Care in Long-Stay Institutions

Dr. Brian FarrugiaMD, FRCP, DipGM(Lond), DipCPC(Glas)

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Long-term care institutions

A discussion on •who should enter and •what standards should be expected in LTC institutions

Reference:Clinical Guidelines:Enhancing the Health of Older People in Long-term Care. Research Unit, of RCPL, BGS, AgeCare

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Vision for Long-term Care

• Enhancing the quality of care to improve quality of life for the resident

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Who enters ?• Unable to live in community family home alone• Severely impaired activities of daily living• Anyone can be returned home even the dying Provided they have support

• Therefore support is the limiting/defining factor and not the condition of the patient

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Where ?

• Sheltered housing• Residential care • Nursing homes• Geriatric hospitals

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Quality of life

• Access to good health care• Dignity• Privacy• Independence• Choice• Human Rights• Fulfillment

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Issues of LTC• Major issue for society• Social justice• Social service • availability• Equity and access• Financing long-term• Consider the stake-holders• Professions involved in LTC• Involvement and information for relatives• Move into LTC is a major life-event - positive ? others as the final loss• potential for rehabilitation• Disappointments, meals, staff overbearing, lack of social and recreational

activity, broken promises, disorientation, bewilderment, depression,• Mortality is high 30% in 1st year in Malta, affects other residents and staff

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Consideration of Stake-holders

• Residents • Friends and family• Professionals• Administration• Politicians• Society

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Involvement and information for relatives and patient

• Informed of problem • Informed of the care plan• Regularly consulted about care plan• Must be satisfied with care provided

Friends and family• difficulties with staff, cleanliness, loss of clothes and personal items,

wandering, poor communication with staff, bed-bound patients appearing neglected sense of loss and even depression guilt feelings may result in acrimonious behavior, Lack of quiet, and respect when patients dying

• Relatives should have the opportunity to participate in relatives committees and practical care

• Staff should be trained to cope and communicate with relatives

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Residents

• Move into LTC is a major life-event - positive ? others as the final loss

• potential for rehabilitation ?• Disappointments, meals, overbearing staff,

lack of social and recreational activity, broken promises, disorientation, bewilderment, depression,

• Mortality is high 30% in 1st year in Malta, affects other residents and staff

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Consider Savings

• Avoiding errors• Infection control• Duplication• Inappropriate care• Safety issues

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The Professionals• Nursing staff: continence promotion, tissue viability• Care workers • health assistants• management• Religious / spiritual• Chiropody• Counseling• Dieticians• Pharmacist• Physiotherapy• Social workers• Speech and language therapy• Occupational therapists• Medicine, psychiatry, surgery, primary care, public health

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Staff • Carry out difficult and demanding work• Under staffed• Low training• Shift working• Benefits of training Lack of hand-overFeel valued - thus respected Improve motivation Increase self-confidence - improve assertiveness Job satisfaction Better work out-put - efficiency Improved communication Enhances teamwork Quality improvement, safety, infection control

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Main domains of quality of care

• Positive care for people with dementia• Detecting and managing depression • Overcoming disability • Preserving autonomy• Promoting urinary continence• Promoting faecal continence• Optimizing medication• Preventing and managing pressure sores• Dying with dignity, at peace and in comfort

Positive care for people with dementia-1

• Common about 50%• Challenges in providing appropriate environment

relatives difficult behaviors: wandering, incontinence, night-time disturbance aggressiveness, relatives: difficult for, and bewildered, require support work physically and emotionally draining

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Positive care for people with dementia -1

• Philosophy: aim at high levels of well being adopt a positive approach recognize all residents as individuals formation of relationship and collaboration with relatives

• Recognition and Diagnosis of cognitive impairment

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Detecting and managing depression - 2

• Common in up to 50%• Causes much suffering• Often undetected and neglected increasing the

likelihood of death• Poorly treated and less referrals• Ion admission usually improves within 2 weeks• Low recognition importance not appreciated significant changes not noted by staff due to shift work lack of time to observe and talk o residents poorly trained staff more difficult to recognize in people with dementia – abn behavior screaming, eating faeces, tearing / removing clothes, groveling on floor increased agitation and restlessness, appetite change, weight loss

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Managing depression -2

• Investigate for anemia, electrolyte disorders, CHF, chronic pain painful arthritis, haloperidol, tetrabenazine, hypo and hyperthyroidism

• Encourage talking about feelings• Activities: trips, visitors, exercise

• Anti depressants• Review watch out for biological symptoms (weight loss, poor fluid / food intake, suicidal ideas Refer if suicidal ideas, lasts more than 2 months

• Access to psycogeriatric specialist

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Overcoming disability - 3

• Wheel chair / Walking stick / walking frame• Seating / transfers• Toilet aids: raised toilet seats

• Bathing aids: grab rails , bath-boards, shower seats, non-slip floors, special baths

• Dressing aids• Washing and grooming• Eating aids• Aids for the senses glasses, talking books, books with large print,

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Preserving autonomy - 4

• Often threatened in institutions• Pts isolated and cut off from general social life• Batch living

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Preserving autonomy - 4 Quality of Care

• Preservation of autonomy• Danger that nursing interactions are

superficial, become routine and task related• Common sense, ethics, human rights

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Preserving autonomy - 4 requirements

Philosophy – central - communicated to all staff – for all dignity, privacy, recognize and respect religious, political and cultural beliefs.

