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CONTENTS

4 An Open Letter from the Canadian Geriatrics SocietyRoger Y.M. Wong, BMSc, MD, FRCPC, FACP

4 A Modest Beginning …Barry Goldlist, MD, FRCPC, FACP, AGSF

5 Cognition-Enhancing Drugs in Dementia: Tips for the Primary Care PhysicianLinda Lee, MD, MClSc(FM), CCFP, FCFP, Carlos Rojas-Fernandez, BScPharm, PharmD, George Heckman, MD, MMATH, MSc, BASc, FRCPC, Micheline Gagnon, MD, BSc, Med, FRCPC, FACP

10 Reduction of MRSA Transmission in a Geriatric Setting following the Implementation of Daily Baths with Disposable 2% Chlorhexidine Gluconate ClothsHeather L. Candon, MSc, CIC, Jane E. Van Toen, BSc, MLT, CIC,

Chingiz Amirov, MPH, CIC

13 How Not to Harm Your Patients: Tips on Prescribing for the ElderlyAnthony Amadio, BScPhm, Vicky Chau, MD, Andrew Wyllie, BScPhm, ACPR, PharmD, Chris Fan-Lun, BScPhm, ACPR, CGP

17 Practical Tips for Recognition and Management of Behavioural and Psychological Symptoms of Dementia Kiran Rabheru, MD, CCFP, FRCP

23 Physician Practice in the Nursing Home: Exploring New ModelsPaul R. Katz, MD, CMD, Patrick Quail, MD, CCFP, CMD, Michael J. McBryde, MBBS, DObst RCOG, CCFP, Jurgis Karuza, PhD

VOLUME 1, ISSUE 1, 2011 3CGS JOURNAL OF CME

CMEC A N A D I A N G E R I A T R I C S S O C I E T Y J O U R N A L O F

Vo l ume 1 , I s s u e 1 • 2 011

EDITOR-IN-CHIEFBarry Goldlist

ASSOCIATE EDITORS-IN-CHIEFShabbir Alibhai, Frank Molnar

ASSOCIATE EDITORSAngela Juby, Robert Lam

MANAGING EDITORSusan Harrison

ART DIRECTORAndrea Brierley

PROOFREADERScott Bryant

MEDICAL ILLUSTRATORVictoria Cansino

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GROUP PUBLISHERJohn D. Birkby

Canadian Geriatrics Society Journal of CME is published threetimes a year by Andrew John Publishing Inc., with offices locatedat 115 King Street West, Suite 220, Dundas ON L9H 1V1.

We welcome editorial submissions but cannot assumeresponsibility or commitment for unsolicited material. Anyeditorial material, including photographs that are accepted froman unsolicited contributor, will become the property of AndrewJohn Publishing Inc.

The publisher and the Canadian Geriatrics Society shall not beliable for any of the views expressed by the authors publishedin Canadian Geriatrics Society Journal of CME, nor shall theseopinins necessarily reflect those of the publisher.

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Every effort has been made to ensure that the informationprovided herein is accurate and in accord with standardsaccepted at the time of printing. However, readers are advisedto check the most current product information provided by themanufacturer of each drug to verify the recommended dose, themethod and duration of administration, and contraindications. Itis the responsibility of the licensed prescriber to determine thedoseages and best treatment for each patient. Neither thepublisher nor the editor assumes any liability for any injuryand/or damage to persons or property arising from thispublication.

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CGS JOURNAL OF CME4 VOLUME 1, ISSUE 1, 2011

AN OPEN LETTER FROM THE CANADIAN GERIATRICS SOCIETY

Dear Colleagues:

On behalf of the Canadian Geriatrics Society (CGS), we are pleased to

present to you the inaugural issue of the Canadian Geriatrics Society

Journal of CME, the official publication of CGS with a focus on

addressing the continuing professional development needs of primary

care physicians and specialist physicians involved in geriatrics in

Canada.

One of the key objectives in the constitution of the Canadian Geriatrics

Society is “to promote the dissemination of knowledge of the clinical

care of the elderly by continuing medical education of physicians

throughout Canada.” In the past, CGS had provided a CME journal,

Geriatrics and Aging, to its membership. Unfortunately, Geriatrics and

Aging ceased publishing in 2010 when its parent company went into

receivership. In recognition of the benefit that a CME journal brings

to our members, the CGS Council explored the possibility of

resurrecting a CME journal. Our efforts have met with success as CGS

has identified a suitable publisher. We are proud to officially launch

the Canadian Geriatrics Society Journal of CME, which has been made

possible as the result of the tireless efforts of many people. Specifically,

we wish to express our heartfelt thanks to the editorial team, composed

of Dr. Barry Goldlist (editor-in-chief), Dr. Shabbir Alibhai (associate

editor-in-chief), Dr. Frank Molnar (associate editor-in-chief),

Dr. Angela Juby (associate editor), and Dr. Robert Lam (associate

editor).

We would like to thank you for your patience and understanding with

us. We envision that the Canadian Geriatrics Society Journal of CME

will publish regular editions moving forward. The topics will once

again cover clinical topics that our members feel will be of great benefit

to their clinical practices. Content for this CME journal will be solicited

from CGS members around the country, allowing us to tap into our

areas of national expertise. We are currently developing a formal

process to assess our members’ educational needs, but until then, do

not hesitate to let us know what topics you are interested in. We look

forward to working with all CGS members on articles that will be both

practical and highly relevant to our practices.

We welcome your feedback. Please feel free to contact the editor-in-

chief at [email protected].

Thank you once again for your support of CGS.

Sincerely,

Roger Y.M. Wong, BMSc, MD, FRCPC, FACP

President, Canadian Geriatrics Society

A MODEST BEGINNING …

This marks the first issue of the Canadian Geriatrics Society Journal of

CME. Unlike the previous society journal, which simply reflected an

affiliation with a privately owned (and excellent) publication, this one

is wholly controlled by CGS. This means that our only purpose is to

satisfy the educational needs of our members. As well, we will not be

at the mercy of higher-level corporate financial difficulties.

Although this issue is a modest beginning, we anticipate that the

journal will become a key component of CGS’s planned interactive

educational program.

We certainly hope you enjoy this edition.

Barry Goldlist, MD, FRCPC, FACP, AGSF

Editor-in-Chief,

on behalf of the editorial team


COGNITION-ENHANCING DRUGS IN DEMENTIA: TIPS FOR THE PRIMARY

CARE PHYSICIAN

With the demographic aging of the

Canadian population and critical

shortage of geriatricians,1 family

physicians will be expected to care for the

majority of patients suffering from dementia.

Studies have demonstrated, however, that many

primary care physicians are not confident in their

ability to manage patients with dementia.2,3

Quality dementia care requires multi-faceted

treatment interventions, and the appropriate

prescribing of cognitive enhancers represents one

important aspect of care. This article reviews

dementia treatment objectives and provides

practical tips for starting, maintaining, and

stopping cognitive enhancers with the

perspective of safe prescribing practice by

primary care clinicians.

In The Nature of Suffering and the Goals of

Medicine,4 Eric Cassell writes of the three goals

of medical care that are applicable to any chronic

disease: (1) make all diagnostic or therapeutic

plans in terms of the sick person, not the disease;

(2) maximize the patient’s function; and (3)

minimize the suffering of the patient and the

family. Suffering, according to Cassell, is defined

as “the state of severe distress associated with

events that threaten the intactness of a person.”5

In terms of suffering, the impact of dementia is

unrivalled: patients with dementia not only suffer

from a progressive, terminal illness but are also

faced with loss of their social identity and a shift

to a highly stigmatized social group.6 Treatment

considerations should include the degree of

suffering in context of the patient’s illness

experience, and the goal of treatment should be

to reduce suffering and improve functioning.

Treatment decisions must therefore be

individualized. In Canada, two types of cognitive

enhancers are available that may be offered to

patients with dementia: the acetylcholinesterase

inhibitors (AchEIs) donepezil (Aricept),

rivastigmine (Exelon), and galantamine

(Reminyl), and the N-methyl-D-aspartate

(NMDA) receptor antagonist memantine

(Ebixa).

Acetylcholinesterase InhibitorsAchEIs work by blocking the enzyme

acetylcholinesterase and thereby inhibit the

breakdown of acetylcholine, a neurotransmitter

required for memory (Figure 1). Since the

introduction of AchEIs in the 1990s, the evidence

supporting their use has been questioned, largely

because of conflicting study results due to

methodological differences and study end points

that are in hindsight questionable. Several

systematic reviews have nonetheless concluded

that AchEIs are modestly effective in modifying

the symptoms of Alzheimer’s disease in measures

of cognitive functioning, activities of daily living,

and behaviour.7–9 Current Canadian consensus

guidelines recommend that AchEIs be considered

as viable treatment options for most patients

with mild to moderate Alzheimer’s disease,

vascular dementia, and mixed dementia

(Alzheimer’s disease with vascular dementia).8

Additionally, the recently revised consensus

statement of the British Association for

Psychopharmacology recommends use of AchEIs

for the treatment of Lewy body dementias

(Parkinson’s disease dementia and Lewy body

dementia).10 AchEIs are not currently

recommended for the treatment of most

frontotemporal dementias. According to the

recent Canadian guidelines, currently available

AChEIs are “modestly efficacious for mild to

moderate AD [Alzheimer’s disease]” and are “all

viable treatment options for most patients with

mild to moderate AD.”8 Additionally, recent

clinical practice guidelines from the American

College of Physicians state that the decision to

initiate a trial of therapy should be based on an

individualized assessment.9 Thus, physicians

must consider each case in proper context when

offering these medications as part of the overall

treatment strategy for patients and their

caregivers.

The decision to initiate an AchEI begins with

ensuring that an adequate baseline cognitive and

functional assessment has been performed using

validated tools such as the Montreal Cognitive

Assessment11 and Functional Activities

Linda Lee, MD, MClSc(FM),CCFP, FCFP, family physician,Kitchener-Waterloo, Ontario;director of the Centre forFamily Medicine MemoryClinic; assistant professor inthe Departments of FamilyMedicine at McMasterUniversity, the University ofWestern Ontario, and Queen’sUniversity

Carlos Rojas-Fernandez,BScPharm, PharmD, Schlegelresearch chair in geriatricpharmacotherapy; assistantprofessor at the School ofPharmacy, University ofWaterloo, Waterloo, Ontario

George Heckman, MD,MMATH, MSc, BASc, FRCPC,Schlegel research chair ingeriatric medicine; associateprofessor in the Department ofHealth Studies andGerontology at the Universityof Waterloo, Waterloo; assistantclinical professor in theDivision of Geriatric Medicine,Department of Medicine,McMaster University, Hamilton,Ontario

Micheline Gagnon, MD, BSc,Med, FRCPC, FACP, head ofgeriatrics at St. Joseph’sHealthcare; professor in theDivision of Geriatric Medicine,Department of Medicine,McMaster University, Hamilton,Ontario

Correspondence may be directed toDr. Lee at [email protected].


