unnecessary.

• Clinicians caring for long-term-care residents need to be able to recognize ASB and distinguish it from UTI, especially as the number of elderly people residing in nursing homes increases.

• Recognizing that ASB is common among residents living in long-termcare facilities, and that it is an entity separate from UTI, will improve patient care.

The challenge• The challenge for the clinician is not in deciding

whether to treat the nursing home resident with ASB, but rather in distinguishing ASB from UTI.

• The most reliable indicator of a true UTI in long-term care residents is symptoms specifically arising from the urinary tract, such as flank pain, dysuria, urinary frequency, or any combination of these, and not just an abnormal urinalysis, a positive urine culture, or nonspecific clinical changes.

Table II: Treatment Recommendations for Asymptomatic Bacteriuria

• Type of Resident Treatment

• Nursing home elderly Not recommended

• Women with diabetes Not recommended

• Persons with planned Start antibiotic therapy before procedure;

• transurethral resection of prostate discontinue after procedure unless catheterized

• Pregnant women treat

Table III: Similarities and Differences of ASB and UTI

• ASB UTI• Similarities Positive urine culture Positive urine culture• Pyuria present* Pyuria present*• Differences May be found in persons Less likely to be found in• with nonspecific symptoms persons with nonspecific• symptoms†‡• No localized urinary tract Symptoms localized to symptoms urinary tract• * Pyuria present in 30% of nursing home elderly with or without bacteriuria4 and• 90% with ASB.1• † Positive predictive value of a positive urine culture and no localizing urinary

tract symptoms is 10% in nursing home residents.3• ‡ Positive predictive value of fever, a positive urine culture, and no localizing

symptoms is 12% in nursing home residents.4,21

In long-term care facilities, a fever threshold of

101ºF should be used as a trigger to evaluate for

infection. A) True B) False

Answer

•  B) False

When evaluating fever in long-term care facilities, a complete

blood cell count should be performed within _______ of

onset of symptoms. A) 12 to 24 hr B) 24 to 36 hr C) 36 to 48 hr

 D) 5 days

Answer

• A) 12 to 24 hr

The degree of pyuria helps differentiate asymptomatic bacteruria and pyuria from

a true urinary tract infection. A) True B) False

Answer

•  B) False

Choose the correct statement about respiratory tract infection in long-

term care facilities. A) Consider transferring patients

with O2 saturation <90% B) Chest x-ray detects 75% to 90%

of pneumonia C) Purulent sputum specimens may

help narrow antibiotic choices D) All the above

Answer

•  D) All the above

When to suspect infection in long-term care facilities

• 1) decline in functional status• new or increasing confusion,• incontinence, • falls, • worsening mobility or oral intake,• or change in cooperativeness• 2) presence of fever• When all patients with fever 101ºF evaluated for infection, only 40% of

infected patients detected• consider change in patient’s baseline temperature or lower fever threshold

(99ºF-100ºF) as trigger to evaluate for infection• as baseline temperatures tend to be lower in geriatric population, fever

threshold of 101ºF too high for this population

Evaluation• evaluate respiratory rate, hydration status, mental

status, and organ systems• small studies suggest breathing rate of 25 breaths/min

represents lower respiratory tract infection (RTI) 80% to 90% of time

• no data about other vital signs (eg, tachycardia)• likelihood of detecting RTI based on physical

examination high (93%); 80% of patients with documented RTI have cough, and 70% have rales “and perhaps some fever”

Hypertensive Urgency Definition• Common names:

High Blood Pressure Urgency• Hypertensive Urgency• What is hypertensive urgency?

A person with hypertensive urgency has a severely elevated blood pressure, but has no symptoms. In someone with hypertensive urgency, the systolic blood pressure (top number) is over 220 or the diastolic blood pressure (bottom number) is over 115. Hypertensive urgency requires treatment within a few days, and usually responds well to blood pressure medication. 

What are the symptoms of a hypertensive urgency?There are usually no symptoms associated with hypertensive urgency. Hypertensive urgency becomes hypertensive emergency if symptoms develop, such as chest pain, difficulty breathing, headacheor vision changes.

How does the doctor treat a hypertensive urgency?Treatment for a hypertensive urgency includes medications to slowly bring down the blood pressure.

Hypertensive emergencies• Hypertensive emergencies are characterized by severe elevations in BP

(>180/120 mmHg) complicated by evidence of impending or progressive target organ dysfunction.

• They require immediate BP reduction (not necessarily to normal) to prevent or limit target organ damage.

• Examples include hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute left ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, or eclampsia.

• Hypertensive urgencies are those situations associated with severe elevations in BP without progressive target organ dysfunction.

