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HBPC Clinical Safari: Management Pearls and Pitfalls for the “Big 5” High Impact Conditions Moderator: Tom Lally, MD Panelists: Duane Kirskey, MD MSCE Lynn Beatty, MD Jon Salisbury, MD David Skorvan, ANP Disclosures • Lally – Kindred Healthcare - Employee • Skorvan – no relevant disclosures • Beatty – Visiting Physicians Association – Employee • Salisbury – no relevant disclosures • Kirksey – no relevant disclosures Objectives • Explain the clinical significance of the following conditions in the home-based setting: • CHF • Behaviors in Dementia • VTE • Recurrent Falls • Decubitus Wounds • Discuss potential challenges of implementing best practices in the management of these conditions in the home-based setting. • Identify practical ways to incorporate treatment strategies for these conditions into home-based medical practice. Heart Failure at Home Jon Salisbury, MD Visiting Physician Services – A member of VNA Health Group Heart Failure At Home “I haven’t sent a heart failure patient to the hospital in over 5 years” Heart Failure • Pathophysiologic: Inability of heart to deliver blood and oxygen • Clinical: Breathlessness and fatigue associated with cardiac disease • Associated by: Fluid retention, edema, elevated venous pressure • Clinical assessment seeks to answer to questions: • Are the symptoms cardiac of non-cardiac in origin? • If cardiac, what is the precise problem? Diagnostic Algorithm • • • • • • • • • • Dyspnea & fatigue Previous MI Angina Hypertension Valvular disease Palpitations (arrhythmia?) Smoking, alcohol abuse, family history • • • • • • Dyspnea Fatigue Edema Tachycardia Rales Raised J.V.P. Murmur Edema 3rd heart sound • • • • • EKG CXR Echocardiogram CBC, CMP, BNP Thyroid Panel Diagnostic Algorithm Continued • • • • • • Systolic LV dysfunction (most common) Diastolic LV dysfunction Valvular disease Rhythm / conduction disturbance Pericardial / endocardial disease Congenital heart disease New York Heart Assoc. Functional Classification and Treatment Pharmacologic Management • ACE Inhibitors: • Enalapril: 10mg BID • Lisinopril: 20 – 40mg QD • Captopril: 100 – 150mg daily (3 times daily dosing) • B-Blockers: • Carvedilol: 3.125 BID x 2 weeks, then double every 2 weeks to highest level tolerated (dizziness) to max 25mg BID • Metoprolol succinate: 25mg QD (severe HF, start 12.5mg BID) • Bisoprolol: 1.25mg/day, max 5mg/day • Hydralazine: 300mg/day (divided doses) • Isorbide dinitrate: 30 – 160 mg/day Pharmacologic Management Continued • Loop Diuretics: • Furosemide: 20 – 80mg/day • Bumetanide: .5 – 2mg/day • Metolazone: 2.5 – 5mg/day (often 3X/week) • Aldosterone Antagonists: • Spironolactone: 25 – 50mg/day • Eplerenone: 25 – 50mg/day • Digoxin: .125 - .25mg/day • ARB’s • Valsartan: 40mg/BID (start), 80 – 60mg/BID maintenance • Candesartan: 4mg/day start, target 32/day • Losartan: (not approved but beneficial) 50mg/day Non-Pharmacologic Treatment • Diet: weight reduction, nutritional status, Na+ intake • Fluid Intake: about 2 liters/day • Smoking: stop or reduce • Exercise: regular moderate physical activity should be encouraged • Alcohol: in moderation • Vaccinations: influenza and pneumococcal What We Also Do • Education, education, education! • Patient and family involvement and decision making • Assess the patient for depression and stressors • Involvement of home nursing care, PT, medications management, CHF programs • Telemonitoring Education • Explain clearly what heart failure is • Explain medications, how they work, dosing schedule, etc… • Explain how their disease may be just as easily be well managed at home • Reassure patient that the diagnosis of heart failure does not have to be a death sentence • Include family / caregivers in education process Additional Management • Daily weights: • Gain > 3lbs, take extra Lasix first, then call us! • Sliding scale of diuretics: • Involve patient and family in dosing schedules • What triggers ER visits? • Usually dyspnea, suggest use of pulse oximetry for reassurance • Anxiety / panic: frequently will use a short acting anxiolytic • Have occasionally utilized MSIR for air hunger /anxiety • Treat depression • Have discussion about Palliative Care and Hospice Care Conclusion • Heart failure can be well treated at home • Admission and readmissions can be significantly reduced • Follow treatment guidelines • Involve patient, family, and caregivers in decision making • Educate! • Discuss hospice / palliative with critical patients • Be reassuring that there can be life after diagnosis of heart failure! Dementia What is dementia? Normal Aging Chart Title 120% 100% 99% 90% 85% 80.00% Axis Title 80% 70.00% 60% 40% 20% 0% Age 20 Age 40 Age 60 Age 80 Axis Title Normal Aging Dementia Column1 Age 100 Mild Cognitive Impairment Chart Title 120% Cognitive Function 100% 99% 90% 85% 80.00% 80% MCI 60% 70.00% 40% 20% 0% Age 20 Age 40 Normal Aging Age 60 Column2 Age 80 Column1 Age 100 Dementia Chart Title 120% 100% 99% 90% 85% 80.00% Axis Title 80% 70.00% 60% 40% 20% 0% Age 20 Age 40 Age 60 Age 80 Axis Title Normal Aging Dementia Column1 Age 100 Dementia Subtypes Subtype % of dementia patients afflicted Progressive Life Expectancy from onest Alzheimer’s 65% Yes 12 Vascular 30% Maybe ? Lewy Body 10% Yes 6 Frontal Temporal 10% Yes 6 ETOH <5% Maybe ? Parkinson’s Dementia <3% Probably ? Other…. Understanding Alzheimer’s • Notebook Analogy: memories are stored much like writing notes in a notebook. • You need both a pen and a notebook! • Page one are your oldest historical memories, (Age three) • Memories are stored in sequential order on subsequent pages. • Onset of Alzheimer’s is when the pen begins to run out of ink! • Next the pages are torn from the notebook, starting from the back and slowly moving forward. Behaviors, Non-Pharmaceutical Treatments • Engagement, (preventive) • Games, hangman vs trivial pursuit….. • Activities: art, music • Outings • Meals • Redirection • The first chapter of their memory book • Distraction • One to one sitter • Music • Sensory room • MORE INFO AT: https://www.effectivehealthcare.ahrq.gov/ehc/products/559/2199/ dementia-agitation-aggression-report-160314.pdf Pharmaceutical Interventions for Behaviors 1. 2. 3. 4. 5. 6. Make sure there are no reversible causes! Diagnose the subtype of dementia Exhaust non pharm interventions Implement robust behavioral tracking system Consider medical options Evaluate urgency, is there high short term risk? 7. Select a pharmaceutical intervention 8. Discuss and document Risk Benefit discussion 9. NOTHING IS FDA APPROVED!!!! Classification of Behaviors in Dementia Primary Symptom Examples Medication Class Psychotic Paranoia, delusions, halluciantions, confabulation Antipsychotic (many options) Neurotic Anxiety, depression, OCD ??? Impulsive Physical or verbal abuse without warning (no filter) Antiepileptic, Valproic Acid or Carbamazepine Pain Response Pain can cause a variety of responses and should be considered as a potential cause of any class of behaviors Pain Medication, APAP to MSO4 Agitation General agitation that cannot be classified elsewhere. Yelling and pacing are common examples. Citalopram, escitalopram, memantine Antipsychotic Choice Antipsychotic FDA approved Movement Side Effects Activating or Sedating Dose Range Cost Liquid Form Available Frequency Quetiapine NO Low Sedating 12.5 – 400 mg/day $$$ No BID-TID Risperidone NO High Activating 0.25 – 4 mg/day $$$ Yes BID Olanzapine NO High 2.5 – 10 mg/day $$ No QD-BID Haloperidol NO High 0.5 – 6mg/day ₵₵ No BID-TID Summary • Rule out other causes, infection, medication, metabolic…? • Investigate and document specifics about the behaviors, behavioral log? • Risk Stratify the patient and behavior • Select medication and sig that best matches patient needs • Review and document Informed Consent while establishing realistic expectations • Educate staff or family about what to monitor • Schedule a close follow up, generally <10 days • Evaluate effect with staff and family • Repeat process as needed…. • ALWAYS CONSIDER WEANING OR DISCHARGE OF THESE MEDS. We give all stable patients a weaning trial after 30 days of stability. Venous Thromboembolic Disease Duane Kirksey, MD MSCE Cleveland Clinic Medical Care at Home Venous Thromboembolic Disease (VTE) • HBPC Prevalence and Significance • Best Practices • Diagnosis • Treatment / Management • Challenges in Home Based Primary Care • When to Refer / Send to Hospital VTE: Prevalence • 3rd Leading Cause of Death1 • Prevalence directly associated with Age2 • Risk Factors • Virchow’s Triad: • Stasis • Hypercoagulability • Endothelial Injury VTE: Prevalence • Home Bound Adults • Lower Risk Than Community Dwelling Adults3,4 • Risk Factors • Respiratory Infection, Recent General Surgery, Mobility Limitation5 • Spinal Cord Injury (Paraplegia / Quadriplegia) • Low Risk after 90 days from injury6 VTE: Significance • Home Bound Adults • Cross-sectional Study of Homebound Adults • 18% with asymptomatic DVT7 • No cases of symptomatic DVT VTE: Best Practice • Diagnosis • Venous Ultrasound • Mobile Radiology • Trained Clinician VTE: Best Practice • Acute Management / Treatment • Anti coagulation • Low Molecular Weight Heparin (LMWH) • Direct Oral Anticoagulants (DOA) • Long Term Management / Treatment • Vitamin K Agonist (VKA) • Direct Oral Anticoagulants VTE: Home Based Practice • Diagnostic Challenges • Availability of Ultrasound • Pulmonary Embolism • Acute Management Challenges • LMWH Delivery • DOA Cost / Formulary VTE: Home Based Practice • Long Term Management • VKA • Monitoring • Interactions • DOA8,9 • Chronic Kidney Disease • Weight Extremes • CYP3A4 and P-gp Interactions VTE: Referral • Diagnostics Unavailable • DOA to start if clinical suspicion and obtain diagnosis later • Clinically Unstable • Hypoxia • Hypotension VTE References 1 Goldhaber SZ. Venous Thromboembolism: epidemiology and magnitude of the problem. Best Practice & Research Clinical Haematology 25 (2012): 235-242. 2 Martinez C, Cohen AT, et al. Epidemiology of first and recurrent venous thromboembolism: A population-based cohort study in patients without active cancer. Blood Coagulation, Fibrinolysis and Cellular Haemostasis. 2014:112 255 – 263 3 Ahmed J, Ornstein K, Dunn A, Gilatio P. Incidence of Venous Thromboembolism in a Homebound Population. J Community Health 2013 38:480-485 4 Arpais G, Ambrogi F, et al. Risk of Venous Thromboembolism in Patients Nursed at Home or in Long-Term Care Residential Facilities. Int J of Vascular Medicine, 2011 5 Leibosn CL, Peterson TM, et al. Rethinking Guidelines for VTE Risk Among Nursing Home Residents: A population-Based Study Merging Medical Record Detail with Standardized Nursing Home Assessments. CHEST 2014;146(2):412-421 6 Jones T, Ugalde V, et al. Venous Thromboembolism after spinal cord injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children. Arch Phys Med Rehabil December 2005 Vol 86 2240 – 2247 7 Arpais G, Ambrogi F, et al. Risk of Venous Thromboembolism in Patients Nursed at Home or in Long-Term Care Residential Facilities. Int J of Vascular Medicine, 2011 8 Cabral KP, Ansell JE The role of Factor Xa inhibitors in venous thromboembolism treatment. Vascular Health and Risk Management 2015:11 117-123 9 Adams SS, et al. Comparative Effectiveness of Warfarin and New Oral Anticoagulants for the Management of Atrial Fibrillation and Venous Thromboembolism: A Systematic Review. Annals of Internal Medicine 2012;157:796-807 Falls in the Elderly – The Sensory Connection Lynn Beatty, MD Demographics In patients over 65: • • • • 20%of falls result in severe injuries (fracture or TBI) 2.5 million ER visits annually 700,000 patients/year hospitalized due to fall >95% of hip fractures are caused by falling (usually falling sideways) • Direct medical costs for fall injuries = $34 billion annually (2/3 are for hospital costs) -CDC Home and Recreational Safety, Falls among older adults, updated1-20-16 http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Approach to Management of Fall Risk Manage Modifiable Risk Factors • Environmental hazards • Medications • Metabolic factors • Musculoskeletal factors • Neuropsychologic factors • Sensory impairment invisible and often overlooked • Disease/Illness related Moncada, Management of Falls in Older Persons, A Prescription for Prevention, American Family Physician 2011;84(11):1267-1276 Sensory Impairment • 3 key sensory components of balance function: • Somato-sensory (touch, vibratory, proprioception) • Visual • Vestibular – the most “invisible” but also highly treatable Vestibular Dysfunction From 2001-2004 35.4% of US adults >40 had vestibular dysfunction (69 million Americans) • Increased prevalence with age (mediated by vestibular dysfunction) • 40.3% lower risk in individuals with > high school education • 70% higher among people with diabetes • Borderline increased risk in hypertension • 8-fold increased risk of falling if symptomatic with dizziness; subclinical vestibular dysfunction also associated with increased risk Agrawal, et al, Disorders of Balance and Vestibular function in US Adults, Data from the NHANES 2001-2004, Arch Intern Med, 169(10):938-944, May 25, 2009 Vestibular Intervention Vestibular evaluation Vestibular exercises Dynamic Visual Acuity (DVA) Stare at object while shaking head; if object