Can Quality of Life (QOL) be measured in a dementia-specific AssistedLiving Facility (ALF)?

Presenting Author(s): Barney Spivack, MD, CMD, Waveny Care NetworkAuthor(s): Barney Spivack, MD, CMD; and Carole Edelman, APRN, BC, CMC

Introduction/Objective: Given the increased clinical, research, administra-tive, and consumer-driven focus on QOL for persons with dementia withinALFs, a practical measurement of QOL appropriate in “real world” settingshas received added importance. The feasibility and utility of resident reportedQOL in a dementia-specific ALF was explored.Design/Methodology: The QOL of all residents (N � 46) in a FairfieldCounty (CT) not-for-profit dementia-specific ALF, was surveyed using theLogsdon QOL-AD (R Logsdon et al Psychosomatic Med 64:510–19,2002), aself-reported easily scored 13 item measure (scored 13–52) suitable for indi-viduals with mild-moderate dementia, that assesses multiple domains. Ap-propriate training of existing staff for the resident interviews was provided.Results: QOL was easy to measure using the Logsdon QOL-AD in ALFresidents, even in those with moderately severe cognitive dysfunction. TheQOL assessment led to additional resident-specific information that had notpreviously been appreciated. The mean QOL score for residents in the ALFwas 35.61 (range 25–46, Std dev 4.4). Of the 13 items assessed, “doing thingsfor fun” received the lowest average score (2.46, range 1–4). Staff found thetool to be helpful in directing needed care interventions.Conclusion/Discussion: QOL can be easily and successfully measuredusing the Logsdon QOL-AD within a dementia-specific ALF by availablestaff following brief training. Meaningful information was captured thatled to changes in care planning, with the goal of improving residentdetermined QOL. Longitudinal measurement of QOL within this andwithin other residential care settings is underway in order to furtherunderstand and develop needed care interventions to enhance QOL.ALFs serving individuals with mild-moderate dementia can use the Logs-don QOL-AD to provide much needed input from these residents onQOL.Disclosures: Barney Spivack, MD, CMD has no disclosures to be made thatare pertinent to this abstract.

Characteristics of elder Mexican Americans with anemia in skillednursing facilities in the Southwestern United States

Presenting Author(s): Kathleen K. Owings, MD, University of Texas HealthScience Center San AntonioAuthor(s): Kathleen K. Owings, MD; Margaret R. Finley, MD, CMD; SandraL. Oakes, MD, FAAFP; Robert C. Woods, MPH; Robert W. Parker, MD; andDavid V. Espino, MD

Introduction/Objective: To compare the characteristics of MA’s with ane-mia to those without anemia admitted to skilled nursing facilities in theSouthwestern United States.Design/Methodology: Subjects 65 and over with a self reported diagnosis ofanemia admitted to skilled nursing facilities were selected from the south-western states of California, Arizona, Colorado, New Mexico and Texas.Subjects were selected from the Hispanic Established Population for theEpidemiological Study of the Elderly (EPESE) which were selected as aweighted probability sample. Those subjects with Medicare numbers werematched to the Center for Medicare Services (CMS) Medicare/Medicaidskilled nursing facility dataset. The selected subject’s were then compared byage, gender, total charges, LOS, number of diagnoses.Results: The prevalence of anemia in MA’s entering SNF’s was 16.1%.Characteristics significantly associated with those subjects with anemia in-clude the overall daily length of stay for combined SNF admissions (OR �1.012, CI � 1.005–1.019), the overall number of billings (OR � 1.39, CI �1.04–1.86) and highest compared to middle category household income (OR� 0.03, CI � 0.001–0.44).Conclusion/Discussion: Older Mexican Americans with higher householdincomes entering SNF’s in the Southwest are prone to longer stays and highergenerated costs when compared to Mexican Americans without anemia.Disclosures: Kathleen K. Owings, MD has no disclosures to be made that arepertinent to this abstract.