• Examples include upper levels of stage II hypertension associated with severe headache, shortness of breath, epistaxis, or severe anxiety.

• The majority of these patients present as noncompliant or inadequately treated hypertensive individuals, often with little or no evidence of target organ damage.

Hypertensive Emergency• Acutely elevated blood pressure, particularly diastolic pressure > 120–130 mmHg

without evidence of target organ damage. Goals: Lower mean arterial pressure to goal or near goal within several hours. Oral medications can be used.

Hypertensive emergency: Hypertension with evidence of target organ damage ( brain, heart, kidneys, eyes). Goals: The goal of initial therapy is to terminate ongoing target organ damage. Lower mean arterial pressure by 20- 25% or diastolic pressure to <100 to 110 mmHg within 30–60 minutes.

(JNC VI) states that the initial goal of therapy in hypertensive emergencies is to reduce mean arterial pressure (MAP) by 20 to 25% (within minutes to 2 hours), then toward 160/100 mmHg within 2 to 6 hours, avoiding excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia.9 If symptoms worsen (e.g., an increase in chest pressure, a decline in mental status) during the reduction of systemic blood pressure, the rate of the reduction should be slowed or treatment should be temporarily halted.

How Aggressive to treat BP in Urgency

• there is no evidence to suggest that failure to aggressively lower BP in the ER or any other location is associated with any increased short-term risk to the patient who presents with severe hypertension and no symptoms.

• Such a patient may benefit from adjustment in their antihypertensive therapy, particularly the use of combination drugs, or reinstitution of medications if noncompliance is a problem.

• Most importantly, patients should not leave the ER without a confirmed followup visit within several days.

Oral agents for Hypertensive Emergencies

• Captopril• Dose: 12.5 to 25 mg orally repeat as needed or give SL. 

Onset/ duration: 15-30 min/6-8 hr, SL 10-20 min/2-6 hr.• Clonidine Dose: Clonidine 0.1-0.2 mg orally x 1, followed by 0.05 to

0.1 mg every 1 to 2 hours to a maximum dose of 0.6 to 0.7 mg. Onset/ duration: 30-60 min/8-16 hr.

• Labetalol Dose: 200-400 mg orally, repeat every 2-3 hours. Onset/ duration: 1-2 hr/2-12 hr.

• Other Many patients may require at least 2 agents. Additional agents to consider are (1) lasix 20mg (rpt as necessary) (2) nifedipine SR 30mg x1 (3) felodipine 5 mg x 1.

Treatment of behavioral symptoms related to dementia

•  Neuropsychiatric symptoms are common in dementia.

• These symptoms include agitation, aggression, delusions, hallucinations, and wandering.

• Depression and sleep disturbances can also occur with dementia.

Aggression • Agitation and aggression may be provoked by several mechanisms

in Alzheimer disease (AD):

• Confusion or misunderstanding due to cognitive, language, or memory deficits

• Frightening, paranoid delusions

• Depression in a patient too impaired to express distress in any other manner

• Sleep disorders

• If aggression appears to emerge in moments of confusion, management is probably behavioral after analysis of the antecedent episodes. If delusions appear to trigger aggression, treatment with antipsychotic medication may be helpful 

Psychosis •  Delusions are more common than hallucinations in demented patients, with a reported prevalence

of 30 percent of patients with severe AD [1]. A long-term follow-up study suggests that it may be more pervasive; among 456 patients with mild to moderate AD followed for a mean of 4.5 years, 34 percent had delusions at baseline, but 70 percent had them during at least one evaluation [ 10]. Hallucinations were present in 7 percent at baseline and in 33 percent at some point over the course of follow-up.

• Paranoid delusions in particular can be very distressing to the patient or caregivers. Common paranoid delusions include beliefs that the house has been invaded, that personal objects have been misplaced or stolen, that family members have been replaced by impostors (Capgras syndrome), or that spouses have been unfaithful.

• The presence of visual hallucinations early in the course of a dementing illness suggests Dementia with Lewy bodies (DLB) disease, a disorder with very specific management issues.

• Nonetheless up to 20 percent of patients with AD can present with hallucinations, mostly commonly visual, less commonly auditory and rarely olfactory hallucinations.

• Delusions or hallucinations may be fleeting or unobtrusive. Pharmacotherapy is not necessary if neither the patient nor the family are disturbed by them; therapy is warranted if these symptoms become problematic. The presence of either delusions or hallucinations is associated with increased risk for cognitive and functional decline; hallucinations predict institutionalization and death

Sleep disorders • Dementias may produce different sleep disturbances:

• Patients who have PD or progressive supranuclear palsy (PSP) appear to have very shallow sleep - mostly stage 1 and 2 - and are probably awakened easily. They also have trouble turning in bed, and that may make them more restless in bed.