Cognit ion-Enhancing Drugs in Dementia

Figure 1. Mechanism of action of acetylcholinesterase inhibitors (AchEIs). CoA = coenzyme A.


Lee et al .

Questionnaire.12 In discussing treatment with an AchEI, it is critical

to set realistic patient and caregiver expectations. It should be made

clear to patients and their caregivers that AchEIs treat symptoms but

are not curative. The anticipated benefit of these drugs for most

patients is to stabilize cognitive functioning for a period of time; a

minority of patients may demonstrate a temporary improvement over

baseline.13 For example, from a practical perspective, clinicians and

caregivers may notice improvements in apathy, attention, and the

ability of patients to engage in functional activities.14 It is also useful

to consider other benefits of these drugs, including the potential for

delayed time to nursing home placement, higher retention in assisted-

living facilities (versus progression into full nursing care), and a higher

likelihood of slower progression.15–18

The next step before initiating these drugs entails assessing relevant

safety considerations. In our training program for family physicians,19

we recommend obtaining a baseline electrocardiogram (ECG).

Because of the known effect of these drugs on cardioinhibition and

bradyarrythmia, which can increase the risk of syncope,20 we suggest

that the opinion of a specialist (internist, cardiologist, or geriatrician)

be sought prior to initiating an AchEI in the following conditions: left

bundle branch block, second- or third-degree heart block, sick sinus

syndrome, or bradycardia with heart rate <50 beats per minute. In

first-degree atrioventricular (AV) block with P–R intervals of 0.26 or

less, AchEIs can be initiated with consideration of repeating an ECG

a few weeks later to ensure no further widening of the P–R interval.

Other contraindications to AchEIs include uncontrolled asthma,

severe chronic obstructive pulmonary disease, and angle-closure

glaucoma. Patients should be warned of common, dosage-related,

often-transient side effects of AchEIs, which include gastrointestinal

symptoms (anorexia, nausea, vomiting, diarrhea), sleep disturbances,

vivid dreams or nightmares, dizziness, urinary frequency, muscle

cramps, and fatigue. If renal or hepatic dysfunction exists, the choice

of AchEI can be guided by the predominant route of elimination

(Table 1).

Dosage escalations are generally made every 4 weeks with an aim to

achieve a minimally effective target dosage (Figure 2). It is

recommended that the patient be reassessed prior to each dosage

escalation to monitor for side effects, particularly syncopal

symptoms,20 and to ensure that blood pressure and heart rate are

maintained. In persons with renal impairment, it is unclear based on

published literature whether target dosages needs to be modified when

using AchEIs that are less dependent on renal clearance (e.g., donepezil

and galantamine); however, in Table 2 we offer a conservative

approach for the family physician (also see below, under “NMDA

Receptor Antagonist”). As noted, it may be prudent to warn patients

with significant renal impairment about symptoms suggestive of

cholinergic excess (nausea, diarrhea, rhinorrhea) when escalating the

dosage of an AchEI. If these symptoms develop, they often occur

within days of the dosage increase, and patients should reduce the

dosage of the AchEI to the previously tolerated dosage. A repeat ECG

may also be considered to ensure that there is no widening of the

P–R interval or development of other types of heart block.

The patient’s cognitive functioning should be reassessed after 3

months21 of achieving a minimally effective dosage of an AchEI and,

if stable, repeated yearly thereafter. Reassessment may be required

sooner if the patient or family members notice a worsening of

symptoms. As dementia is a progressive disease, stabilization of

cognition, behaviour, or function is considered a positive treatment

response. Switching to a different AchEI may be considered if patients

develop intolerable side effects or if there is progressive cognitive

decline. If a switch is made due to side effects, a washout period of 1

week is recommended prior to initiating a different AchEI according

to the dosage titration schedule outlined in Figure 2. While there is

limited evidence to support switching AchEIs due to non-response, it

has been suggested that up to 50% of initial non-responders to one

AchEI may respond to a different AchEI.10 Switching in this case can

be easily accomplished by replacing the AchEI with its dosage

equivalent alternative: refer to Figure 2 to find the vertically aligned

dosage equivalent, with no washout period suggested.

NMDA Receptor Antagonist Unlike AchEIs, memantine works by blocking glutamatergic NMDA

receptors. Memantine can be used to treat moderate to severe

Alzheimer’s disease either as monotherapy or in combination with an

AchEI.8 Studies have demonstrated modest benefits on cognition and

behaviour.22,23 Overall, this drug is well tolerated. In clinical trials, the

most commonly reported side effects included agitation, falls,

dizziness, and diarrhea, but these occurred at the same (or lower) rates

as those in placebo-treated patients. Dosage adjustment is required in

patients with renal impairment. In those patients with a creatinine

Table 1. Dosing Guidelines for Cognitive Enhancers and Pharmacokinetic and Pharmacodynamic Parameters

Predominant Route Minimal Effective Drug Selectivity Half-Life of Elimination Starting Dosage Dosage Usual DosageDonepezil (Aricept) AchEI 70–80 h Hepatic 5 mg qam 5 mg qam 10 mg qamRivastigmine* (Exelon) AchEI and BuChEI 2 h Renal 1.5 mg bid 3 mg bid 4.5 mg bidGalantamine (Reminyl) AchEI and nicotinic 10 h Hepatic, some renal 8 mg od 16 mg od 16–24 mg od

modulatorMemantine (Ebixa) NMDA receptor 60–100 h Renal 5 mg qam 10 mg bid 10 mg bid

antagonistAchEI = acetylcholinesterase inhibitor; BuChEI = butyrylcholinesterase inhibitor; NMDA = N-methyl-D-disparate. *Exelon Patch 5 is equivalent to rivastigmine 3 mg bid oral dosage; Exelon Patch 10 is equivalent to rivastigmine 6 mg bid oral dosage.Adapted, with permission, from a table created by William B. Dalziel, MD, The Ottawa Hospital.


Cognit ion-Enhancing Drugs in Dementia

clearance (CrCl) of 30–49 mL/min, it is recommended that the dosage

initially be 10 mg/d and, if tolerated, increased to 20 mg/d.24 For those

with severe renal impairment (CrCl <30 mL/min), the suggested

dosage is 10 mg/d. It is worth noting that these dosing guidelines as

well as those for AChEIs (see Table 2) are based on estimated CrCl

rates using the Cockcroft-Gault method, not estimated glomerular

filtration rates (eGFRs), which are commonly reported by laboratories.

For older persons, eGFRs provided by laboratories (based on the

Modification of Diet in Renal Disease [MDRD] method) tends to

overestimate the actual CrCl.25 We therefore recommend that if a

patient’s eGFR is within 5–10 mL/min of the cut-off for dosage

adjustment, CrCl be calculated using the Cockcroft-Gault method26

(see Table 2 footnote) in order to obtain a more accurate CrCl

estimation to guide dosing.

Discontinuation of Treatment The decision to discontinue treatment must be individualized based

on the balance of benefits and harm. It is reasonable to discontinue a

cognitive enhancer in the following circumstances: when the patient’s

dementia progresses to a stage where there is no meaningful benefit

from continued therapy; when the patient’s overall condition is

deemed palliative; when there is no beneficial response, or intolerable

side effects occur; or when the patient is non-adherent and the patient

or proxy decision maker decides to stop the treatement.8,21 Sometimes

when a cognitive enhancer is discontinued, a noticeable deterioration

occurs,27 reflecting positive benefits of treatment that had not been

recognized. Patients should therefore be closely monitored after

stopping cognitive enhancers and considered for prompt

reinstatement of treatment should a significant decline in cognition,

functional abilities, or behaviour occur. For some patients,

interrupting therapy for prolonged periods of time (6 weeks in one

study28) may result in the loss of treatment benefits that cannot be

regained.

Conclusions While a few considerations are required in ensuring the safe use of

cognitive enhancers, these medications can be properly initiated and

managed by primary care physicians. For appropriate patients, the use

Table 2. Suggested Dosing Adjustments for Renal Impairment

CrCl (mL/min)* AchEI Dosage Adjustments>61 Any AchEI can be used and titrated to the

minimum effective dosage40–60 Any AchEI can be used but exercise caution† when

exceeding 16 mg/d of galantamine or 6 mg/d of rivastigmine

<39 Consider using donepezil as it is has mainly hepatic clearance, but exercise caution† in exceeding 5 mg/d; galantamine is not recommended for use in patients with CrCl <9 mL/min

CrCl (mL/min)* NMDA Receptor Antagonist (Memantine) Dosage Adjustment

>50 None required30–49 If patient tolerates 10 mg/d after 7 days, begin further

titration to target 20 mg/d15–29 Suggested dosage is 10 mg/d

AchEI = acetylcholinesterase inhibitor; CrCl = creatinine clearance; NMDA = N-methyl-D-disparate. *See text for further details. CrCl as estimated by the Cockcroft-Gault method:

CrCl = (140 − Age) ×Weight (kg) × K, Scr (μmol/L)

where K represents a constant of 1.23 for men and of 1.04 for women, and Scrindicates serum creatinine.†Watch for symptoms of cholinergic excess (nausea, diarrhea, runny nose); usually willoccur within days of dosing increase. Consider an electrocardiogram to ensure nowidening of P–R interval.

Figure 2. Dosage titration of cognitive enhancers.*Dosage titration is generally every 4 weeks, although slower titration may beused if side effects occur. Dosage titration assumes normal renal function. †Exelon Patch 5 is equivalent to rivastigmine 3 mg bid oral dosage. Exelon Patch 10is equivalent to rivastigmine 6 mg bid oral dosage. Adapted, with permission, from a figure created by William B. Dalziel, MD, TheOttawa Hospital.

†

40 8 12 16

Key PointsThe decision to treat with a cognitive enhancer should bebased on an individualized assessment.Realistic patient and caregiver expectations should beestablished.An adequate baseline cognitive and functional assessmentmust be performed prior to initiating treatment.A baseline electrocardiogram should be obtained and aspecialist’s referral considered in the presence of certainconduction abnormalities. A conservative approach to dosage escalations issuggested for patients with renal impairment.

of cognitive enhancers can contribute to holistic, compassionate

dementia care that allows patients to maintain their quality of life and

independent living for as long as possible.

AcknowledgementsDr. Lee has received educational grants or honoraria from Pfizer,

Janssen-Ortho, Novartis, Astra-Zeneca, and Solvay. Dr. Rojas-

Fernandez has received consulting honoraria from Otsuka

Pharmaceutical Inc (US), received grants from Pfizer, Purdue, and

Astra Zeneca, and served on an expert panel for Ortho-McNeil (US).