Comparison of pneumococcal, influenza and tetanus vaccination rates inassisted living residents with matched cohorts in outpatient clinic

Presenting Author(s): Sagar Panse, MD, Abington Memorial HospitalAuthor(s): Ellen Mangin, CRNP; Mary T. Hofmann, MD, CMD; SagarPanse, MD; Mary C .Naglak, MD; and Hal Hockfield, MD

Introduction/Objective: Infections are one of the ten leading causes of deathin the United States (US). Elderly patients are particularly susceptible toinfections, which tend to be more severe in them. Effective vaccines areavailable to prevent pneumococcal, influenza and tetanus infections. TheCenters for Disease Control (CDC) recommends annual influenza vaccina-tion after age 50 years, single dose pneumococcal vaccination after age 65years, and tetanus booster ten years after last tetanus vaccine. Vaccinationrates vary by state; data for nursing home patients is limited. Our studycompares the rates of vaccination among adults in an assisted living homewith an age and gender matched cohort of adults attending an outpatientclinic and CDC reported vaccination rates for US adults �65 years in 2003.Design/Methodology: We conducted a retrospective chart review from July2005 to June 2006 of 50 randomly selected adults in an assisted living homeand a cohort of 50 adults matched for age and gender attending an outpatientclinic. All patients met CDC criteria for pneumococcal, influenza and tetanusvaccination and were cared for by the same medical group.Results: The mean age (87.8, 87.6 years) and gender (90% female) werecomparable for residents in assisted living and outpatient clinic respectively.Rates of chronic pulmonary disease (16%, 12%), cardiovascular disease (38%,32%), diabetes (14%, 10%), hypertension (70%, 68%) and cancer (12%,16%) were not significantly different between the two groups. The influenzavaccination rate was significantly higher for adults in assisted living (92%)than for those attending the outpatient clinic (50%) (P � 0.001). The CDCreported influenza vaccination rate for US adults �65 years in 2003 was69.9%. The pneumococcal and tetanus vaccination rates for adults in assistedliving (48%, 8%) were similar to vaccination rates for adults attending theoutpatient clinic (30%, 10%). The CDC reported pneumococcal vaccinationrate in 2003 was 64.2%. Adults in assisted living had a higher mean numberof outpatient visits/year (11.9) compared to adults attending the outpatientclinic (3.7). Influenza and pneumococcal vaccines were more likely to beadministered (p 0.01, 0.001) if the number of outpatient visits/year weregreater than five.Conclusion/Discussion: Influenza vaccination rates were higher amongadults in assisted living than for those attending an outpatient clinic,which could be due to the state’s requirements and frequent healthcarepractioner visits at assisted living homes. Rates of pneumococcal andtetanus vaccinations were similar in both groups. Patients with 5 or morevisits were more likely to receive influenza and pneumococcal vaccines.Overall tetanus vaccination rate in our study population was only 9%.Compared to the CDC reported rates in 2003, our overall influenzavaccination rate was similar (71% vs. 69.9%) but our pneumococcalvaccination rate was lower (39% vs. 64.2%).Disclosures: All authors have stated that there are no disclosures to be madethat are pertinent to this abstract.

Decision making capacity in a patient with pontocerebellar degeneration

Presenting Author(s): John Batsis, MBBCh, Mayo Clinic College of MedicineAuthor(s): John A. Batsis, MBBCh; and Amanda B. Ebright, MD

Introduction/Objective: 1. Review methods by which one establishes deci-sion making capacity (DMC)2. Differentiate between capacity and competence.Design/Methodology: Case Report.Results: A 72 year-old male residing in an independent apartment withoutany family support, traveled alone across country for medical follow up at ourinstitution. He had a long-standing history of pontocerebellar degenerationwith progressively worsening gait instability. Over time, he sustained multiplefractures of his spine, ribs and arms from recurrent falls. He reported incon-sistent use of a four wheeled walker, falling two-three times per week, anddifficulty navigating stairs. Collateral history suggested he had significantdifficulties performing his basic activities of daily living (ADL). Midwaythrough his outpatient evaluation, he fell in his hotel room sustaining a lip

