Assisted Living Consult - PDF document

Assisted Living Consult May/June 2005 ilent killers are stealthy,symptoms or warnings. If caughtor controlled. tion and learn some lessons that Telling the VTE Story Public awareness campaigns beginby noting VTEÕs widespread impact.ple are affected by some form ofpeople will die from it. roughly the same number of people VTEÕs incidence increas-es with age, so its prevalence isgrows. Annually, more than 250,000and preventable. PE alone has athree-month mortality of 17%. hot inflamed skin from perivascular Assisted Living Challenge: Awareness ofVenousThromboembolism ick, RPh, MBA, FASCP Venous thromboembolism complication, pulmonary continued on page 11continued on page 11 May/June 2005 Assisted Living Consult breath. So one might ask why thiscondition is considered a silentkiller when it speaks clearly throughif not mostif not mostemainbecome critical. Without betterinformation dissemination, at-riskpatients will not receive appropriatescreening, diagnosis, and prophy- Awareness in Assisted Living appropriate and important target forregarding blood clots for severalreasons. These include: basics of VTE and enlighten resi-can enable early recognition andtreatment.Staff education should addressVTE risk factors in order of fre-quency. One recent study suggeststhe most prevalent are previouscancer, age over 75 years, andchronic respiratory disease. patients. However, data suggests acute immobilization increases riskregardless of age. There are numer-ous reported cases of blood clots inile for prolonged periods of time er risk factors germane to the ALFpopulation are falls resulting indiagnosis of heart failure. Withmore than two-thirds of ALF resi-carrying a chronic heart diseaserecent fracture, VTE awareness is wareness Increases Prevention or history of cancerÑare unalter-able. However, others can be iden-tified and addressed before theybecome problematic. For example,seated or supine positions improvesblood flow in the legs, so residentsHydration seems to play a roleand other visitors, and residentsthemselves should be remindedwater or other liquids regularly.residents should be encouraged toinformation is easily incorporated inbold, colorful posters similar tothose used in airports to warnbout ÒTravelers ThrombosisÓ orÒEconomy Class Syndrome.Ó Thesecan be posted in dining halls, recre-ation areas, lobbies, and other loca-tions where residents, visitors, andstaff are likely to see them. Makes a Difference When staff understand the risk fac-tors of VTE and how to prevent it,edge into their regular interactionswith residents. For example, theycan make it a point to ask residentsoffer residents something to drinkthe resident becomes acutely immo-monitor residents with dementia toensure they are imbibing enoughe cognitively impaired. Specifically, underprescribing ofVTE prophylaxis has been docu cians who care for ALF residentsoften need to be reminded to con-ment when previously ambulatorypatients are confined to bed formore than a day or two. When resi-dents return from a hospital orly for total knee or hip replacement,staff should ask if the resident is onVTE prophylaxis. Many at-riskpatients benefit from prophylaxis ventions Exist But Are Not Always Used Evidence-based interventions havebeen acknowledged for VTE. Nursing homeconfinement increasesrisk of VTE 10.6 times, and acuteimmobilization increases risk regardless of age. eightening Awareness of Venous (continued from page 8) Assisted Living Consult May/June 2005 based interventions are neverapplied appropriately because thethemÑthe care providers closest tohe patientÑare unaware of them.Heightening awareness among res-idents, families, and care providerscan help residents age in place inbeen proven to prevent blood clotsbut are a reasonable option in resi- include graduated compressionstockings, intermittent pneumaticcompression, and venous footinclude increased age, a history ofgastrointestinal bleeding, previousless than 30%, or creatinine greaterthan 1.5 mg/dL. With two risk fac-a bleed within a year. Three ormore risk factors indicate high risk, om the Prescription Pad oven to prevent VTE and arethe prophylactic dose for theseed to treat an actual VTE. potential adverse event. Therefore,residents who fall or are at risk forrelated injuries may need increasedinteractions can increase bleedingagulant effect. These include aspirinor over-the-counter analgesics ofnaproxen) and popular alternative/complimentary products (see Tablefere with the clottinginhibitors (eg, ibuprofen, indo-methacin, dipyridamole, hydroxy-chloroquine, NSAIDs, ticlopidine Addressing Resident, Family Concerns have preferences about administra-oute or concerns about the For example,an injectable drug may frighten oresident with dementia. Prescribers must consider the resi-dentÕs renal function (a considera-bid conditions, and age-relatedtreat VTE are described here. Warfarin (Coumadin . Warfarinequently using the internationalproduct has numerous food inter-broccoli, turnip greens, mango)that require a consistent and some-impaired individuals or for resi-dents who eat unpredictably. Thefact that Micromedex (a widely-used, peer reviewed electronic clin-ical data system) lists Òunsupervised A dementiapatient who is losing weight, hasfarin, even with closesupervision. Risk factors for bleedinginclude increased age, a history ofgastrointestinalbleeding, previousstroke, diabetes mellitus,hematocrit less than30%, and creatinine greater than 1.5 mg/dL. able 1. Herbal/Anticoagulant Combinations of Concern Herbal agents causing additive Herbal agents counteractinganticoagulant effectanticoagulant effect Alfalfa, anise, arnica, astragalus, bilberry, Coenzyme 10, Saint JohnÕs Wortblack current seed oil, bladderwrack, oil, buchu, capsacin, catÕs claw, celery, oil, fenugeek, feverfew, garlic, ginger, ginkgo, guggul, papaya extract, red clover, May/June 2005 Assisted Living Consult . Heparin is relatively lessally is administered intravenously orsubcutaneously two or three times aay; so it can require a great deal ofstaff time and/or increase the riskfor non-adherence. Women olderthan 60 are at higher risk of bleed-ing, and heparin mandates regularThromboplastin TAPTTAPTTrequires periodic