Dr. Heckman has received grant-in-aid funding from CIHR and

HSFO, received salary support from HSFC, and served on advisory

boards for Pfizer, Janssen-Ortho, and Novartis. Dr. Gagnon has

received honoraria and served on advisory panels for Pfizer, Novartis,

Lundbeck, and Janssen-Ortho, and has received research grants from

Pfizer.

This article has been peer reviewed.

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Lee et al .


Heather L. Candon, MSc, CIC,infection control practitioner,Baycrest Geriatric Health CareSystem, in Toronto, Ontario

Jane E. Van Toen, BSc, MLT,CIC, infection controlpractitioner, Baycrest GeriatricHealth Care System

Chingiz Amirov, MPH, CIC,director, Infection Preventionand Control, Baycrest GeriatricHealth Care System

Correspondence may be directed [email protected].

REDUCTION OF MRSA TRANSMISSION IN A GERIATRIC SETTING FOLLOWING THE IMPLEMENTATION OF DAILY BATHS WITH

DISPOSABLE 2% CHLORHEXIDINE GLUCONATE CLOTHS

Many chronic care facilities and nursing

homes contend with endemic rates of

methicillin-resistant Staphylococcus

aureus (MRSA) colonization among residents.

Risk factors for MRSA acquisition in chronic care

patients include prior treatment in an acute care

facility, prolonged hospitalization, complexity of

co-morbidities, administration of multiple anti-

biotics, intravenous therapy, multiple wounds,

and the presence of a gastric tube.1,2 Studies have

indicated that colonized residents in nursing

home settings are six times more likely to develop

an infection than are non-colonized patients,

thereby potentially increasing the risk of

mortality.3 Few studies have been conducted

investigating control measures to prevent MRSA

transmission among elderly residents in chronic

care facilities or nursing home settings.4

Over a 3-year period, 21% of all nosocomial

MRSA cases at Baycrest Geriatric Health Care

System originated within a single Acute Care and

Transition (ACT) unit. Given the condition of

residents and the multiple-bed ward rooms

present in this unit, there was an urgent need to

implement an infection prevention and control

intervention to limit MRSA transmission. An

interrupted time series design was used to

evaluate the effectiveness of daily bathing with

2% chlorhexidine gluconate (CHG)–impreg-

nated disposable cloths on all patients in the ACT

unit to reduce the incidence of MRSA.

MethodsThe study was approved by the research ethics

board at Baycrest. The requirement for written

informed consent was waived. The study was

conducted in a 27-bed ACT unit at Baycrest, from

October 2008 to October 2009. Two patient

groups were included in this study: the pre-

intervention period included all patients on the

unit from October 2008 to March 2009; the post-

intervention period included all patients on the

unit from May 2009 to October 2009. During the

1-month washout period, between pre- and post-

intervention time periods, unit staff were

educated in the use of 2% CHG bathing cloths.

Patients on the ACT unit were >65 years of age,

with an average age of 87 years. The ACT unit is

an alternative to preventing an admission to an

acute care hospital for elderly patients with

subacute or chronic disabilities requiring

assessment and treatment interventions. Patients

are admitted from other Baycrest units, the

community, acute care hospitals, emergency

departments and other chronic care facilities.

Colonization pressure (CP) was calculated to

verify that the reservoir of MRSA was similar for

both study periods. CP was calculated monthly

pre- and post-intervention (Number of MRSA

Patient-Days × 100 ÷ Total Number of Patient

Days).5 MRSA patient days on the ACT unit were

counted starting with first day a patient was

identified as MRSA positive until that patient’s

death or discharge.5

To assess MRSA transmission on the ACT unit,

Baycrest policy is to collect swabs within 48 hours

of admission and on discharge. An MRSA point

prevalence survey was performed on the first and

last days of the post-intervention period.

Compliance with timely MRSA swab collection

was monitored pre- and post-intervention.

Pooled swabbing technique (multiple swabs from

the same patient processed in one broth culture)

was used to test specimens from the nares,

perianal area, and any wounds or indwelling

devices. Results were available within 24–48

hours of specimen collection. MRSA-colonized

or -infected patients were placed on contact

precautions pre- and post-intervention.

The intervention consisted of nurses providing

daily baths with disposable 2% CHG cloths (Sage

Products Inc., Cary, Illinois) for all patients on

the ACT unit. All other bathing products (basins

and non-rinse bath products) were removed

from the unit to ensure compliance with the

intervention. Consistent compliance with the


Candon et al .

bathing protocol and product availability was enforced. Patients were

bathed with 2% CHG cloths as per package instructions, avoiding all

mucous membranes and facial areas. There were no other changes in

practice on the unit (e.g., environmental cleaning, indwelling device

maintenance, etc.).

The main outcome measure was the incidence of new ACT-acquired

MRSA. Data were analyzed using the SPSS program (SPSS Inc.,

Chicago, Illinois). We considered p values <.05 to be statistically

significant. MRSA acquisition rates during the two study periods were

compared using a chi-square test. The t test was used to compare

demographic data pre- and post-intervention.

ResultsDuring the pre-intervention period from October 2008 to March

2009, 169 patients were admitted to the ACT unit and there were a

total of 3,811 patient days. Post-intervention, May 2009–October 2009,

there were 168 admissions and a total of 3,598 patient days. Swab

collection compliance on admission and at discharge was 95% for both

pre- and post-intervention. Demographics of patients for both study

periods were similar (Table 1).

The CP pre- and post-intervention did not differ significantly (p = .79,

t test), with average colonization being 11.8% and 10.8%, respectively.

We do recognize that during June of the post-intervention period, the

CP was much lower than in other months; however, this did not affect

the significance between study periods.

Following the implementation of disposable 2% CHG cloths for

bathing on the ACT unit, the incidence of MRSA decreased

significantly, from 4.99 pre-intervention to 0.56 post-intervention per

1,000 patient days (p < .001, chi-square analysis). Overall, this

represented an 89% reduction in ACT unit–acquired MRSA

transmission (Figure 1).

DiscussionDaily bathing of geriatric patients on an ACT unit with disposable 2%

CHG-impregnated cloths resulted in an 89% relative decline in

incidence of MRSA. Previous studies have examined the utility of

disposable 2% CHG bathing cloths as a preoperative skin preparation

and as a daily bathing regimen in such settings as medical intensive

care, general medicine, and trauma units.6–9 To our knowledge, there

are no studies that have investigated the effect of daily bathing with

2% CHG cloths in a geriatric setting.4

It has been well established that length of stay in a healthcare facility,

especially a nursing home, is a risk factor for MRSA acquisition.4 Many

geriatric facilities struggle with controlling MRSA transmission.4

Interventions focusing on reducing MRSA incidence have been largely

behavioural based, and results are generally not sustained over time.10

By implementing daily bathing with disposable 2% CHG cloths, a

non-behavioural intervention, the reduction in MRSA transmission

was sustained over time. This is valuable in chronic care, where lengths

of stay can last from months to years. Our study has led to Baycrest

implementing the use of daily 2% CHG bathing cloths as a standard

of care on the ACT unit.

We acknowledge that there may have been specific patient-related risk

factors rendering patients more susceptible to MRSA acquisition;

Table 1. Patient Demographics for the Pre-intervention and Post-intervention Study Periods afterAdmission to the ACT Unit

Demographic Variables Pre-intervention Post-intervention p ValueNo. of MRSA cases acquired 19 2 .0002*Average MRSA incidence 4.99 0.56 .0002* (per 1,000 patient days)Patient days 3,811 3,598 .55MRSA patient days 450 389 .56CP (%) 11.8 10.8 .79Admissions 169 168 .98Discharges 166 173 .79Deaths 30 27 .78Average LOS (days) 20 16 .21Occupancy (%) 77 72 .47Median age, in years (IQR) 89 (83–93) 88 (83–90) .17Average Braden Scale score† 16.1 16.7 .20

ACT = Acute Care and Transition; CP = colonization pressure; IQR = inter-quartile range; LOS = length of stay;MRSA = methicillin-resistant Staphylococcus aureus.*Statistically significant result (p < .05).†Braden Scale assesses a patient’s risk of developing a pressure ulcer by examining six criteria: sensory perception, moisture,activity level, mobility, nutrition, and friction and shear. An adult with a score of 18 or less is considered at risk for developing pressureulcers.

Key PointDaily bathing with 2% chlorhexidine gluconate clothssignificantly reduced the incidence of methicillin-resistantStaphylococcus aureus in a geriatric setting from 4.99 to0.56 per 1,000 patient days, representing an 89%reduction.


CHG to Reduce MRSA Transmission in Geriatric Setting

however, patient demographics (see Table 1) appeared similar for both

the pre- and post-intervention periods. Although this interrupted time

series design was useful, we recognize that a randomized control trial

is the most robust method for controlling for confounding variables.

AcknowledgementsWe would like to acknowledge the receipt of an unrestricted

educational grant from Sage Products, Inc. Sage Products Inc. had no

role in the development, analysis, or preparation of this manuscript.

We would also like to acknowledge the Baycrest Acute Care and

Transition Unit staff, especially Judy Ritchie, for their ongoing

dedication to patient quality.

These findings were reported in a poster presented at the Community

and Hospital Infection Control Association – Canada National

Education Conference, May 29 – June 3, 2010, in Vancouver, British

Columbia.


References1. Loeb MB, Craven S, McGeer AJ, et al. Risk factors for

resistance to antimicrobial agents among nursing home residents.

Am J Epidemiol 2003;157:40–7.

2. Guerrero J, O’Grady S, Takata-Schewchuk J, Gardam M. 2006.

Usefulness of post-antibiotic treatment screening for methicillin

resistant Staphylococcus aureus in a complex continuing care

facility. Can J Infect Control 2006;21:31.

3. Capitano B, Lesham A, Nightingale CH, et al. Cost effect of

managing methicillin-resistant Staphylococcus aureus in a long-

term care facility. J Am Geriatr Soc 2003;51(1):10–6.

4. Hughes C, Smith M, Tunney M. Infection control strategies for

preventing the spread of meticillin-resistant Staphylococcus

aureus (MRSA) in nursing homes for older people. Cochrane

Database Syst Rev 2008;(23):1.

5. Williams VR, Callery S, Vearncombe M, Simor AE. The role of

colonization pressure in nosocomial transmission of methicillin-

resistant Staphylococcus aureus. Am J Infect Control

2009;37:106–10.

6. Evans HL, Dellit TH, Chan J, et al. Effect of chlorhexidine whole-

body bathing on hospital-acquired infections among trauma

patients. Arch Surg 2010;145:240–6.