POSTER ABSTRACTS B5

laceration and head and elbow soft tissue injuries. He was admitted due toconcerns that he was a vulnerable adult who was unsafe to return to anunsupervised environment. Comprehensive geriatric assessment, and physicaland occupational medicine evaluations were performed. His Folstein mini-mental state examination score was 26/30. He demonstrated impaired judg-ment and problem solving abilities. He was felt to be unsafe to live indepen-dently and 24-hour supervision and ADL/IADL assistance was recommendedPsychiatry was asked for a second opinion and concluded he lacked insightinto the progressive functional deterioration caused by his neurodegenerativeillness but did possess some understanding of the risks and benefits of hisliving situation and alternatives. Overall, they concluded he retained DMCabout his living situation. A family member traveled to our institution andaccompanied the patient back to his prior living situation.Conclusion/Discussion: Competence and capacity are often incorrectly usedinterchangeably by lay people and physicians alike. DMC is a physiciandetermination based on clinical examination as to whether a patient canmake specific medical decisions for himself. Determination of DMC can bemade by any physician, not only a psychiatrist. It requires assessment of thepatient’s ability to understand information, apply information to his situation,use reasoning based on facts and personal values and communicate andexpress a clear choice. Patients may have DMC on certain issues and notothers. Competence, however, is a legal determination referring to the degreeof mental soundness necessary to make global decisions. All patients aredeemed competent unless adjudicated otherwise by a court. Our case focusedon the question of “Does this patient have the capacity to make a determi-nation regarding his living environment? While he had limited insight intothe longitudinal nature of his disease, and was unable to express comprehen-sion of our recommendations for his other medical issues, he satisfied theconditions for DMC on this specific issue. His autonomy was respected and hewas discharged to his home.Disclosures: John A. Batsis, MBBCh and Amanda B. Ebright, MD have nodisclosures to be made that are pertinent to this abstract.

Decreased incidence of dehydration with continuous PEG tube waterflushes vs. intermittent PEG tube water flushes

Presenting Author(s): Barbara L. Williams, MSN/FNP-C, Long Term Care ofTidewaterAuthor(s): Barbara L. Williams, MSN/FNP-C; Cindy Hatcher; and William N.Hovland, MD, CMD

Introduction/Objective: Patients with PEG tubes require water flushes nor-mally ordered 4-5 times throughout the day and after each medication. TheBUN’s of these patients are often found to be high. When the amount ofwater was increased to compensate for the dehydration the BUN oftenremained high. It was hypothesized that the water flushes were not beinggiven as ordered. To improve the patients hydration status these patients werecontinuously hydrated with water from 6PM to 6AM and given their nutri-onal fluids from 6AM to 6PM. In some cases the times may have been slightlyaltered. Nevertheless, the BUN’s of these patients were observed both beforeand after implementing the intervention to determine if continuous PEGWater flushes improved hydration.Design/Methodology: A small sample of patients were randomly chosen fromone facility. A retrospective study reviewed the BUN’s of these patient’sbefore implementing continuous PEG water flushes. Then a prospective studyreviewed the BUN’s of these same patients after the continuous PEG waterflushes was implemented. The study has gone on for some patients as long aa year. At the end of that time the BUN’s were compared to see if the changewas significant. A Registered Dietician calculated the water and nutritionalneeds of each of the patients.Results: Over the course of approximately one year the BUN’s of the patientsimproved. An incidental finding however showed some of the patientsdeveloping hyponatremia. To correct this these patients were given normalsaline flushes to compensate for the hyponatremia. After implementing thisthe sodium improved.Conclusion/Discussion: A larger sampling of patients needs to be studied. Amedical search found no other information regarding using this method withhydration in regard to PEG tubes. If anyone uses this method the electrolytesneed to be monitored to watch for hyponatremia. It was popular with the

nurses as it saved time preventing the need to flush the patients PEG tube 4-5times throughout the day.Disclosures: Barbara L. Williams, MSN/FNP-C has no disclosures to bemade that are pertinent to this abstract. William N. Hovland, MD, CMDreceived no financial support as a speaker for Ortho Biotech Products, L.P.