• Patients with PSP may be awakened by choking episodes at night that are triggered by sleeping on their backs.

• Patients with PD also probably have more periodic leg movements of sleep (PLMS or restless legs). These are highly treatable by shifting or adding a small dopamine agonist dose at bedtime.

• Patients with dementia with Lewy bodies (DLB) disease have a high incidence of rapid eye movement (REM) sleep behaviors. Nocturnal confusion may arise from awakening out of REM sleep into a dark room. This is also treated fairly easily with low doses of clonazepam.

SPECIFIC TREATMENTS 

•  A number of treatment options exist for the management of neuropsychiatric symptoms in dementia. However, efficacy is incomplete and often comes at a cost of side effects, including increased mortality. A proactive approach, with collaboration between health care providers, patients, caregivers, and community agencies may provide additional benefits in managing these troublesome symptoms

Nonpharmacologic management •  Increasing evidence suggests that nonpharmacologic

measures, including behavioral methods, may be effective in reducing agitation and anxiety in patients with dementia [26]. Behavioral interventions employ different strategies and techniques. These include identifying any preceding events that generate agitation, determining whether unmet needs can be anticipated and alleviated, and avoiding environmental triggers such as a sudden change in surroundings 

aggression or agitation with assisted bathing

• "person-centered bathing," an intervention focused on resident comfort and preferences, and "towel-bath," an in-bed bag bath method that kept the resident covered at all times and cleansed by using gentle massage. Both treatment groups showed significant declines in all measures of agitation, aggression, and discomfort compared with controls. The postulated mechanism underlying the effectiveness of the improved personal care involved a reduction in the insistent, task focused, impersonal, and intrusive "usual care" methods that can provoke agitation and aggression [27].

Other therapies• At least three placebo-controlled trials have

reported a significant benefit of aromatherapy compared with placebo in patients with dementia and agitation, with almost complete compliance and no adverse effects [28-30]. Lemon balm or lavender oil are most frequently used and can be delivered by either inhalation or skin application. The mechanism by which these agents may be effective is unclear.

Other therapies• Exercise training in combination with caregiver-education may improve

outcomes in patients with Alzheimer disease (AD). A randomized trial in 153 community-dwelling patients with AD found that compared with routine medical care, patients who were assigned to exercise (goal minimum of 30 minutes per day) and whose caregivers received training in managing behavioral problems had improved physical functioning and less depression

• Music therapy and pet therapy also have some evidence of efficacy • In preliminary studies, massage and touch therapy appear to be potentially

beneficial in the immediate management of agitated behavior and in encouragement to eat

• Certain behavioral problems may respond better to behavioral therapies than to medical therapy. These include wandering, hoarding or hiding objects, repetitive questioning, withdrawal, and social inappropriateness 

A randomized, controlled trial of bright light therapy for agitated behaviors in dementia

patients residing in long-term care.• nt J Geriatr Psychiatry. 1999 Jul;14(7):520-5.

• Lyketsos CG, Lindell Veiel L, Baker A, Steele C.

• Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA. kostas@jhmi.edu

• BACKGROUND: Agitated behaviors are common in dementia patients residing in chronic care settings. Their occurrence may be associated with lack of adequate exposure to sunlight and with circadian rhythm disturbances.OBJECTIVE: Prior research has suggested that bright light therapy (BLT) may reduce agitated behaviors in dementia patients. The aim of this study was to test the efficacy of BLT in a randomized, controlled, crossover clinical trial. METHOD: Fifteen patients with dementia and agitated behaviors residing in a chronic care facility were randomized in a crossover design to morning BLT for 1 hour per day or to a control condition with dim light exposure. Patients were treated in either condition for 4 weeks, followed by 1 week on no treatment, prior to being crossed over to the other condition. RESULTS: Eight out of 15 patients completed the entire study. The rest completed at least 2 weeks of study. Patients randomized to the BLT condition exhibited a statistically significant improvement in nocturnal sleep from a mean of 6.4 hours/night to 8.1 hours/night 4 weeks later (p<0.05). The sleep of patients in the control condition did not improve significantly. There were no other significant differences between baseline and follow-up, nor between BLT and control treated patients on the other outcome measures, which included the Behavioral Pathology in Alzheimer Disease scale (Behave-AD) and the Cornell Scale for Depression in Dementia. CONCLUSION: Patients with dementia in chronic care who exhibit agitated behaviors sleep more hours at night when administered morning BLT. However, BLT does not lead to improvements in agitated behaviors in institutionalized patients with dementia with non-disturbed sleep-wake cycles. Copyright 1999 John Wiley & Sons, Ltd.