7. Rauk PN. Educational intervention, revised instrument

sterilization methods, and comprehensive preoperative skin

preparation protocol reduce cesarean section surgical site

infections. Am J Infect Control 2010;38:319–23.

8. Bleasdale SC, Trick WE, Gonzalez IM, et al. Effectiveness of

chlorhexidine bathing to reduce catheter-associated bloodstream

infections in medical intensive care unit patients. Arch Intern

Med 2007;167:2073–9.

9. Kassakian SK, Mermel LA, Jefferson JA, et al. Impact of

chlorhexidine bathing on hospital-acquired infections among

general medical patients. Infect Control Hosp Epidemiol

2011;32:238–43.

10. Kretzer EK, Larson El. Behavioural interventions to improve

infection control practices. Am J Infect Control 1998;26:245–53.

Pre-intervention Post-interventionM

RS

A incid

ence p

er

1,0

00 p

atient

days

8

7

6

5

4

3

2

1

0

Reduction in MRSAtransmission by 89%

(p <.001)4.8

7.4

2.8

5.5

4.2

5.1 5.1

1.8 2.0

0.0 0.0 0.0 0.0

CHG bathing implemented

ColonizationPressure (%)

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

15.8 14.1 10.1 8.5 7.9 14.2 18.6 1.0 14.3 16.1 8.7 7.0Wash-

Out

2008 2009

Figure 1. Results of aninterrupted time-series study:methicillin-resistantStaphylococcus aureus (MRSA)transmission rates andcolonization pressure. Baycrest Acute Care and TransitionUnit–acquired MRSA transmission ratesbefore (October 2008 – March 2009)and after (May – October 2009) theimplementation of a daily bathingregimen using disposable clothsimpregnated with 2% chlorhexidinegluconate (CHG). Colonization pressure(%) by month is indicated at the bottomof the figure.

CGS JOURNAL OF CME VOLUME 1, ISSUE 1, 2011 13

Anthony Amadio, BScPhm,pharmacy resident, MountSinai Hospital, Department ofPharmacy Services, in Toronto,Ontario

Vicky Chau, MD, fellow,Division of Geriatric Medicine,Department of Medicine,University of Toronto, inToronto, Ontario

Andrew Wyllie, BScPhm,ACPR, PharmD, druginformation pharmacist, MountSinai Hospital, Department ofPharmacy Services

Chris Fan-Lun, BScPhm,ACPR, CGP, geriatrics clinicalpharmacist, Mount SinaiHospital, Department ofPharmacy Services

Correspondence may be directed to

[email protected].

HOW NOT TO HARM YOUR PATIENTS: TIPS ON PRESCRIBING FOR THE ELDERLY

Polypharmacy increases the risk of adverse

drug reactions (ADRs) in the elderly.1 It

has been estimated that by the year 2041,

25% of the Canadian population will be over the

age of 65 years, although more recent census data

suggest that this may happen sooner.2 The fact

that patients aged 60–79 years fill an average of 35

prescriptions per year, which is estimated to

increase to 74 per year in patients over the age of

80 years, suggests the risk of ADRs is high.3

Indeed, the risk is underestimated given that 68%

of older adults also use over-the-counter (OTC)

medications.4 A study looking at ADRs in the

community determined that 95% of ADRs are

predictable and that 28% are preventable.5

Notable ADRs in the elderly include falls,

cognitive impairment, constipation, insomnia,

and mortality.

Clinicians should attempt to optimize medication

therapy while aiming to improve outcomes and

reduce ADRs. The process of conducting periodic

medication reviews is a practical way of achieving

this goal and can lead to discontinuing

inappropriate medications, changing medications

to those documented to be safer in older adults,

reducing dosages, or employing additional

therapy.

New signs and symptoms should be investigated

before being treated, and ADRs should be

included in the differential diagnosis. This may

lead to the discovery of an ADR and avoid a

harmful and unnecessary prescribing cascade

(Figure 1).

The following patient case highlights some

commonly prescribed medications in elderly

patients and the risks associated with these drugs.

The resolution of the case follows a discussion of

potentially harmful medications in this

population.

Case ReportMs. P was an 81-year-old woman admitted to

hospital with a right hip fracture. She presented

with a 2-week history of progressive left leg

edema, pain, and erythema that contributed to

instability and resulted in a fall while walking to

the bathroom at night. Her past medical history

included hypertension, atrial fibrillation (AF),

renal insufficiency, osteoporosis, osteoarthritis,

and urinary frequency.

Her medications included acetylsalicylic acid

(ASA) 81 mg daily, metoprolol 25 mg bid, digoxin

0.0625 mg daily, amitriptyline 50 mg qhs,

warfarin 2 mg daily, calcium 500 mg daily,

vitamin D 1,000 units daily, alendronate 70 mg

weekly, lorazepam 1 mg qhs prn, tolterodine 2 mg

bid prn, and ibuprofen 200 mg qid prn. A

comprehensive geriatric assessment was requested

by her orthopedic team.

Potentially InappropriateMedications This patient was taking a number of medications

that may have contributed to her fall and

subsequent admission to hospital. Outlined below

are five medications or classes of medications that

Prescribing Cascade

NSAIDArthritis Pain

Worsens HeartFailure

DigoxinCHF Symptom

Control

Delirium

RisperidoneAntipsychotic

Figure 1. Example of a prescribingcascade. CHF = congestive heart failure; NSAID =nonsteroidal anti-inflammatory drug. Source:Reprinted from The Lancet 346(8966), Rochon PAand Gurwitz JH, Drug therapy, 32–6, Copyright 1995,with permission from Elsevier.6


Tips on Prescribing for the Elderly

have been identified by the Beers criteria7 and are potentially unsafe

for use in elderly patients. The rationale for avoiding these medications

is provided, and safer alternatives are suggested.

Digoxin for AF and Congestive Heart Failure Age-related changes to total body water, lean muscle mass, and renal

function predispose older patients to developing digoxin toxicity. This

toxicity presents as nausea, blurred vision, weakness, and confusion;

patients with more severe cases can experience heart block, delirium,

and psychosis. In older patients, these ADRs also occur at serum

concentrations considered to be in the therapeutic range

(1–2.6 nmol/L).8

β-Blockers and non-dihydropyridine calcium channel blockers

(e.g., verapamil, diltiazem) are preferred as initial therapy for rate

control of AF as they more effectively control heart rate (HR) during

exercise. The addition of digoxin can be considered in those patients

whose HR remains refractory despite optimal therapy.8

In patients with congestive heart failure (CHF) whose symptoms

persist despite optimized first-line therapies, digoxin can be considered

for symptomatic control. If initiated, digoxin should not be abruptly

discontinued as this may lead to worsening heart failure and increase

the risk of hospitalization.9 A safe approach to the use of digoxin in

elderly patients is to target lower serum concentrations. In studies,

older patients whose digoxin levels were between 0.6 and 1.2 nmol/L

did not experience worsening CHF symptoms compared with those

whose serum levels were >1.3 nmol/L. A reduced risk of

hospitalization and mortality was also observed with lower serum

concentrations.10,11

Tricyclic Antidepressants for Depression, Insomnia, andNeuropathic PainA major concern with tricyclic antidepressants (TCAs) is the elevated

anticholinergic activity and related adverse effects (cognitive

impairment, constipation, dry mouth, dizziness, and falls), especially

with first-generation agents such as amitriptyline and doxepin.12 The

rate of depression in the geriatric population has been reported as

approximately 15%, and 15–25% of nursing home residents suffer from

a major depressive disorder.13 These numbers highlight the need for

screening elderly patients and weighing the risks and benefits of therapy.

Selective serotonin reuptake inhibitors (SSRIs) and selective

norepinephrine reuptake inhibitors (SNRIs) are less anticholinergic

than TCAs and are thus considered safer in elderly depressed

patients.14 These medications do carry their own risks, and the guiding

principle of “start low and go slow” should still be applied. Studies

comparing the efficacy of TCAs and SSRIs15 have not shown either

agent to be superior for treating depression, thus leaving TCAs as a

viable option in older patients who cannot tolerate SSRIs. Among the

TCAs, agents such as nortriptyline and desipramine have relatively

lower anticholinergic activity and may be preferable in these

situations.16

For older patients with untreated insomnia, non-pharmacological

therapy including sleep hygiene, stimulus control, and cognitive

behavioural therapy (CBT) should be preferred over medications. The

need for TCAs to aid in sleep should be reassessed, and the use of TCAs

over less anticholinergic options should be re-examined. Sedating

antidepressants such as trazodone and mirtazapine may be preferred

over TCAs in this setting because of the lower anticholinergic activity;

however, evidence to support their use is lacking in patients without

underlying depression.

TCAs have been used successfully to treat neuropathic pain. However,

their anticholinergic effects limit their use in older patients.

Gabapentin and pregabalin are other first-line agents that are not as

anticholinergic as TCAs and can be considered, but slow dosage

titration is necessary due to side effects such as sedation.17 As discussed

above, the lowest effective dosages should always be used and, in these

cases, adjunct acetaminophen or low-dose opioids may help to lower

dosages and reduce pain.

Nonsteroidal Anti-inflammatory Drugs for PainMusculoskeletal pain from injury or arthritis can be a common

symptom in older patients and negatively impact their quality of life.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective options

for both chronic and acute pain; however, their mechanism of action

(prostaglandin inhibition) can cause or worsen hypertension, CHF,

acute renal failure, and upper gastrointestinal bleeds (UGIBs).18,19 All

drugs in the NSAID class appear to cause these adverse events, with

the exception of UGIBs, at similar rates.19 Cyclooxygenase 2 (COX-2)

selective agents (e.g., celecoxib) appear to cause fewer gastrointestinal

bleeds than do non-selective agents (diclofenac, ibuprofen, etc.).20

Non-pharmacological options such as structured physical activity can

be effective in relieving pain in arthritic patients. If pain is

unresponsive to activity, regularly dosed acetaminophen should be

considered first-line therapy. If pain control is still insufficient, low-

dose opioids can be added along with increased monitoring for side

effects of constipation, sedation, and cognitive impairment.21 NSAIDs

remain an option but require a discussion with the patient of the

benefits and risks, including the need for increased monitoring of

cardiac and renal functions. The need for pain relief should also be

assessed continually, which may prompt discontinuation of the drug.

Oxybutynin and Tolterodine for Overactive BladderOveractive bladder occurs in an estimated 18% of the Canadian

population and negatively impacts quality of life for patients. The

Key PointsPhysiological changes combined with polypharmacyincrease the risks of adverse drug reactions (ADRs) inelderly patients.Routine medication reviews and a team-based approachmay help reduce ADRs.Medication therapy needs to be individualized (treatmentplans created and goals of therapy established).Thorough histories of signs and symptoms should betaken to avoid a prescribing cascade.The medications discussed in this article carry anincreased risk for ADRs in elderly patients; the risksassociated with these drugs must be weighed against thepotential benefits of treatment.