Developing a practical guide for diabetes management in long-term carefacilities: An inter-disciplinary approach

Presenting Author(s): Roberta Meyers, MD, MPH, CMD, Hennepin CountyMedical CenterAuthor(s): Roberta Meyers, MD, MPH, CMD; Laurel A. Reger, MBA; andJoanne M. Peterson, RN, BS, CDE

Introduction/Objective: The prevalence of diabetes in long-term care facil-ities (LTCFs) in the U.S. is 22% to 25%. Most persons working in LTCFs willencounter residents who have diabetes. Guidelines for the management ofthese residents exist; three important examples are guidelines developed bythe American Medical Directors Association, the California HealthcareFoundation/American Geriatrics Society and the European Diabetes Work-ing Party for Older People. These are primarily directed toward physicians,rather than “hands-on” LTCF staff. In 1992, under the auspices of theMinnesota Department of Health (MDH), an inter-disciplinary group ofnurses, physicians, dieticians and pharmacists developed a guide for themanagement of diabetes in LTCFs in Minnesota and distributed it to allLTCFs in the state. Periodic revision and re-distribution of the document hasoccurred. It has been available from the MDH on request. A group wasre-convened in 2005 to revise the guide with specific objectives: 1) review thecontent of the relevant guidelines currently available, 2) define the targetaudience for the MDH guide, and, 3) solicit peer review.Design/Methodology: Upon review of existing guidelines the group reachedconsensus that information and recommendations intended for “hands-on”LTCF staff would make a unique contribution. Topics were assigned tospecific group members. The entire group reviewed all materials. Membersmet and communicated with one another frequently and reached consensuson all the material. Since few studies regarding diabetes have been done onpersons older than 65 years, or those in LTCFs, recommendations were basedprimarily on expert opinion. Prior to completion, review was solicited fromnursing, social work, pharmacy and physician colleagues.Results: A comprehensive document was created that includes generalmanagement topics in addition to topics uniquely related to LTCFs such asthe management of diabetes during the hospital-LTCF transition, manage-ment in tube fed residents, and management during terminal illness. Specificsections are intended for nursing assistants. Training materials for staff,education materials for LTCF residents, and an appendix with information onmedications, medical nutrition therapy and standing orders are included.Conclusion/Discussion: Disease-specific, comprehensive information andrecommendations intended for “hands-on” LTCF staff add to existing guide-lines for diabetes management. These recommendations are often based onexpert opinion, rather than evidence, therefore, an inter-disciplinary processwith peer review is important. The guide is unique because of its availabilitythrough a state department of health.Disclosures: Roberta Meyers, MD, MPH, CMD has no disclosures to bemade that are pertinent to this abstract.

Development of the decision making tool: A brief tool for measuringdecisional capacity

Presenting Author(s): Kenneth Brubaker, MD, CMD, Masonic VillageAuthor(s): Kenneth Brubaker, MD, CMD; Kerrie D. Smedley, PhD; and VickiL. Gillmore, RN, PhD, NHA

Introduction/Objective: The present study investigates the use of a briefinstrument (The Decision Making Tool) for measurement of medical treat-ment decisional capacity among older adults with varying degrees of cognitiveimpairment. The Decision Making Tool is based on areas of decision makingtraditionally used in other measures (e.g. the MacArthur Competence As-sessment Tool for Treatment; MacCAT-T).Design/Methodology: The sample was comprised of 100 residents of a skilled

B6 JAMDA – March 2007