Other therapies

• Behavioral approaches can be combined with medications. As an example, a sleep disorder may require both behavioral and pharmacological management (eg, trazodone). An activity program, avoidance of daytime naps, elimination of evening alcohol and coffee, and delaying bedtime are all useful.

Antipsychotic agents • Atypical neuroleptics have been the agents of choice for

treating hallucinations in patients with dementia. However, these drugs may increase mortality and are not approved for the treatment of behavioral disorders in patients with dementia by the US Food and Drug Administration (FDA). Nonetheless, their benefits often still outweigh their risks in patients with dementia when treatment of hallucinations and delusions is critical. In the absence of other effective agents, we continue to use them cautiously, after informing the patients and families of the potential risks.

Mortality risk • The US Food and Drug Administration (FDA) reported in a public

health advisory that the use of second generation antipsychotic medications, aripiprazole, olanzapine, quetiapine, and risperidone, for the treatment of behavioral symptoms in elderly patients with dementia is associated with increased mortality [43,44]. Their findings were confirmed in an independently conducted meta-analysis, as well as a subsequent randomized, placebo-controlled study [45,46]. The reported odds ratio for increased mortality in these analyses ranged from 1.54 to 1.7. Similar concerns have been raised for haloperidol and other conventional antipsychotics as well; and short-term and long-term treatment appear to be problematic [45,47,48]. (See "Antipsychotic medications: Treatment issues", section on Mortality issues in elderly patients.)

Typical antipsychotics • A systemic review of typical antipsychotics included

two meta-analyses of 12 trials plus two additional studies ofhaloperidol, thioridazine, thiothixene, chlorpromazine, trifluoperazine and acetophenazine, and concluded that, in the aggregate, there was no clear evidence of benefit for these agents in patients with dementia [36]. A Cochrane review concluded that haloperidol may help control aggression, but not other neuropsychiatric manifestations of dementia [37]. No trials compared agents with one another.

Atypical antipsychotics • These agents include clozapine, olanzapine,

risperidone, and quetiapine and have been somewhat more extensively studied. Two independently conducted systematic reviews have concluded that these agents have, at most modest efficacy. Of seven trials studied, four found a statistically significant benefit for the primary endpoint with olanzapine or risperidone; there were no studies of clozapine and quetiapine for this indication at the time of this analysis.

Lewy Body Dementia• Patients who have dementia with Lewy bodies (DLB)

disease may be especially sensitive to antipsychotic medication and may experience idiosyncratic, life-threatening adverse reactions. Very low doses of the atypical neuroleptics (ie, olanzapine, quetiapine, and clozapine) should be used to initiate treatment for patients who have behavioral symptoms related to DLB. Risperidone and the typical antipsychotic agents should not be used in patients who have DLB. ]

Clinical Use

• We reserve their use for patients who have neuropsychiatric symptoms, particularly psychosis, that are severe and debilitating and inform patients and families of the risks.

• There is often no good alternative. Somnolence is also concern with all of these agents, and may be dose limiting.

Atypical antipsychotics • Olanzapine can be started at a dose of 2.5 mg daily and titrated

up to a maximum of 5 mg twice a day. This drug appears to be at least modestly effective for treating the neuropsychiatric symptoms of dementia in patients with AD or vascular dementia. The incidence of extrapyramidal symptoms is low at this dose.

• Quetiapine is an alternative, starting at a dose of 25 mg at bedtime and titrating up to a maximum of 75 mg twice a day. There is little data regarding the effectiveness of quetiapine in this setting.

• Risperidone at no more than 1 mg daily also appears to be at least modestly effective, but higher doses are associated with increased side effects.

Atypical antipsychotics

• Treatment should be maintained only if benefits are apparent.

• Discontinuation should be attempted at regular intervals

Antidepresents

A systematic review published in 2005 analyzed five randomized controlled trials that investigated the use of serotonergic antidepressants including sertraline, fluoxetinecitalopram, and trazodone in the treatment of neuropsychiatric symptoms.

It showed some minor benefits with sertraline, citalopram and trazodone

Cholinesterase inhibitors

• A 2005 systematic review reported that two meta-analyses and six randomized controlled trials of cholinesterase inhibitors for neuropsychiatric symptoms of dementia generally found small but statistically significant efficacy.

Memantine

• Has some data for improvement of the NPI in moderate to severe dementia.