Amadio et al .

anticholinergic agents oxybutynin and tolterodine have an

antispasmodic effect on the detrusor muscle, which decreases urinary

urgency and frequency. They are the most commonly used and

effective agents available22 because of their potent anticholinergic

effects, which can be amplified in older patients. The combination of

bladder training, pelvic muscle exercise, relaxation, and voiding diaries

with these agents may help to lower the required dosage of these

medications and reduce the risks of ADRs.22

In order to individualize therapy, there are a number of formulations

that exist: immediate- and extended-release tablets and capsules and

a transdermal oxybutynin patch. Available data suggest that there is

no difference in efficacy between immediate- and extended-release

products, and neither oxybutynin nor tolterodine offers a clinical

advantage over the other. However, a Cochrane Review found

oxybutynin use to be more likely to result in discontinuation of

therapy secondary to adverse events.23 The transdermal and oral

preparations appear to have similar efficacy and ADRs.24

The results of one study were analyzed to look at whether there is a

treatment difference in older (>65 years) compared with younger

patients. It was found that treatment was more effective than placebo,

with similar adverse event rates. However, older patients suffered from

more episodes of dry mouth.25

Benzodiazepines for InsomniaBenzodiazepines have been shown to be effective for the short-term

treatment of insomnia, but use for extended periods has been linked

to cognitive and memory impairment and poor sleep structure.

Another concern is daytime sedation, especially with longer-acting

agents, which can predispose patients to falls, fractures, and motor

vehicle accidents. Patients have also experienced tolerance and

withdrawal syndromes with long-term use.26

These agents should be periodically reassessed and, if possible, plans

should be made to taper the dosage slowly and eventually remove these

agents.27 Patients on short-acting agents are more likely to experience

withdrawal, and this can be managed by first switching to a long-

acting agent prior to the discontinuation of therapy.

Patients should be assessed for other conditions that may be causing

the insomnia, and these underlying issues should be treated first. For

the management of insomnia, non-pharmacological therapies such as

stimulus control and sleep hygiene28 should be first-line therapy. If

required, short courses (i.e., <1 week) of benzodiazepines are

preferred. Trazodone remains an option for insomnia and can be

considered, but data for its use in non-depressed individuals are

lacking.29 Non-benzodiazepine sedatives and hypnotics (i.e.,

zopiclone) can be tried, but again only for short periods of time as

their effectiveness appears to diminish with prolonged use and next-

day drowsiness may still be observed.28,30

A meta-analysis of sedative hypnotics in older patients countered the

belief that non-benzodiazepines are safer than benzodiazepines. There

was no significant difference in cognitive or psychomotor adverse

events, and the same benefit seen in younger patients did not translate

to elderly patients. The increased rate of adverse events (number

needed to harm [NNH] for any adverse event rate = 6) suggests that

these agents may not be suitable for elderly patients.31

Case ConclusionOn assessment, there was no evidence of delirium or history of

cognitive impairment in Ms. P. Her physical examination was relatively

unremarkable aside from erythema and peripheral edema in her lower

extremities, with chronic venous skin changes. She also reported a

history of functional incontinence due to her inability to get to the

washroom on time, her long-standing history of chronic leg edema,

and osteoarthritis.

ASA was discontinued because she was on warfarin and did not have

strong indications for antiplatelet therapy. Metoprolol was continued

as her preoperative blood pressure was 125/65 mm Hg and her heart

rate was 75 bpm. The digoxin was stopped because she had no history

of systolic CHF. Her digoxin level upon discharge was 1 nmol/L. Her

amitriptyline dosage was reduced to 25 mg qhs, with further tapering

instructions after discharge. She did not have a history of depression

or a neuropathic component to her pain. Lorazepam and tolterodine

were discontinued as they both have been associated with an increased

risk of delirium. Moreover, the patient infrequently used lorazepam

and reported grogginess in the morning after use. The ibuprofen was

stopped because of renal insufficiency. Instead, Ms. P was started on

acetaminophen 1 g tid and low-dose hydromorphone q4h prn for pain

management.

After surgical repair of her hip, she developed mild CHF requiring

diuresis. She did not tolerate the hypotensive effects of metoprolol and

required the re-initiation of digoxin to optimize her arrhythmia

control. She continued her medications for bone health, and an

outpatient bone mineral density test was arranged.

Ultimately, Ms. P was successfully transferred to rehabilitation care,

with the eventual goal of returning home to the community.

DiscussionAll medications have inherent risks that need to be weighed against

the benefits before initiating therapy. Elderly patients appear to be at

an increased risk for adverse events, especially from select medication

classes. Efforts to limit the prescribing and use of these agents in older

patients can reduce harm and help to avoid dangerous prescribing

cascades.

AcknowledgementWe thank Lisa Burry for reviewing the manuscript.

This article has been peer reviewed.Conflict of interest: None declared.

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24. Dmochowski RR, Sand PK, Zinner NR, et al. Comparative

efficacy and safety of transdermal oxybutynin and oral

tolterodine versus placebo in previously treated patients with

urge and mixed urinary incontinence. Urology 2003;62(2):237–

42.

25. Zinner NR, Mattiasson A, Stanton SL. Efficacy, safety, and

tolerability of extended-release once-daily tolterodine treatment

for overactive bladder in older versus younger patients. J Am

Geriatr Soc 2002;50(5):799–807.

26. Wagner AK, Zhang F, Soumerai SB, et al. Benzodiazepine use and

hip fractures in the elderly: who is at greatest risk? Arch Intern

Med 2004;164(14):1567–72.

27. Baillargeon L, Landreville P, Verreault R, et al. Discontinuation

of benzodiazepines among older insomniac adults treated with

cognitive-behavioural therapy combined with gradual tapering:

a randomized trial. Can Med Assoc J 2003;169(10):1015–20.

28. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral

therapy vs zopiclone for treatment of chronic primary insomnia

in older adults: a randomized controlled trial. JAMA

2006;295(24):2851–8.

29. Schatzberg AF, Cole JO, DeBattista C. Manual of clinical

psychopharmacology, 6th edition. Washington (DC): American

Psychiatric Pub.; 2007.

30. Wang PS, Bohn RL, Glynn RJ, et al. Zolpidem use and hip

fractures in older people. J Am Geriatr Soc 2001;49(12):1685–

90.

31. Glass J, Lanctot KL, Herrmann N, et al. Sedative hypnotics in

older people with insomnia: meta-analysis of risks and benefits.

BMJ 2005;331(7526):1169.

Kiran Rabheru, MD, CCFP,FRCP, geriatric psychiatrist, theOttawa Hospital and ElizabethBruyere Continuing Care;associate professor, Universityof Ottawa, Ottawa, Ontario


[email protected].

PRACTICAL TIPS FOR RECOGNITION AND MANAGEMENT OF BEHAVIOURAL AND

PSYCHOLOGICAL SYMPTOMS OF DEMENTIA

In 2010, there were 505,351 Canadians

affected by Alzheimer’s disease and related

dementias. This number is projected to grow

to 581,252 in 2015 and a staggering 1,042,113 in

2035.1 This translates to a new case every 5

minutes in 2008, and one every 2 minutes in 2038!

The economic burden of dementia is estimated to

double in every decade, increasing from

$15 billion in 2008 to a startling $153 billion in

2038.1 Patients suffering with dementia typically

experience alterations in cognition, function, and

behaviour. While all three are affected, it is the

behavioural domain that has proved to be the

major challenge in dementia care and is

experienced by over 90% of patients.1 These

behavioural and psychological symptoms of

dementia (BPSD) can cause a great deal of

emotional turmoil and pose a physical risk to the

patient, family, and other caregivers. BPSD are

known to be the most common cause of

institutionalization and prolong in-hospital

lengths of stay. Many retirement homes and long-

term care facilities find patients with BPSD very

difficult to care for as these institutions are ill

equipped to care for aggressive and disruptive

behaviours as their staff are inadequately trained

and insufficient in numbers. Safety of other frail

and vulnerable residents becomes a major issue,

often leading to injuries and even death. The

picture is complicated by many patients with

BPSD who are incapable of making informed

choices regarding the complex decisions related

to their own care. This places an additional

burden on scarce clinicians’ time as they are

required to communicate and obtain informed

consent from substitute decision makers (SDMs).

Since extremely complex clinical issues are at play,

SDMs find giving consent a very difficult process,

especially when there are multiple family

members with divergent opinions involved.

Caregiver Attitude and EducationAll persons treating or caring for patients with

dementia must be aware of their own attitudes

and biases toward the illness and the individual

patients. The quality of interaction and personal

“approach” of the caregiver toward each patient

varies tremendously, and can significantly affect

how a patient responds clinically; this can reduce

the need for psychotropic drug use. An

appropriate level of understanding of dementia

and education related to best care practices are

critical for successful outcomes.

Systematic Approach to BPSDA systematic approach is critical for successful

outcomes in dealing with any BPSD. A “SMART”

approach is suggested below as an aide for

caregivers2:

• Safety – remove patient to safe environment• Medical – perform an organic workup to

treat reversible causes; reduce medication

load

• Assess competency – decisions regarding personal care, finances, driving; protect

assets

• Rest, nutrition, hydration ensured; address problems with pain, ambulation, vision,

hearing, constipation

• Trial of medication – cholinesterase inhibitor/antipsychotic/antidepressant/

mood stabilizer

Non-pharmacological Interventionsand the Prevention of BPSDNon-pharmacological approaches and proactive

recognition of the behaviour trigger(s) may often

avert behavioural crises altogether. Developing

simple approaches to address these early signals

are the key to preventing BPSD. All patients must

have non-pharmacological interventions tailored

to their individual care needs for routine

implementation. Look for signs of increased levels

of distress, irritability, mood disturbance, and

suspiciousness. Be alert for a decreased level of

social activity, increased time spent in bed, a poor

appetite, decreased weight, and a reversal of the

sleep-wake cycle. Many BPSD are rooted in

frustrations resulting from unmet needs based on

social and environmental factors such as social

isolation, the need for touch or intimacy, the need


for privacy during personal care, environmental noise, and

temperature. Other triggers to consider include physical or verbal

limitations such as the inability to verbally communicate needs or

wants or to express physical or emotional distress, and the inability to

move the body or a limb at will. Biological triggers to consider include

difficulty with vision, hearing, the mouth or dentition, and

swallowing; dehydration and malnourishment; skin problems

(dryness, itching, pressure sores); bowel problems (constipation);

urinary problems (infection, retention, incontinence); and feet

problems (painful lesions). These factors should be routinely checked

in all patients who are unable to express their own needs verbally as

many serious problems can be easily prevented.