Personal needs – attainments and goals individual and bed times clothing preference activities food preference form of address

Activities – recreational and creative, systematically organized, hobbies room, volunteers music and art therapists may contribute

Exercise – encouraged, physiological, functional, psychological benefits

Environment – ensure privacy, independence, personalization, possessions, cupboards, individual space

Access to advocacy - helps represent and safeguard the interests of residents

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Promoting urinary continence - 5

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Promoting faecal continence - 6• Distressing and unpleasant for all• From soiling underwear to smearing, storing and throwing• Causes: (diagnosis is a must)

constipation and faecal impaction

neurogenic cognitive impairment incontinence : constipate then give regular enemas colorectal disease diarrhoea anal sphincter defects

uninhibited defecation : Regular toileting and regular laxatives• Anyone performing anal stimulation, insertion of supp must be trained• Toilet clean, warm, quiet, safe, and comfortable

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Optimizing medication - 7

• Approx 3% of all deaths in Sweden• Hospital admissions 6% of all acute admissions• 5th leading cause of death in USA• Nosocomial incidence of ADE is about 7%• Costly 200$ billion in USA

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Optimizing medication - 7

• Most older people who require drug therapy take multiple drugs

• High levels of prescribing common – poly-pharmacy• Costly, adverse effects• Review monthly and at every consultation• Withdrawing medicines may be the best clinical

decision

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Optimizing medicationrequirements - 7

• Polypharmacy* increases risk of adverse effects and drug interactions• physiological changes of ageing alter handling and response to drugs• Appropriate medication in minimal doses• Regular medication review esp. anti-psychotics• Meds omitted by nurses, pharmacists can review and

suggest

* No exact number but indicates drugs inappropriately used

https://files.pbworks.com/download/FXjux7jiZ1/unmfm/45170322/Stopp%20and%20Start%20criteria_inappropriate%20prescribing%20in%20the%20elderly.pdf 28

Optimizing medication - 7

• Medicines can be grouped as:• Those that keep the patient well and improve

day-to-day quality of life e.g. analgesics, thyroxin or anti-angina drugs.

• prevention of illness statins, aspirin, warfarin or bisphosphonates omeprazole

include consideration of risks and benefits of Rx the length of time required for benefit and the life expectancy of the patient.

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Optimizing medication - 7• medication incidents still remain an important

cause of hospitalization. • Factors to consider when stopping a drug wishes of the patient, clinical indication and benefit appropriateness, adherence duration of use prescribing cascade

• Only stop or reduce one drug at a time• Tapering the dose helps reduce likelihood of an

adverse withdrawal event

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Preventing and Managing Falls-8

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Preventing and managing pressure sores-9

• Common 10-15% – suffering – unnecessary cost • Tools - formal assessment of risk for pressure ulcers. • The three most widely used scales: Braden Scale, Norton Scale, Waterlow Scale. • Braden Scale: commonly used in the USA, consists of six items: sensory perception, moisture, activity, mobility, nutrition, and friction and shearing. • Norton Scale: developed in the UK, consists of five items: physical condition, mental condition, activity, mobility, and incontinence. • Waterlow Scale: consists of nine items: build/weight for height, visual exam of skin in area at risk, sex and age, continence, mobility, Malnutrition Screening Tool score, and special risk factors including tissue • malnutrition, neurological deficit, and major surgery or trauma.• only some factors overlap,; specifically activity, mobility, nutrition/malnutrition, incontinence, and cognition. • each scale assigns different weights to factors

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Preventing and managing pressure sores- Requirements - 9

• Risk assessment tool used by nurses on adm

• Nutritional Support higher protein = faster healing under nourishment exists, loss of appetite , cannot feed themselves, dementia

• Special support surfaces turning patient alternating pressure mattresses pillow for heels

• Training for staff

• Audit

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Preventing Ulcers• In addition to avoiding the pain and adverse health outcomes associated with pressure ulcers, • Prevention strategies cost substantially less than treatment. treatment costs may be as much as 2.5 times the cost of preventionGuidelines recommend various preventive strategies: Repositioning/support surfaces low air loss mattresses; alternating pressure mattresses; sheepskin, foam, overlay Skin care including moisturizers and management of incontinence Nutrition nutritional supplementsUnderlying risks for pressure ulcers vary according to patient physical impairment; body weight; contractures nutritional status incontinence specific medical co morbidities: DM / PVD /PND /skin disease / trauma setting: acute care hospital, operating room, or wheelchair user in the community

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