Antiepileptic drugs• Carbamazepine was effective in a placebo-

controlled study of agitation in nursing home patients with advanced dementia [72]. Relatively low doses were used, with a modal dose of 300 mg/day achieving a mean serum level of 5.3 mcg/mL. However, a subsequent trial found no benefit [73], and a systematic review concluded that there is currently not enough evidence of benefit for carbamazepine to recommend its use for neuropsychiatric symptoms

Antiepileptic drugs

• Valproate improved aggressive behavior in several earlier reports. However, a systematic review that analyzed three randomized controlled trials and two studies of valproate concluded that neither the short or long-acting preparations were effective for treatment of neuropsychiatric symptoms of dementia

Antiepileptic drugs

• Gabapentin is often used because of its relatively mild side effect profile, but its efficacy is questionable, with one open-label prospective study showing little benefit.

• Lamotrigine has been advocated based on case reports, but no randomized, placebo-controlled studies have been published to date.

Benzodiazepines • Benzodiazepines have limited value in patients with AD. They are

not recommended for the management of neuropsychiatric symptoms of dementia. One randomized controlled trial of a benzodiazepine for neuropsychiatric symptoms of dementia found benefit for both intramuscular lorazepam and intramuscular olanzapine compared with placebo at two hours after treatment; the benefit of lorazepam was not sustained at 24 hours on one outcome scale [77].

• Benzodiazepine side effects include worsening gait, potential paradoxical agitation, and possible physical dependence. Benzodiazepine use should be limited to brief stressful episodes, such as a change in residence or an anxiety-provoking medical event

Sexually inappropriate behavior

• Given the absence of controlled clinical data, treatment for this problem is necessarily empiric. Behavioral interventions (redirection, distraction, avoiding stimulants) should be tried first. If this is insufficient, medication trials seem reasonable [14,20]. One systematic review concluded that the preponderance of anecdotal data provided the most support for antidepressant agents, making these the first drug of choice (see'Antidepressants' below [21]. Another valid approach may be to examine the context of other behavioral symptoms that the patient may be experiencing and to try an agent that seems most appropriate for the overall symptom complex [17].

Sexually inappropriate behavior

• A limited number of studies have investigated this problem, almost always in men, and usually in the form of small case series or case reports. Efficacy has been reported with a variety of psychotropic medications including antidepressants, antipsychotic agents, and cholinesterase inhibitors, as well as gabapentin, pindolol, and cimetidine. Hormonal agents have also been used with anecdotal reports of efficacy. However, given their side effect profile, these are not considered first line agents.

Hormonal agents • While hormonal agents (eg,

medroxyprogesterone acetate, diethylstilbestrol, estrogen, leuprolide) have also been used with anecdotal reports of efficacy in treating sexually inappropriate behavior in individuals with dementia, these are not considered first line agents given their side effect profile 

Drug Categories of Concern in the Elderly

• Analgesics: NSAIDs are widely used; several are available without prescription. Serious adverse effects include peptic ulceration and upper GI bleeding; risk is increased when an NSAID is begun and when dose is increased. Risk of upper GI bleeding increases when NSAIDs are given withwarfarin or aspirin . NSAIDs may increase risk of cardiovascular events and can cause fluid retention. Selective COX-2 inhibitors (coxibs) cause less GI irritation and platelet inhibition than other NSAIDs. Nonetheless, coxibs have a risk of GI bleeding, especially in patients taking warfarin or aspirin (even at low dose) and in those who have had GI events. Coxibs, as a class, appear to increase risk of cardiovascular events, but that risk may vary by drug; their use should be approached cautiously. Coxibs have renal effects comparable to those of other NSAIDs. Monitoring serum creatinine is necessary, especially in patients with other risk factors (eg, heart failure, renal impairment, cirrhosis with ascites, volume depletion, diuretic use).

Drug Categories of Concern in the Elderly

Digoxin: Digoxin clearance decreases an average of 50% in elderly patients with normal serum creatinine levels. Therefore, maintenance doses should be started low (0.125 mg/day) and adjusted according to response and serum digoxin levels. Digoxin must be used with caution in patients with heart failure. In men with heart failure and a left ventricular ejection fraction of ≤ 45%, serum digoxin levels > 0.8 ng/mL are associated with increased mortality risk. Among women with heart failure and depressed left ventricular function, digoxin , regardless of serum level, is associated with increased mortality risk.

Drug Categories of Concern in the Elderly

• Antihyperglycemics: Doses of antihyperglycemics should be titrated carefully in patients with diabetes mellitus. Risk of hypoglycemia due to sulfonylureas may increase with aging. Chlorpropamide is not recommended because elderly patients are at increased risk of hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) and because the drug's long duration of action is dangerous if adverse effects or hypoglycemia occurs. Risk of hypoglycemia is greater with glyburide than with other oral antihyperglycemics.