Non-pharmacological interventions for BPSD are summarized below:

• Approach – A kind, unrushed, non-confrontational, face-to-faceapproach may work best.

• Schedules – Employ patient-centred care schedules.• Demands – Reduce demands on the patient.


Practical T ips for Recognition and Management of BPSD

Figure 1. Non-pharmacological options for the treatment of behavioural and psychological symptoms of dementia (BPSD).

• Communication – Communicate more effectively.• Personal care – Meticulous attention to good personal care is

essential.

• Activity and environment – Ensure that daytime activities and the environment are appropriate.

Non-pharmacological options for the treatment of BPSD are

presented in Figure 1.

Three-Phase Approach to BPSDIn the event of an acute behavioural crisis, safety is the first priority.

This includes safety of the patient, other residents and family

members, and staff involved in caring for the patient. Caregivers and

front-line staff should routinely receive training for age-appropriate

and dementia-specific behavioural crisis interventions. Caregivers

facing an acute behavioural crisis should notify emergency services or

hospital staff for prompt back-up. Temporary application of the least

restrictive physical or chemical intervention may be necessary as a

safety measure and to allow careful assessment of the patient.

Treatment of BPSD is divided into three phases: acute, medium, and

long-term (Figure 2).

Behavioural Vital SignsIn any acute behavioural crisis, it is important to document the

patient’s vital signs, including behavioural vital signs (BVS). When

done accurately, BVS monitoring may give clues to the etiology of the

behaviour disturbance, suggest targeted pharmacotherapy for

behavioural symptoms or clusters (Figure 3), and help monitor the

effectiveness of interventions over time. Please refer to the Behavioural

Vital Signs Tool3 available at the Canadian Academy of Geriatric

Psychiatry website.

Process of Targeting Drug Therapy for BPSDAn algorithm for the management of BPSD is presented in Figure 4.

A step-by-step approach should be taken:

Acute Phase1. Consider the target symptoms/clusters for drug therapy (see the

BVS Tool).

2. Consider the overall behavioural frequency, severity, and impact

(see BVS Tool).

3. Decide on an appropriate drug therapy for use in an acute

behavioural crisis.

Medium Term4. Decide on an appropriate pharmacotherapy for medium-term

use (4–6 weeks).

5. Perform a mandatory review and consider tapering the

medication, if appropriate, after 4–6 weeks.

Long Term6. Carefully review whether long-term drug therapy is required

(for >6 weeks).

7. Carefully document the impact of drug therapy for all phases

(see the BVS Tool).


Rabheru

ACUTE

MEDIUM

LONG-TERM

SAFETY Patient, Staff, Residents

ASSESS 1) Rule out delirium2) Medicate or not?

MAINTENANCE 1) On what?2) How long?

Figure 2. Phases and goals of treatment of behavioural andpsychological symptoms of dementia (BPSD).

‘Aggression’

Aggressive resistancePhysical aggressionVerbal aggression

Walking aimlesslyPacingTrailing

RestlessnessRepetitive actions

Dressing/undressingSleep disturbance

HallucinationsDelusions

Misidentifications

SadTearful

HopelessLow self-esteem

AnxietyGuilt

WithdrawnLack of interest

Amotivation

‘Agitation’

‘Psychosis’‘Depression’

‘Apathy’

Figure 3. Behavioural symptoms and clusters. Source: Adapted from McShane.4

Identify and document target cluster(s)/symptom(s): consider BVS Tool

Rule out new medical and psychiatric causesNew-onset behavioural problem =

delirium until proven otherwise

Implement caregiver-led non-pharmacological interventions and monitor closely

Initiate pharmacological treatment if target symptom(s) sufficiently severe, persistent,

disturbing, or dangerous

Start appropriate initial and maintenance pharmacotherapyMonitor effects and side effects

If not meeting therapeutic goals, consider switching agents, adjunctive therapy,

or consult geriatric psychiatry

Figure 4. Algorithm for the management of behavioural andpsychological symptoms of dementia (BPSD). BVS = behavioural vital signs. Source: Adapted from Mintzer and Brawman-Mintzer.5

http://www.cagp.ca/resources/Documents/Module%202%20-%20BVS%20Tool.pdf

http://www.cagp.ca/resources/Documents/Module%202%20-%20BVS%20Tool.pdf

Therapy for Severe Symptoms during Acute PhaseThe goals to accomplish during the acute phase are (1) to ensure thesafety of all, (2) to allow for physical and laboratory examinations to

rule out medical causes for the acute change in behaviour and (3) to

provide the time and opportunity for communication between the

physician, family, and other caregivers to develop a treatment plan.

Considerations are as follows:

• Target symptoms: Limited to physical or verbal aggression, aggressive resistance, aggressive psychosis, and aggressive

agitation

• Frequency of behaviour: Usually constant, several times a day, at least once a day but severe in each case

• Severity of behaviour: How difficult is it to distract or redirect the patient? Usually impossible in acute phase

• Impact of behaviour: Usually with significant potential for serious harm to self or others

• Suggested medications: Consider an antipsychotic ± benzodiazepine for a few doses only, usually one or two doses.

This can be administered by mouth if the patient is compliant;

give intramuscularly if non-compliant. Used to regain necessary

safety for all. Recommended for acute mangement only and must

not constitute medium or long-term therapy

The choice of recommended agent(s) includes the following:

• Atypical antipsychotics: See Table 1. Patients known to have

dementia of Lewy body type (DLB) or Parkinson’s disease

dementia (PDD) should receive quetiapine if at all possible. If

other antispychotics are used, consider lowering the dose to

minimize adverse effects.

• Typical antipsychotics:

• Haloperidol: 0.25–0.5 mg PO tablets, liquid, or IM q2–4h as

needed and tolerated. Maximum dose: 2 mg for many

dementia patients; lower for patients with DLB/PDD.

• Loxapine: 2.5–5 mg PO, liquid, or IM q2–4h as needed and

tolerated. Maximum dose 10–25 mg; lower for patients with

DLB/PDD.

• Benzodiazepines: Lorazepam 0.5–1 mg PO, liquid, sublingual, or

IM q2–4 hours as needed and tolerated. Can be combined with

haloperidol or loxapine for greater efficacy and to reduce the dose

for each medication individually.

Medium-Term TherapyThe goal in the medium phase is to provide transitional drug therapysupport for 4–6 weeks following an acute episode of BPSD. Once an

acute delirium has been adequately treated medically or ruled out as

a cause of BPSD, a decision must be made as to whether to continue

or stop the psychotropic medication. Atypical antipsychotics do confer

modest benefits in treating aggression and psychosis over 6–12 weeks

(Table 2), with a number needed to treat that ranges from 5 to 14.

However, they are associated with a number of major adverse

outcomes and side effects, including sedation, parkinsonism, gait

disturbance, dehydration, falls, chest infections, accelerated cognitive

decline, stroke, and death. Therefore, they should only be continued

for persistent and severe symptoms that have a major impact on safety,

as described above. It is important to review the need for ongoing

antipsychotic therapy after 4–6 weeks of treatment as many people

with BPSD experience a significant improvement or resolution of

symptoms over that period.

Long-Term Management of Severe Symptoms: Beyond6–12 WeeksThe goal of long-term management is to continue treatment in orderto maintain a patient’s function and quality of life. This is to be done

with the least effective dosage and for the shortest possible duration,

while maintaining safety as well as optimal physical and mental health.

Of the atypical antipsychotics, only risperidone has Health Canada

approval for short-term use for aggression ± psychosis. Risperidone

and olanzapine have stronger evidence base than quetiapine, but

quetiapine is often chosen preferentially in patients with DLB or PDD

due to an increased risk of extrapyramidal side effects in these patients.

The benefit of long-term use beyond 12 weeks is not known. Longer-

term trials (up to 12 months) have not shown consistent benefit.

Symptoms often fluctuate and are unstable over time, particularly in

the case of Alzheimer’s dementia, where hallucinations tend to resolve



Table 1. Suggested Treatment with Atypical Antipsychotics in Acute/Urgent Situations for BPSD

Atypical Medication Usual Dosage and Formulation Usual Frequency Maximum Dose in 24 HoursRisperidone 0.25–1 mg PO tablets, liquid, or M-tabs* q2–4h as needed and tolerated 2 mg for many dementia patients

Not DLB/PDDMay be higher in other conditions, e.g., schizophrenia, bipolar disorder, etc.

Olanzapine 2.5–5 mg PO tablets (Zydis) q2–4h as needed and tolerated 10 mg for dementia patientsNote: IM formulation is available, but May be higher in other conditions, there is little experience with its use in e.g., schizophrenia, bipolar disorder, etc.Canada with the elderly dementia population.Dosage 2.5–5 mg IM, max. 10 mg/24 h. Not given IV.

Quetiapine 12.5–25 mg bid 75.0 mg bid (150.0 mg tablet split = 2 × 75.0 mg)

BPSD = behavioural and psychological symptoms of dementia; DLB = dementia of Lewy body type; PDD = Parkinson’s disease dementia. *M-tabs are rapid-dissolving tablets.

over a period of a few months, but delusions, aggression, and agitation

may be more persistent. Therefore, long-term antipsychotic therapy

beyond 6 months should only be undertaken with meticulous

behavioural charting and documentation of the need for antipsychotic

therapy. Careful consideration and documentation of the benefits and

risks of long-term therapy are critical. Several national and

international guidelines now recommend periodic attempts to taper

the antipsychotic medication and monitoring for breakthrough

symptoms.

The choice of recommended agent(s) includes the following:

• For non-severe symptoms, such as agitation. These are verbal or

motor activities that are repetitive and purposeless. They are

often moderate in frequency, severity, and impact, with little or

no risk of harm to self or others. The recommended drug class is

antidepressants (see below for details).

• For depression and/or anxiety symptoms, antidepressants are

recommended (see below for details):

• Risks: all associated with higher risk of falls, fractures,

hyponatremia, gastrointestinal bleeding

• Citalopram 10–40 mg PO daily

• Sertraline 25–200 mg PO daily

• Venlafaxine XR 150–300 mg PO daily

• Special point: sedating – mirtazapine 7.5–30 mg PO hs

(sedating: promotes sleep, appetite, weight gain)

• Trazodone 12.5–200 mg PO daily. Special point: sedating –

useful in divided doses for agitation and to promote sleep

Other Classes of Medications and Target Symptomsfor BPSD Cholinesterase InhibitorsCholinesterase inhibitors may attenuate mood, anxiety, apathy,

agitation, and psychotic symptoms if used in patients with very mild

symptoms of BPSD. They are not replacements for antidepressants or

antipsychotics. Recommended agents are galantamine 8–24 mg/d,

donepezil 5–10 mg/d, and rivastigmine 3–9 mg/d.