appears to shake or becomes blurry = deficit Modified CTSiB Stand upright under 4 sensory conditions x 30 s each Stare at object while shaking head; while nodding head. Goal = 5 minutes total per day; safe to do alone on couch; PT can help increase challenge & duration Principles of Wound Care David Skovran, ANP Mount Sinai Visiting Doctors Program Prevalence • An estimated 2.5 million pressure ulcers are treated each year in acute care facilities in the United States • Prevalence of pressure ulcers is widespread in all settings with estimates of 10% to 18% in acute care, 2.3% to 28% in long term care, and up to 29% in home care (National Pressure Ulcer Advisory Panel, 2009) Agency for Healthcare Research and Quality (2006 Analysis of pressure ulcers) • Pressure ulcer related hospitalizations ranged from 13 to 14 days and cost $16,755 to $20,430 per patient compared with average stay of 5 days and cost of about $10,000 • Pressure ulcers were a secondary diagnosis in 457,800 hospital admissions, up from 245,600 in 1993. These patients admitted primarily for pneumonia, infections, or other medical problems, either developed pressure ulcers before or after admission Pressure Ulcer Staging • Stage/Category I ulcers emerge without frank denudation or ulceration of skin that is red and nonblanchable. • Stage/Category II ulcers are partial thickness wounds involving the epidermis and dermis • Stage/Category III ulcers appear as fullthickness skin loss involving damage or necrosis of subcutaneous fat that may extend down to, but not through, underlying fascia Pressure Ulcer Staging continued • Stage/Category IV ulcers present with full thickness tissue loss; deep tissue layers such as muscle, tendon, ligaments or bone are visible. • Unstageable ulcers present as full thickness skin loss but the true depth of the ulcer is obstructed by necrotic tissue in the form of slough or eschar. • Suspected Deep Tissue Injury (DTI) characteristically presents as either a blood-filled blister or ecchymosis with purple or maroon colored intact skin Stage 1 Stage 2 Stage 3 Stage 4 Stage 4 Pressure Ulcer Prevention • Turning and positioning • Frequently turn and reposition lying patients every 2 hours and seated patients every 15 minutes. • Friction and Shear forces: • Prolonged upright positioning and repositioning of the body without surface barriers such as a sheet can subject the body to both persistent and dynamic shear forces. Pressure Ulcer Prevention • Support Surfaces Group 1: considered preventative – composed of gels, foam, water or air Group 2: Composed of powered low air loss mechanism Group 3: Composed of fluidized-air and particulates such as silicone beads Cleansing Wounds • Clean with each dressing change • Minimizing trauma to the surrounding skin. • Recommended that the ulcers be cleaned with noncytotoxic cleansers such as saline or water • In general, povidone-iodine solution, hydrogen peroxide, isopropyl alcohol and sodium hypochlorite (bleach) marketed as Dakin’s solution should be avoided given their high destruction of viable tissue and imposed delay in wound healing except in select circumstances. Debriding the Wound 1. Autolytic: 1. the use of dressings and formulations that promote the body’s natural enzymes to continually remove cellular debris from the wound 2. Usually done by any dressing that keeps wound moist, such as hydrocolloids and hydrogels 2. Enzymatic: 1. Enzymes degrade and remove necrotic tissue (examples: Collagenase, Sodium Chloride marketed as Hypergel) 2. Used when large amounts of slough or with some eschar 3. Some sting/inflammation Debriding the Wound 3. Non-enzymatic debridement: Sodium hypochlorite (bleach) or marketed as Dakin’s Solution™ • Topical, broad spectrum antimicrobial with efficacy in the clinical setting of MRSA, Vancomycin-resistant enterococcus and other antibiotic resistant bacteria, is widely used in a variety of difficult wound types • It is often used at ¼ strength to limit toxicity to surrounding tissue Debriding the Wound • Sharp Debridement • Indicated when chemical debridement has been unsuccessful or when more rapid tissue closure is desired • Necrotic tissue is removed using a scalpel, scissors, forceps, or curette Choice of Wound Care Dressings • Stage 1 ulcers and Suspected Deep Tissue Injury • In areas of moisture or irritation from urine or feces, an moisture barrier such as vitamin A/D cream or zinc oxide may be used. • A thin