Beers' List—Drugs NOT to UseTracking Prescriptions In the Elderly

can be a Quality Measure• Some Of the Drugs On the List• A few trade names are listed after the generic name. The medication may also be prescribed under

other names or be incorporated in another combination product.• Older people are very susceptible to adverse effects of drugs with anticholinergic effects.• cyproheptadine (Periactin)• diphenhydramine (Benadryl)• belladonna alkaloids (Bentyl, Donnatal, many others in combination products)• Many other drugs can contribute to confusion, delirium, and other brain dysfunction• meperidine (Demerol)• methocarbamol (Robaxin)• propoxyphene (“Darvon,” Darvocet”)• propanatheline (Pro-Banthine)• barbituates• Other drugs are on the list for miscellaneous reasons.• thyroid, desiccated (Armour Thyroid)• estrogens

Commonly Used Medications May Produce Cognitive

Impairment In Older Adults• Many drugs commonly prescribed to older adults for a variety of

common medical conditions including allergies,hypertension, asthma, and cardiovascular disease appear to negatively affect the aging brain causing immediate but possibly reversible cognitive impairment, including delirium, in older adults according to a clinical review now available online in the Journal of Clinical Interventions in Aging, a peer reviewed, open access publication. Drugs, such as diphenhydramine, which have an anticholinergic effect, are important medical therapies available by prescription and also are sold over the counter under various brand names such as Benadryl®, Dramamine®, Excederin PM®, Nytol®, Sominex®, Tylenol PM®, and Unisom®. Older adults most commonly use drugs with anticholinergic effects as sleep aids. 

Pressure ulcers• INTRODUCTION — Pressure ulcers are a

significant problem in institutionalized elderly patients and critically ill patients, causing pain, decreasing quality of life, and leading to significant morbidity and prolonged hospital stays.

• Pressure ulcers are ischemic soft tissue injuries resulting from pressure, usually over bony prominences.

ASSESSMENT AND STAGING 

• The treatment of pressure ulcers begins with a comprehensive assessment of both the patient's general medical condition and the wound.

• Wounds should be evaluated for stage, size, sinus tracts, necrotic tissue, exudate, and the presence of granulation.

• Photographs of all wounds are helpful.

Staging of pressure ulcers• Stage Description

• I Skin intact but with non-blanchable redness for >1 hour after relief of pressure.

• II Blister or other break in the dermis with partial thickness loss of dermis, with or without infection.

• III Full thickness tissue loss. Subcutaneous fat may be visible; destruction extends into muscle with or without infection. Undermining and tunneling may be present.

• IV Full thickness skin loss with involvement of bone, tendon, or joint, with or without infection. Often includes undermining and tunneling.

• Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

• Suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear.

• * From the National Pressure Ulcer Advisory Panel.

GENERAL TREATMENT PRINCIPLES 

•  Preventive measures, with a focus on positioning and support to minimize tissue pressure, should be provided for all patients, including those with pressure ulcers. Any ulcer development should underscore the need to review and intensify preventive measures that are already in place.

Treatment of pressure ulcers• Treatment of pressure ulcers depends on the stage and severity of

the ulcer, The general approach to management of a patient with a pressure ulcer should include the following:

• Reduce or eliminate underlying contributing factors by providing pressure relief with proper positioning and support surfaces.

• Provide appropriate local wound care, which may include debridement for patients with necrotic tissue, based on the ulcer's characteristics.

• Consider adjunctive therapies, such as vacuum-assisted closure• Monitor and document the patient's progress

Monitoring • The following parameters of care should be monitored daily and

documented• Evaluation of the ulcer• Status of the dressing, if present• Status of the area surrounding the ulcer• Presence of pain, and adequacy of pain control• Presence of possible complications, such as infection• Documentation may be facilitated by using one of the scales for

healing ulcers• Appropriate therapeutic goals should be set that consider

discharge potential, quality of life, and prognosis.

Pressure Ulcer Scale for Healing (PUSH)• AssessmentsInstructionsAssign a subscore (cm2)Total the subscores• Size (length x width)Measure the greatest length and width using a centimeter ruler.