NMDA Glutamate Receptor AntagonistN-methyl-D-aspartate (NMDA) glutamate receptor agonists may be

useful in stabilizing agitation and may have an antipsychotic sparing

effect; however, they may also exacerbate the symptoms in some

patients. They are usually recommended for moderate to severe

Alzheimer’s dementia. They are not replacements for antidepressants

or antipsychotics. The recommended agent is memantine 10–20 mg/d.

Short-Acting BenzodiazepinesShort-acting benzodiazepines must not be used for BPSD on a long-

term basis. They are useful for the acute phase treatment of severe


Rabheru

Table 2. Guidelines for Maintenance Therapy of BPSD with Atypical Antipsychotics

Atypical Antipsychotic Starting Dosage Usual Daily Dosage Maximum DosageRisperidone 0.25 mg/d in very old, frail, 1 mg/d for most dementias; 2.0 mg/d for most dementias –

or patients with DLB or PDD not for patients with DLB or PDD not for patients with DLB or PDDUsual starting dosage is 0.5 mg/d May be given as single dose Dosages may be higherMay be increased q3–5d by or divided dose, as tolerated (e.g., in schizophrenia) or lower 0.25–0.5 mg/d, as tolerated (e.g., in DLB or PDD)

Official indication for BPSD in Canada

Olanzapine 1.25–2.5 mg/d in very old, frail, 5–10 mg/d for most dementias; 10 mg/d for most dementias – or patients with DLB or PDD not for patients with DLB or PDD not for patients with DLB or PDDUsual starting dosage is 2.5–5 mg/d May be given as single dose Dosages may be higher May be increased q3–5d by or divided dose, as tolerated (e.g., in schizophrenia) or lower1.25–2.5 mg/d, as tolerated (e.g., in DLB or PDD)

Quetiapine 6.25–12.5 mg/d in very old, frail, 100 mg/d for most dementias; 150 mg/d – some dementiaor patients with DLB or PDD may be lower for patients patients need higher dosagesUsual starting dosage is 12.5–25 mg/d with DLB or PDD Wide range of dosingMay be increased q3–5d by Wide range of dosing Consider first for patients with DLB 25–50 mg/d, as tolerated May be given as single dose or PDD

or divided dose, as tolerated Dosages may be higher (e.g., in schizophrenia) or lower (e.g., in DLB or PDD)

BPSD = behavioural and psychological symptoms of dementia; DLB = dementia of Lewy body type; PDD = Parkinson’s disease dementia.

Key PointsBehavioural and psychological symptoms of dementia(BPSD) are very common and have a major negative impacton patients’ and caregivers’ quality of life.A systematic approach is critical when managing BPSD(“SMART”): safety; medical; assessment of competency;rest, nutrition, hydration ensured; address problems withpain, ambulation, vision, hearing, constipation; and trial ofmedication. A comprehensive set of behavioural vital signs (see BVSTool) must be monitored to systematically help recognizebehavioural target symptoms and clusters of BPSD, and tomonitor the effectiveness of various interventions.Non-pharmacological therapies must be an integral part ofmanaging every patient with BPSD. Pharmacological therapy must target specific behaviouralsymptoms or clusters of BPSD. The therapy must becarefully monitored for efficacy and adverse effects, and betime limited.

anxiety in patients with BPSD (see above). They may also be used for

sedation prior to a specific procedure (e.g., a computed tomography

scan, a catheterization, or on bath days). They are not replacements

for antidepressants or antipsychotics. The recommended agent is

lorazepam 0.25–2mg PO as needed, used sparingly.

Miscellaneous MedicationsValproic acid, carbamazepine, lithium, lamotrigine, gabapentin,

opioids, β-blockers, and hormone therapy have insufficient evidence

for use as first-line agents for treatment of BPSD.

Author’s Guide for Stopping Drug Use in BPSDTo stop the use of antidepressants in BPSD, slowly wean or taper the

drugs over 2–3 months after symptoms have been stable for 9–12

months. For cholinesterase inhibitors and memantine in BPSD, slowly

wean or taper over 2–3 months when the patient has reached a stage

of dementia with little or no independent function.

SummaryIn summary, treating patients who have BPSD with sensitivity, respect,

and patient-centred care may help to prevent the onset of symptoms.

Once symptoms develop, many improve within 4–6 weeks of watchful

waiting without the need for drugs. The physician and other caregivers

must tailor a treatment plan specifically to the person’s needs, with

valuable input from the family. Antipsychotic drugs work for just over

half of those with BPSD. They can cause side effects that can become

serious if used for longer than 12 weeks. The physician must review

the use of antipsychotic drugs after 6 weeks and stop the drug after 12

weeks, if possible. Patient and family input is critical at all stages of

treatment decision making, where possible and appropriate. Careful

observations and documentation of behavioural symptoms will clarify

and simplify treatment decisions.

AcknowledgementsThe author has done presentations for and is on the advisory boards

of Pfizer, Lundbeck, and Bristol-Myers.


References 1. Alzheimer Society of Canada. Rising Tide: The Impact of

Dementia on Canadian Society. Toronto (ON): The Society;

2010.

2. Rabheru K. Take a ‘S-M-A-R-T’ approach: unpredictable course

of dementia symptoms can be managed. Can Fam

Physician2003;49: 389.

3. Rabheru K. Behavioral Vital Signs Tool. Toronto (ON): Canadian

Academy of Geriatric Psychiatry; http://www.cagp.ca/resources/

Documents/Module%202%20-%20BVS%20Tool.pdf. Accessed

December 19, 2011.

4. McShane RH. What are the syndromes of behavioral and

psychological symptoms of dementia? Int Psychogeriatr 2000;12

Suppl 1:147–53.

5. Mintzer JE, Brawman-Mintzer O. Agitation as a possible

expression of generalized anxiety disorder in demented elderly

patients: toward a treatment approach. J Clin Psychiatry 1996;57

Suppl 7:55–63.

BibliographyDe Deyn PP, Rabheru K, Rasmussen A, et al. A randomized trial of

risperidone, placebo, and haloperidol for behavioral symptoms

of dementia. Neurology 1999;53(5):946–55.

Ellison M. Agitation in dementia: update and prospectus. Psych Times

2008;25(2):1–2.

Guidelines and Protocols Advisory Committee. BC Provincial

Dementia Guidelines for Family Physicians. Victoria (BC): BC

Ministry of Health, 2007; http://www.bcguidelines.ca/pdf/

cognitive.pdf. Accessed December 19, 2011.

Mittal V, Kurup L, Williamson D, et al. Review: risk of cerebrovascular

adverse events and death in elderly patients with dementia when

treated with antipsychotic medications: a literature review of

evidence. Am J Alzheimers Dis Other Demen 2011;26:10–28.

Passmore MJ, Gardner D, Polak Y, Rabheru K. Alternatives to atypical

antipsychotics for the management of dementia-related

agitation. Drugs Aging 2008;25(5):381–98.

Patterson CJS, Gauthier S, Bergman H, et al. The recognition,

assessment and management of dementing disorders:

conclusions from the Canadian Consensus Conference on

Dementia. Can Med Assoc J 1999;160(12 Suppl):s1–15.

Rabheru K. Depression in dementia: diagnosis and treatment. Psych

Times 2004;21(13):1–2.

Schuyler D. Recognition of apathy as marker for dementia growing.

Psych Times 2007;3(10):1–3.

Third Canadian Consensus Conference on Diagnosis and Treatment

of Dementia; Official Website, 2007; http://www.cccdtd.ca/.

Accessed December 19, 2011.



PHYSICIAN PRACTICE IN THE NURSING HOME:EXPLORING NEW MODELS


Paul R. Katz, MD, CMD, vice-president Medical ServicesBaycrest Geriatric HealthCentre, and professor ofmedicine, University ofToronto, in Toronto, Ontario

Patrick Quail, MD, CCFP, CMD,medical leader supportiveliving integrated seniors andcommunity care, Calgary Zone,Alberta Health Services, inCalgary, Alberta

Michael J. McBryde, MBBS,DObst RCOG, CCFP, medicaldirector of residential andassisted living, Fraser HealthAuthority, in Surrey, BritishColumbia

Jurgis Karuza, PhD, directorof program evaluation,Baycrest Geriatric HealthCentre, and professor ofmedicine (status only),University of Toronto


[email protected].

Nursing homes (NHs) play an increasingly

vital role within the health care

continuum. Physicians who practise in

this setting, however, often lack credibility despite

having a significant impact on quality of care. This

article seeks to highlight physician workforce issues

related to NH care with a focus on training,

medical staff organization, and quality. In this

report, NHs refer to both long-term care (LTC)

homes and other institutions for persons with

disabilities, such as complex continuing care

hospitals (CCC).

While there is no question that the Canadian

population is aging, there has been some debate

about the health of the elderly and their need for

LTC services. Increasing obesity has tempered

previous declines in disability, presaging increasing

numbers of older adults with significant physical

and functional limitations.1 These trends, as well as

an ever-increasing prevalence of dementia, will,

according to some estimates, call for an additional

400,000 LTC beds by 2038.2 Even now, almost a

third of adults 85 years and over reside in nursing

homes,3 and 25% of all deaths occur in NHs.4

Interestingly, there is a lack of consensus that this

rising tide of older adults will have a significant

negative impact on health care in Canada. On one

side are the crisis proponents, most notably Foot,5

who argue that the future growth in older adults

will create major increases in health care

expenditures that are unlikely to be sustained given

the current funding rates. On the other side are the

theorists6,7 who argue that the growth in health care

costs and government expenditures due to the

increased numbers of older adults will be

manageable and will result in only modest

increases in the gross domestic product (GDP)

devoted to health care. Most of the projected

increased costs are due to other factors (e.g., costly

new drugs, growing public expectations,

investment in more health technology). An

important corollary to their argument is the need

to develop new technologies and integrated health

care systems (as discussed below) that bring about

greater productivity and efficiencies.

NHs have become a critical component of the

health care continuum and are often key to

successful transitions. This is reflected, in part, by

the diversity of the population served. In the

United States, 20% of all admissions to NHs have

a length of stay less than 3 months, reflecting short-

term rehabilitation, while almost 45% have stays

less than 12 months.8 Further, in the United States,

discharge to an LTC facility is the second most

common type of discharge from acute hospitals.9

In Ontario, 17% of residents are discharged from

CCCs back to acute hospitals within the first 90

days from admission. Further, the acute hospital is

a frequent discharge destination for NH residents,

ranging from 34% in the Yukon Territory to 89%

in Manitoba.10 In many jurisdictions, alternative

level of care (ALC) bed days and emergency

department (ED) wait times are inextricably linked

to NH bed availability. Increasing emphasis on

person-centred care and performance-based

reimbursement highlight the role of the NH within

the continuum.

