July 2020
Moving Ahead
Gary Bernett, MD, CMD
What more could I add to the literature and musings that now surround the most influential event of recent times? For one, the hope is that whatever the new norm is, it will come soon and uneventfully. With this in mind, it might be time to start considering some of the opportunities that have arisen and lessons we have learned during the last three months in the LTC trenches.
  
Among the many hardships that facilities dealt with, staffing became critical. This, in part, can be explained by the mandated prolonged absence from work for COVID + diagnosed employees and the refusal of some employees to work in a facility where there were afflicted patients. In preparation for a nursing crisis, Genesis instituted a “non-essential medication initiative.” With the consent of patients or the POA’s, our medical directors and clinicians put non-essential medications on hold for 14 days, and depending on the status of the building, renewed this hold for another 14 days. At the end of the “holding period,” we encouraged clinicians, where it felt appropriate, to deprescribe some of these meds completely. This was performed in many cases, and was done safely and without adverse outcome.

Historically, one of the focuses of LTC medicine, and Geriatrics in general, is polypharmacy.  To some degree, medications are never discontinued. Instead, they become “the gift that keeps on giving,” even when no longer demonstrating any beneficial therapeutic effect. Monthly medication reconciliations become nothing more than the reordering of the existing list of meds, with no thought to reduction in number, dosage, or to ongoing need or benefit.
To put it simply, there are six reasons to deprescribe: drugs should be eliminated when they are not indicated, not efficacious, do not achieve a patient's goals, have risks that outweigh benefits, make no sense whatsoever, or where nursing time could be better spent than administering these meds.

The University of Maryland School of Pharmacy in conjunction with the US Deprescribing Research Network has produced an outstanding guideline entitled  Optimizing Medication Management during the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care.  The recommendations included are easily utilized in the world after COVID-19, and it behooves us to be opportunistic and make these changes now. In the April 2020 edition of JAGS*, the following points were made in support of deprescribing in the LTC population:

  • Polypharmacy in this population is strongly associated with an increased risk of adverse drug events
  • In the United States, the median length of stay in a nursing home before death is 5 months
  • In this context, patients frequently do not live long enough to realize the benefit of their prescribed medicines
  • The consumption of multiple pills may be physically and emotionally burdensome
*JAGS 68:762-769, 2020

Below is a list of some of the medications that should be considered early on for discontinuation:

  • MVI
  • Herbal/naturopathic/homeopathic medication
  • Antihistamines
  • Decongestants
  • Fish Oil
  • Probiotics
  • Docusate
  • Statins and all hypercholesterolemia drugs
  • H2 Antagonists
  • PPIs

Other medications that should be considered include:

  • Cholinesterase inhibitors
  • Memantine
  • Long term oral steroids
  • Long term oral NSAIDS
  • Bisphosphonates
  • The Beers list

Deprescribing is a process that should not only be incorporated into the routine of visits, both monthly and regulatory, but should also be considered at admission. It is a task that should be borne by all primary care providers and considered to be part of the IDT/QAPI meeting. Though it has not been demonstrated to prolong life, it has been shown to improve the quality of life associated with decreased severity of drug related side effects. For these reasons and more, I would take advantage of the march to the new norm and Carpe Diem , Seize the Day, and begin to deprescribe.  

Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.
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Upcoming PMDA Events

  • Regional Meeting - 9/15/20 - Virtual. Registration fees: $25 PMDA Members; $30 non-members
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PMDA COVID-19 (Coronavirus) Update:
PMDA is very aware of the concerns with the spread of the coronavirus. The PMDA board and staff are closely following and monitoring the situation on a daily basis. At this point, PMDA plans to move forward with the in-person meeting in November at the Hotel Hershey, working with the hotel to ensure the safety of all of our attendees, speakers and staff. Please visit The Hotel Hershey's website to see how the Hotel Hershey is preparing for our meeting.
PMDA's Spring Conference on Post-Acute and Long-term Care Issues in the Era of COVID-19 Now Available
PMDA has packaged the conference presentations and PowerPoints for easy access to the important topics covered during the 2020 virtual spring conference, including:

  • Advanced Care Planning and Breaking Bad News presented by Alexander Nesbitt, MD
  • Transitions of Care in the Era CO of VID-19 presented by Firas Saidi, MD, CMD
  • Telemedicine, New COVID Codes and Modifiers presented by Michael Owen, PA-C
  • Outbreak Management in the LTC Setting/PPE/ Lessons Learned presented by Joshua Uy, MD
 
Each recording is $15 plus 6% sales tax. 
AMDA is excited to announce that its inaugural Leadership, Ethics & PALTC Virtual Symposium will take place November 20-21, 2020. Open to everyone who works in the PALTC setting, this live, online, interactive program will focus on the myriad leadership and ethical challenges that have emerged because of the COVID-19 pandemic. Over the coming months, please visit the meeting webpage for more details on the program, schedule, learning objectives, and credit information. Registration will open September 1!
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AMDA's APEX Learning Management System is your one-stop shop for all of AMDA's online education offerings. Access the searchable catalog that includes all education and product offerings filtered by program format, content, credit type, and other criteria. Register for upcoming webinars and listen to archived sessions; purchase annual conference recordings; sign up for the Core Curriculum and the QAPI course; listen to podcasts; purchase and download products and resources; and more. Check out everything APEX has to offer and get started. 
AMDA's Board Adopts Statement on Racial Inequities

In response to recent events, the AMDA Board of Directors has adopted a Statement on Racial Inequities that notes, "The current pandemic has revealed the wide racial gaps among older adults stricken with COVID-19 in our nursing homes that is mirrored in our PALTC direct care workforce. We can and must do better as a nation, not only to heal systemic racism in the U.S., but also to honor our residents of color, and to support those who care for them." 
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2020 International Pressure Ulcer/Injury Guideline: The Long-Term Care Specific Updates
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