Multiply the two measurements to obtain an estimate of surface area.0 – 0Subscore • 1 - <0.3 2 - 0.3-0.63 - 0.7-1.04 - 1.1-2.05 - 2.1-3.06 - 3.1-4.07 - 4.1-8.08 - 8.1-129 - 12.1-

24.010 - >24• Exudate Estimate the amount of drainage after removal of the dressing.0 - NoneSubscore1

- Light 2 - Moderate3 - HeavyTissue type• Assess the presence of sloughing or necrosis0 - ClosedSubscore1 - Epithelial tissue 2 -

Granulation tissue3 - Slough4 - Necrotic tissue• Add together all subscores =Total score• Changes in the score over time provide an indication of the healing process. The score goes

down with improvement and increases with wound deterioration.* Version 3.0 National Pressure Ulcer Advisory Panel (www.npuap.org).Adapted with permission from: National Pressure Ulcer Advisory Panel. Version 3.0 Pressure Ulcer Scale for Healing (PUSH). Copyright ©1998 National Pressure Ulcer Advisory Panel.

Healing

• Ulcers heal through a process that includes granulation, wound contraction, reepithelialization, and scar formation.

• Thus, a stage 4 ulcer remains stage 4 throughout the healing process.

• The practice of changing the stage as the ulcer heals, known as reverse staging, is not recommended 

Nutrition• Nutritional intake should be assessed. This assessment may include protein and

caloric intake, hydration status, serum albumin and/or prealbumin, and total lymphocyte count’ Nutritional deficiencies should be corrected.

• If oral intake is not adequate to ensure sufficient calories, protein, vitamins, and minerals, nutritional supplementation with enteral and parenteral nutrition is recommended to correct deficiencies. A retrospective cohort study of 882 patients with pressure ulcers at 95 long-term care facilities demonstrated that total caloric intake of at least 30 kcal/kg promoted healing and decreased the size of stage 3 and 4 pressure ulcers.

• Increased dietary protein intake also promotes the healing of pressure ulcers. • The protein target is usually 1.5 g/kg/day, although some authors advocate

higher protein intake.

Supplements• Data do not support nutritional supplementation for

patients who do not have nutritional deficiencies • Vitamin C and zinc supplementation are

commonly employed to promote healing but their efficacy has not been conclusively demonstrated.

• A number of small randomized trials have evaluated the role of nutritional supplements but methological flaws and study size preclude confirmation of clinically significant results.

Mattresses and tissue pressure relief •  To date, there are no randomized trials available to identify whether repositioning makes a

difference in the healing rates of pressure ulcers or what the optimal repositioning regimen would be. Nevetheless, in the absence of data, as a practice with good face value, patients should be positioned to minimize or avoid all pressure on the wound. Pressure-relieving support surfaces are also helpful in reducing tissue pressure. These support devices, as defined by the National Pressure Ulcer Advisory Panel Support Surface Standards Initiative, are outlined below:

• Non-powered support surfaces (previously known as static), such as foam, do not require electricity. These supports can be used if the patient can assume a variety of positions without bearing weight on the ulcer.

• Overlays are an additional support surface, designed to be placed on top of another support surface. Foam, air, or water overlays are useful for patients who can assume a variety of positions without bearing weight on the ulcer.

• Powered or dynamic support surfaces require electricity. Air currents or mechanical rotation regulate or redistribute pressure against the body. Examples of such beds include alternating pressure mattresses, low air loss beds, and air fluidized mattresses. Specialized powered beds should be considered when the patient cannot readily be repositioned, has a large ulcer or ulcers at multiple sites, or if the pressure ulcer does not show evidence of healing.

Stage 1 treatment • The development of stage 1 ulcers is a

warning that more serious lesions may follow if appropriate preventive measures are not instituted in a timely fashion. Stage 1 ulcers may be dressed with transparent films for protection. Most importantly, preventive measures should be reviewed and intensified.

Stage 2 treatment • Stage 2 treatment — Stage 2 pressure

ulcers usually require an occlusive or semipermeable dressing that will maintain a moist wound environment. Wet-to-dry dressings are avoided since these wounds generally require little debridement.

Dressing choices•  Dressings serve to protect the wound from trauma and

contamination, and facilitate healing by absorption of exudate and protection of healing surfaces.

• Excess fluid causes wound maceration, while dessication will slow epithelial cell migration.

• Many different types of dressings are available. Although varying circumstances may favor choosing one dressing over another, no dressing has been shown to be consistently superior to another in clinical trials. Factors to keep in mind while selecting an appropriate dressing include the presence of heavy exudate, dessication, infected or necrotic tissue.

Stages 3 and 4 • Treatment of wound infections,

debridement of necrotic tissue, and appropriate dressings will accelerate healing of Stage 3 and 4 pressure ulcers.

• Surgery is necessary for some full thickness pressure ulcers.

Dressing choices• Dressings serve to protect the wound from trauma and

contamination, and facilitate healing by absorption of exudate and protection of healing surfaces. Excess fluid causes wound maceration, while dessication will slow epithelial cell migration.