platelet counts,blood in stool during the entirecourse of therapy. This product isin individuals with diabetes or renalinsufficiency. It has numerous drugsporins, penicillins, nitroglycerin,redness, mild pain, and bruising atthe injection site are common, residents to rotate sites. Low molecular weight heparins[dalteparin, enoxeparin, tinzaoid] e expensive in terms of acqui-twice daily from a fixed-dosedown, each productÕs packagesite rotation. Additionally, staffshould counsel residents not toanticoagulants, no routine clottingtests are required; and the risk ofdrug-induced bleeding is lower.This reduces overall cost. Periodicand stool occult blood tests areneeded during the course of treat-restrictions have been identified.ing are common. Fondaparinux (Arixtra anticoagulant with a differentadministered subcutaneously. ForALF staff, a key point is that its usein residents who weigh less than 50110 pounds110 poundsenal impair-ment, or are older than 75 yearsold is a concern that prescribersneed to address in advance. Forreduced. As with other medications,occult blood tests are recommend-ed during the course of treatment.eactions do occur fre-quently, as does fever. Awareness Strategy The use of VTE prophylaxis in ALFsenhance resident care by makingess it and monitor treat- of thorough staff education andtraining is that hospital dischargeplanners are likely to be more recep-where staff are knowledgeable aboutVTE and its treatment. Using the most powerful methodsavailable to share key points willensure that the message reaches allappropriate parties. This meansincluding information and tips instaff and resident newsletters, hang-efforts. It also means using variousinterventions. However, this infor- able 2. Fast Facts About Anticoagulation ꔀWhen residents return from hospitalization, check to see if they are on or should beꔀResidents should not discontinue anticoagulation without the prescriberÕs knowledge.ꔀInjectable anticoagulation products are not interchangeable unit for unit or mg for mg.ꔀResidents who are on warfarin or heparin must adhere to the prescribed laboratorytest schedule exactly.ꔀIf a manufacturerÕs pre-filled syringe is used and it has an air bubble, do not expelbubble before injecting the anticoagulant subcutaneously.ꔀSubcutaneous anticoagulants require injection site rotation. Each one is different, soresidents or people who help them should read the productÕs specific directions.ꔀAdvise residents to make certain lifestyle changes: brush teeth with soft toothbrush,use electric razor, avoid activities that may lead to bruising.ꔀResidents should avoid alcohol while using all of the anticoagulants.ꔀAddress the issue of needle and syringe disposal in advance, so people involved in theꔀMost anticoagulant-related problems can be predicted and prevented. continued on page 21continued on page 21 It is important to note that withanticoagulants, bleeding is a potential adverse event. Assisted Living Consult May/June 2005 increase enrollee adherence to pre-scription drug regimens throughmedication refill reminders, specialackaging, compliance programs,and other means. Further, to ensurethat the appropriate medicationsare prescribed, these services couldevents and patterns of overuse andunderuse of prescription drugs. minor roles for the MTMS program:ꔀPerforming patient health statusꔀFormulating prescription drugtreatment plansꔀManaging high cost specialtyꔀEvaluating and monitoringpatient response to drug therapyProviding education and trainingꔀCoordinating medication therapywith other care managementꔀParticipating in state-permittedinteractions, in targeted beneficiar-ies. These medication-related prob-ꔀIndication퀀Additional drug therapy needed퀀Unnecessary drug therapyꔀEffectiveness퀀Ineffective drug therapy퀀Dosage too lowꔀSafety퀀Adverse drug reactionꔀConvenience퀀Adherence to therapy Uncertainties RemainÉAnswers Forthcoming to present an opportunity to ensureeffective medication managementfor seniors, there remain severalquestions about how the programregarding the MTMS to the discre-tion of the private prescription drugprovide the services, and what thethese beneficiaries are, the agencyꔀHave multiple chronic diseasesꔀTake multiple Part D drugsAre likely to incur annual costsfor covered Part D drugs that ex-ceed a predetermined level asspecified by the Secretary ofspecific, the other two are vagueand wide open to interpretation bythe prescription drug plans. Theseorganizations could choose toever the drug plans interpret anddefine these criteria, in turn, willdetermine what beneficiaries willbe eligible to receive the MTMS.MTMS that remains is who willplans. Various disciplines haveappropriate practitioners to serveas qualified providers of thesegroupÑnurses, pharmacists, physi-more intensive or extensive andreviews and coordination with resi-dentsÕ physicians to assure opti-Slowly, however, answers areMTMS are coming into focus. Forexample, Community Care Rx is thethrough Outcomes PharmaceuticalHealth CareÑit will pay consultantpharmacists to provide the follow-ꔀComprehensive medicationr$30 fee$30 feePrescriber consultation to alterꔀPatient consult that does notequire prescriber intervention MTMS should include enhanced enrollee understanding through beneficiaryeducation counseling and other means of promoting appropriate use of medications and reducing the risk of potential adverse events. May/June 2005 Assisted Living Consult nursing homes. Medications areed from institutional phar-macies that provide special pack-opriately. However, thisconsider ALFs to be long term careThe new Medicare prescriptioneffect this coming January, sepa-rates ALFs from skilled nursingare managed. This is becauseÑaccording to the final rules regard-term care facility. As a result, ALFseniors will be excluded fromee important benefits offeredonly to nursing home residents.dually eligible residents, ie, thoseeceive Medicare and Medi- Introducing MTMS: Roles and Purpose One aspect of the Medicare pre-back in ALFs is a provision forCenters for Medicare and Medicaidstanding through beneficiary omoting the appropri-ate use of medications and reduc- MTMS and the MillionDollar Question: How Will ALFResidents Benefit? Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD