Strategies for Reducing Falls in Long-Term Care

Falls necessitate a comprehensive root cause analysis that looks beyond the most obvious reasons for falls. Such reviews are essential in developing sustainable and efficacious fall prevention programs and in promoting a culture of safety. In this article, the authors provide two case scenarios that demonstrate why individual risks need to be carefully explored. They also review some common fall risk factors and interventions that can be used to reduce those risks.

Managing Chronic Pain in Older Adults: A Long-Term Care Perspective

Every resident deserves appropriate pain management, and healthcare providers must be adequately prepared with the knowledge and information to meet their residents’ needs. This review presents information on common types of pain in older adults, describes how to assess pain, and discusses options for management, including nonpharmacologic therapies and medication management with mild analgesics and opioid-based therapies.

Resident-Focused and Evidence-Based Management of Diabetes Mellitus in the Nursing Home Setting

Sliding-scale (SS) insulin use is still prevalent in nursing homes (NHs), even though it has been shown to be an ineffective and risky approach when used long term, increasing hypoglycemia risk and leading to possible prolonged periods of hyperglycemia. Transitioning NH patients away from SS insulin toward safer medications, such as basal-bolus insulin, is challenging. This article reviews the safety and efficacy associated with SS insulin use and describes a process for transitioning NH residents away from SS insulin toward safer insulin regimens.

Venous Thromboembolism Prophylaxis for Chronically Immobilized Long-Term Care Residents

Although chronic immobility is a known venous thromboembolism (VTE) risk factor, there are still many unanswered questions regarding the need for VTE prophylaxis in patients with this risk factor. This review summarizes the available literature regarding VTE prophylaxis for patients with chronic immobility and describes current practices in long-term care (LTC) facilities. Currently, the literature does not recommend prophylaxis for chronic immobility as a single risk factor for thromboembolism.

Aortic Stenosis: What Long-Term Care Providers Need to Know

As the population continues to age, aortic stenosis (AS) will be encountered more frequently in the long-term care (LTC) setting. Patients may or may not have symptoms, but once symptoms manifest, AS has poor outcomes when left untreated. This review article summarizes the presentation and diagnosis of AS and outlines current management options, including medical therapy, surgical aortic valve replacement, and transcatheter aortic valve replacement. It also describes the outcomes of these therapies from an LTC perspective.

Challenges Associated With Managing Suicide Risk in Long-Term Care Facilities

Little information about suicidal ideation and behavior in long-term care (LTC) facilities is available. Nonetheless, the implementation of the Minimum Data Set 3.0 requires that LTC facilities screen their residents for suicide risk and have protocols in place to effectively manage residents’ responses. In this article, the authors briefly discuss the risk factors of suicide in the elderly and the problems that suicidal ideation and behavior pose in the LTC environment. The authors explain issues that arise when trying to manage suicide risk in the elderly LTC population with general, traditional approaches. These inherent issues make it difficult to develop an effective protocol for managing suicide risk in LTC facilities, leading the authors to propose their own framework for assessing and managing suicide risk in the LTC setting.

How Nurses Affect Pain Management Practices in Nursing Homes and Shape Families’ Perceptions of Care

Despite the high prevalence of chronic pain among older adults in long-term care settings, a search of the literature indicates a poor pattern of pain management practices, suggesting that management of pain in these patients is limited and only partially effective. This article reviews nurses’ and families’ involvement in pain management care for older adults living in nursing homes and outlines some barriers to effective pain management, including a lack of pain education among nursing staff; attitudes of staff caregivers; organizational barriers that impede effective communication among residents, physicians, and staff caregivers; and the lack of a clear understanding by nursing personnel of families’ perceptions and concerns as they relate to the care of their loved one. When nursing staff listen to and collaborate with families, rather than viewing them as a barrier to care, more appropriate services may be provided, resulting in better pain management, more positive outcomes, and improved overall care. 

Palliative Care of Pressure Ulcers in Long-Term Care

Pressure ulcers are highly prevalent among older adults and elders receiving palliative care in numerous care settings. A palliative care approach to wounds involves a comprehensive assessment of existing wounds and prevention of new wounds. Treatment of wounds and their associated complications is typically driven by symptom management to improve patient comfort and quality of life. While much is known about palliative wound care in general, evidence to guide palliative care of pressure ulcers, specifically in older adults residing in long-term care (LTC) settings, is severely lacking. Many LTC facilities may follow the evidence-based guidelines developed by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel. Although these organizations make specific recommendations to palliative care providers, scientific evidence should be strengthened and expanded upon. This article reviews the current body of medical literature on the palliative care of pressure ulcers in older adults, particularly those in LTC settings; examines how the medical literature compares with clinical practice guidelines; and identifies gaps where further research is needed.

Antithrombotic Therapy for Atrial Fibrillation: An Update on Safety, Evidence-Based Treatment Decisions, and the New Oral Anticoagulants

Atrial fibrillation is common among frail elders in long-term care (LTC) and is a significant risk factor for severe stroke. This risk can be reduced with antithrombotic therapy, but the risk of bleeding complications from these treatments may in some cases outweigh their stroke-reduction benefits. Therefore, the decision to initiate antithrombotic therapy should be made after each patient’s benefits and risks are systematically estimated and discussed with the patient and his or her family so that a shared decision is reached. If the benefits of antithrombotic prophylaxis are judged to outweigh the risks, the clinician must then consider each patient’s comorbidities and preferences when deciding which agent to prescribe. Compared with warfarin, new oral antithrombotic agents are associated with potentially improved clinical outcomes, have better safety profiles, and are more convenient for patients and clinicians. However, clinical trials evaluating these agents excluded patients with conditions and risk factors common among patients residing in LTC settings, suggesting cautious consideration is warranted before prescribing these agents to this population. Regardless of which antithrombotic agent is chosen for a particular patient, facilities should closely monitor patients and employ policies and procedures to ensure its safe use. This article provides a review of the safety of various antithrombotic agents and how LTC providers can make evidence-based treatment decisions when prescribing these agents.  

Hoarding by Elderly Long-Term Care Residents

There has been great interest in the psychology behind hoarding behavior in popular culture recently; however, little is known about the prevalence of this potentially destructive behavior among elders residing in long-term care (LTC) facilities or how best to manage it. Although LTC facilities have provided care to elderly persons with such behaviors for decades, they have done so without the support and benefit of evidence-based research. The dearth of clinical knowledge on hoarding in this specific patient population, who tend to be more clinically complex than younger hoarders, presents a unique and pressing challenge to healthcare providers. The authors reviewed the current body of available literature and identified areas in which further studies are needed.

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