adhesive barrier such as a transparent dressing or thin hydrocolloid is advised to limit friction. Choice of Wound Care Dressings • Hydrocolloids (marketed as: DuoDerm, Comfeel, Tegasorb, Restore): • Hydrophillic colloid particles bound to polyurethane foam • Remain in place for 5-7 days. Often used to “seal” a wound that is otherwise clean in order to promote healing. • NOT for heavy drainage Choice of Wound Care Dressings • Stage 2 Ulcers: • Superficial and minimal drainage wounds • • • • Petrolatum dressing (example: Xeroform) Hydrocolloid Sodium based (example: Hydrogel) More Exudative • Packing with calcium alginate (example: Algisite) or sodium carboxymethylcellulose (example: Hydrofibers) Choice of Wound Care Dressings • Sodium Based – (example: Hydrogels) • Water-based, non adherent crossed linked polymer, hydrophilic. Keep the wound bed moist and cool Choice of Wound Care Dressings • Petrolatum – (example: Xeroform) • A sterile, fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate USP Petrolatum • Helps maintain a moist wound environment Choice of Wound Care Dressings • Calcium Algisite • Calcium-sodium salts of alginic acid (seaweed) • Useful to fill cavities, pockets, undermining, moisture retentive • Not recommended for use in wounds with low drainage as the dressing can dry out the wound • Also available impregnated with silver, offers additional barrier to bacterial growth Choice of Wound Care Dressings • Hydrofibers (marketed as Aquacel): • How it works: Like an alginate, the absorption of wound fluid causes this synthetic carboxymethylcellulose fiber to create a gel with enhanced absorption over alginates. • Available impregnated with silver • The benefit over alginates is that the frequency of wound care dressings can be several days longer. Choice of Wound care Dressings • Stage III and IV Ulcers: treated similarly • The goal is to fill the crater bed with the right material to promote absorption while maintaining a moist, bacteria-free wound environment • Less Exudative: • Pack with Hydrogels • More Exudative • Pack with Alginates or Hydrofibers • Consider Silver impregnated fibers Venous Stasis Ulcers • Chronic leg ulcers caused by chronic venous insufficiency (CVI) are the second most common wound-type treated in home-based primary care settings. • Poorly functioning vein valves or venous occlusion causes CVI • Risk factors for CVI include age (over the age of 30), family history, female sex, repeated venous thromboses, multiple pregnancies and obesity. Behavioral factors including prolonged standing and sitting, and heavy lifting Venous Stasis Ulcers • Treatment: • Compression is the mainstay of effective venous stasis ulcer care. • There are two main options for compression: • Paste bandage impregnated with zinc oxide, glycerin and gelatin – marketed as the Unna boot • Multi-layer compression bandaging system – marketed as Profore™ Wound References • Haesler, E (Ed.). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. [Internet] 2014. Available from: http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-1614-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf. • Krapfl, LA, Gray, M. Does Regular Repositioning Prevent Pressure Ulcers? Journal of Wound, Ostomy and Continence Nursing 2008; 35(6): 571 - 577. • Alvarez OM, Kalinski C, Nusbaum J, Hernandez L. Pappous E, Kyriannis C, Parker R, Chrzanowski G, Comfort C. Incorporating Wound Healing Strategies to Improve Palliation (Symptom Management) in Patients with Chronic Wounds. J Pall Med. 2007; 10(5): 1161-1189. • Kelechi T, Johnson JJ. Guideline for the Management of Wounds in Patients With Lower-Extremity Venous Disease. JWOCN 2012;39(6):598-606 • Shi L, Carson D. Collagenase Santyl ointment: a selective agent for wound debridement. J Wound Ostomy Continence Nurs. 2009;37(6 Suppl):S12–16. • Nisbet HO, Nisbet C, Yarim M, Guler A, Ozak A. Effects of Three Types of Honey on Cutaneous Wound Healing. Wounds.2010;22(11):275-283. • Barnea Y, Weiss J, Gur E. A review of the applications of the hydrofiber dressing with silver (Aquacel Ag®) in wound care. Therapeutics and Clinical Risk Management 2010;6:21-7. • Eberhardt RT, Raffetto JD. Chronic Venous Insufficiency. Circulation. 2014;130:333-46. • O’meara S, Cullum N, Nelson EA, Dumville JC. Cochrane Database Syst Rev. 2012 Nov 14;11:CD000265. Panel Discussion Go to: 2Shoesapp.com/AAHCM2016 1. Click on the session you are in 2. Ask and vote on questions