• Many different types of dressings are available. Although varying circumstances may favor choosing one dressing over another, no dressing has been shown to be consistently superior to another in clinical trials. Factors to keep in mind while selecting an appropriate dressing include the presence of heavy exudate, dessication, infected or necrotic tissue.

Ulcers with heavy exudate• An absorptive dressing should be employed to avoid build up of chronic

wound fluid that can lead to wound maceration and inhibition of cell proliferation and healing. An appropriate wound dressing can remove excess wound exudate while maintaining a moist environment to accelerate wound healing.

• Dressings with absorptive qualities include alginates, foams, and hydrofibers.• Calcium alginates are highly absorptive and are useful for wounds with

significant exudate. Calcium alginates are derived from brown seaweed and form a gel on contact, promoting moist interactive healing.

• Foams provide thermal insulation, high absorbency, and a moist environment. They can be easily cut to shape and do not shed fibers. Foams are useful for sloughy or exudative wounds.

• Hydrofibers can also be used for highly exudative wounds and are highly absorbent. They are appropriate for sloughy or exudative wounds.

Dessicated ulcers• Dessicated ulcers lack wound fluids, which provide tissue growth factors to facilitate

reepithelialization. Thus, pressure ulcer healing is promoted by dressings that maintain a moist wound environment while keeping the surrounding intact skin dry. Choices for a dry wound include saline moistened gauze, transparent films, hydrocolloids, and hydrogels.

• Saline moistened gauze that is not allowed to dry will promote a moist wound environment, although occlusive dressings are equally effective and reduce the nursing time required for wound care.

• Transparent films provide an effective barrier for retaining moisture; they are good secondary dressings when combined with another product for stage 3 or 4 ulcers (full thickness wounds) or may be used alone for stage 2 ulcers (partial thickness wounds). Films are especially useful at the later stages of wound healing when there is no significant exudate.

• Hydrocolloids generally provide an effective barrier for retaining moisture and are useful for promoting autolytic debridement. They come in a variety of sizes and shapes for use on different parts of the body. A comparison randomized trial of transparent films with hydrocolloid dressing in the management of stage 2 and shallow stage 3 pressure ulcers demonstrated the transparent film dressing improved the ability to assess the ulcer and improved patient comfort although the time to wound closure was nearly identical between the two groups.

• Hydrogels provide a high concentration of water contained in insoluble polymers and provide a good choice for dry sloughy wounds with low levels of exudate.

Debridement 

• Necrotic tissue promotes bacterial growth and impairs wound healing. Accordingly, it would seem that removal of necrotic tissue by wound debridement is an important element of pressure ulcer treatment. Randomized trials, however, compare different methods of debridement but have not focused on the effectiveness of debridement per se.

Debridement • Five approaches to debridement are available; they are often used in combination.• Sharp debridement involves the use of a scalpel or scissors. This is the most rapid form of debridement; it is indicated when

there is evidence of cellulitis or sepsis. Sharp debridement is also used to remove thick eschar and when there is extensive necrotic tissue. The exception is patients with heel ulcers covered by a thick, dry eschar. Sharp debridement is not recommended at this site, because of the proximity of bone.

• Mechanical debridement is a nonselective method of removing necrotic tissue and debris from a wound. This is most commonly done with wet-to-dry dressings. Mechanical debridement is best for wounds that contain thick exudate, slough, or loose necrotic tissue. Wet-to-dry dressings will remove both nonviable and viable tissues; caution is required to avoid damaging healthy tissue.

• Enzymatic debridement is done with the topical application of proteolytic enzymes such as collagenase, fibrinolysin, and deoxyribonuclease to remove necrotic tissue. The topically applied enzymes work synergistically with endogenous enzymes to debride the wound. These agents may produce excess exudate and cause local irritation to the surrounding skin. Papain was used for debridement in the past but was removed from the US market due to hypersensitivity reactions.

• Autolytic debridement uses semiocclusive (transparent film) or occlusive dressings (hydrocolloids or hydrogels) to cover a wound so that necrotic tissue is digested by enzymes normally present in wound tissue. This often works best on wounds with minimal exudate. It should not be used in the presence of infection.

• Biosurgery or the use of maggots is another effective method of debridement. The larvae produce enzymes to break down dead tissue without harming healthy tissue. This can be considered when sharp debridement is contraindicated due to exposed bone, joint, or tendon. Sterile larvae of the Lucilia sericata fly are utilized.

• Debridement should stop once necrotic tissue has been removed and granulation tissue is present. Care should be taken with respect to debridement of the ischial spine as this will potentially affect weightbearing and can lead to breakdown of the ischium on the opposite side. Removal of both ischial spines will increase the risk of perineal problems and the formation of urethocutaneous fistulas.