As NH residents have become increasingly frail

over the past one to two decades, suffering from

multiple physical and cognitive decrements, the

quality of care delivered to these individuals

remains inconsistent and generally suboptimal

throughout North America.11–13 Of the many

variables that impact quality, the caregiving

workforce is among the most powerful. This is seen

most clearly in the relationship between nurse-to-

resident ratios, educational level, and quality of

care.11–14 Unfortunately, the ratio of nurses to

residents remains relatively low in Canada

compared with those in the United States.12 In most

countries, including Canada, few licensed

caregivers have attained undergraduate or graduate

training in geriatrics. The fact that 23.5% of

Medicare beneficiaries in the United States

admitted to an LTC institution are readmitted

within 30 days speaks to both quality and resource

gaps.9 Estimates are that 40–78% of these

admissions are potentially preventable.15 In British

Columbia, 25% of all deaths among residents in

free-standing residential care facilities still occur in

the hospital.16

While the link between the nursing workforce and

quality is clear, relatively little is known about the physician workforce

in NHs. Estimates, both in the United States and Canada, are that 20–

25% of primary care physicians care for NH residents.17,18 In Ontario,

the majority of residents are attended by family physicians, many of

whom have limited training in the care of the elderly. While it is

estimated that physicians currently spend 70% of their time with older

adults, the medical school curriculum devoted to geriatrics is less than

1%. The rather limited supply of geriatricians (211 per 2007 data) is

far below the projected minimum number of 538 needed to respond

to the growing number of older adults in Canada.19

Surveys from professional organizations such as the American Medical

Directors Association bolster the perception of ongoing issues related

to physician recruitment and retention. The fact that Canada’s

primary care workforce of 33,000 physicians is aging (average age of

49 years) also speaks to future shortages within the LTC sector.20

Indeed, between 1990 and 2000, there was a 5% decline in the

proportion of general practitioners providing services to LTC

facilities.21

In 2002, a survey of 100 attending physicians in the Calgary region

revealed that only 40% were satisfied or very satisfied with the practice

of LTC and 60% of the total were interested in an alternative

remuneration model.22 Physicians who had been in practice less than

10 years were more dissatisfied than older physicians. Furthermore,

respondents reported a 69% intention to quit practice within 5 years

of the survey, and of this group only 30% were satisfied with the

practice of LTC. However, physicians who visited on a weekly basis,

who visited during the day, had more than 10 patients, and were in

the second half of their career appeared to be more satisfied.

Dissatisfaction with LTC practice should not be attributed to a lack of

role definition as this has been clearly articulated over the past several

years based on regulatory mandates and professional standards.23 Table

1 summarizes these key physician responsibilities. It has been argued

that the manner in which physicians perform their role in NHs

correlates directly with quality. The three physician-related factors

posited as most important to optimizing quality include physician

competence, physician commitment to the NH, and the extent to

which the organizational structure empowers, supports, and integrates

physicians into the NH24 (Table 2).

A literature is just now emerging that is lending credence to this

construct. Paralleling the evidence base that links nursing staffing

levels, educational attainment, and quality,11,12,14 physician presence in

the NH, medical director certification, and nurse-physician

communication have been shown to improve care.25,26 Katz and

colleagues have also recently defined dimensions of NH medical staff

organization and linked them to quality measures.27

With clear role definitions and evidence highlighting the physician’s

impact on care in the NH, why does the public continue to perceive

the physician as “missing in action?”28 While some of this perception

is rooted in the reality of physician shortages as discussed earlier, much

of it also relates to what might be referred to as the “Dangerfield

Effect,” named after the late, great comedian Rodney Dangerfield, who

repeatedly lamented getting “no respect.” In essence, there is a lack of

respect, and underappreciation, for the unique physician skills

necessary to attend to the host of clinical, ethical, legal, and

interdisciplinary issues that characterize the contemporary NH. This

lack of respect extends to both the public and much of the leadership

in medicine, in part a consequence of the continued primacy of the

medical model and its hyper-focus on acute care. There remains a lack

of understanding of the complexity of LTC practice and its vital role

within the continuum.

Changing this paradigm will require attention to extant undergraduate

and graduate training models.29 As pointed out above, only 1% of

medical school training focuses on geriatric medicine, with

inconsistent exposure to LTC. Medical students and residents require

meaningful exposure to NH care as well as time with physician role

models. These role models can not only demonstrate the skill set

necessary to practise in the NH but also highlight many of the lifestyle

advantages of an LTC practice. Transforming many facilities into

“teaching nursing homes” will go a long way toward improving

quality, recruiting the next-generation workforce, and advancing an

LTC-focused research agenda.30 The recent awarding of three LTC

Centres for Research, Education and Innovation in Ontario is a direct

response to this need.

Research will likely take many directions, ranging from the impact of

care guidelines to new organizational models. The case examples that

follow, although somewhat different in form and outcomes, highlight

the potential impact of new physician funding paradigms and may

serve as a guidepost for future demonstrations.

Case History: CalgaryThe need to better support medical practice and improve patient

outcomes in NHs prompted the new model of patient care described

below. Today, this model is operational in four LTC sites in Calgary,

with a dedicated medical staff of 23 physicians partnered with seven

nurse managers and providing weekly facility visits.

The perceived advantages of an alternative remuneration model


Physician Practice in the Nursing Home

Table 1. Physician Responsibilities in the Nursing Home• Comprehensively assess each resident and assist in care plan

development and coordination• Ensure the highest practicable well-being of each resident• Implement treatment to enhance or maintain function and avoid

accidents • Respond in a timely and appropriate fashion to a change in function• Physically attend to each resident consistent with provincial/federal

guidelines• Ensure appropriate and timely diagnostic tests and freedom from

unnecessary drug use• Optimize the resident's ability for self-determination • Determine each resident’s decision-making capacity while establishing

advance directives

Table 2. A Model for Nursing Home PhysiciansCommitment, conceptualized as a percentage of the physician’s practicedevoted to NH care and the amount of time, on average, spent per NHpatient encounterPhysician NH practice competency, defined by specialized training andexperience necessary to handle the complex medical care in a highlyregulated, interdisciplinary care context that is the contemporary NHOrganizational structure, reflects the cohesive integration of the medicalproviders into the culture of the facility NH = nursing home.

(Alternate Relationship Plan [ARP]) are that physicians have more

time to interact with other team members in a collaborative fashion

and provide more appropriate care. An alternative payment model

also facilitates the care of complex or challenging patients by freeing

physicians from the sometimes-perverse incentives of the fee-for-

service system. Most importantly, it promotes interdisciplinary

practice and strengthens the relationship between the physician and

the rest of the team.

An alternative payment model was designed primarily to support

physician practice with the intention of reintegrating physicians into

the total care of the patient. Support from the LTC provider

organization was sought at the design stage. At the centre of the model

is a new relationship with a nurse manager (known as an associate

team leader, or ATL) who would facilitate the physicians’ visits.

Physicians would visit once a week at a set time on the same day and

meet with the ATL prior to seeing patients. They would then use the

physician visit form to review the patients to be seen. This would also

allow for some shared care planning and organization of the

physicians’ time in the facility. Prioritization would be given to those

patients who were unwell, and routine clinical activities could be

arranged ahead of time. It would be the responsibility of the ATL to

complete the physician visit form prior to the arranged time by visiting

each unit to establish concerns and priorities. In essence, the ATL and

the physician would jointly plan their work for the duration of a

session.

During visits, the ATL and the physician would round on each unit

and meet with the professional staff, usually the registered

nurse/licensed practical nurse, to further review concerns on the

physician visit form and identify new problems. Planned clinical

activity would include the assessment and treatment of intercurrent

medical problems, admissions, three monthly medication reviews,

annual physical examinations, meeting with residents and families,

medication reconciliations, the review of antipsychotic medication,

care conferences, and shared care planning with the unit staff, allied

health staff (occupational therapy, physical therapy, clinical pharmacy,

social work, nutrition), and health care aides.

The physician would be paid on a sessional basis for hours spent

providing care in the facility. No fee-for-service billing could be used

except for work outside of the visits such as phone calls out of hours

or call-back visits to the centre.

The principles of the alternative payment plan were laid out and

interest was sought from the existing medical staff. Eight physicians

expressed interest and an informal assignation of “ARP physician” was

used with each participating physician. There was regular

communication to the group regarding progress and updates as well

as regular informal meetings to discuss planning. The physicians

continued to use the fee schedule until the ARP was finally approved

in July 2008. A process of gradual conversion of medical staff to ARP

status was possible over the intervening 6 years through attrition and

the ability to assign to chosen attending physicians (i.e., there was

usually no physician in the community to follow new admissions). By

this time, there were 12 family physicians (mostly new physicians as

the original group retired or lost interest) who were being paid at the

hourly provincial rate on a sessional basis. Physicians chose how many

hours a week they wished to work, and a rough formula of seven

patients per sessional hour was used to calculate patient censuses based

on the wishes of each physician. Physicians chose which sites they

worked out of and which day of the week they would be available to

round on their patients. From the outset, physicians were encouraged

to consider taking on at least a half-day a week. Physicians signed an

individual service agreement and were free to return to fee-for-service

at any time. Physicians would provide their own on-call service during

the day (with Primary Care Network on call after hours and on

weekends and statutory holidays). Physicians made their own

arrangements during vacations. Physicians usually saw only their own

patients during rounds, but could asked to see their colleagues’

patients if deemed necessary by staff. One physician provided skin and

wound consultation to the group. Development funding through the

Medical Services Development Innovation Fund (MSDIF) was

approved for 3 years to assist in the implementation of the model, for

quality improvement activities (fall and fracture prevention and

hospital transfers), and for the hiring of a project manager.

Since implementation, there have been quarterly physician meetings

where operational issues and quality improvement activities are

discussed as well as planning for future growth and development. A

mailing list Listserv-type is active and keeps the physicians up to date


Katz et al .

Table 3. The ARP Model

Workforce Indicators• 90% ARP physician coverage (542 of 602 beds) • Approximately 10 minutes of physician time per resident per week• Physician demographic shift (63% female [originally 100% male]);

69% overseas trained; 73% under age 50 years (originally 75% over 50years)

• 50% increase in number of attending physicians since July 2008 (currently 24 physicians)

• 50% increase in the number of patients under the care of an ARP physician

Satisfaction • Universal acceptance by physicians and staff• Physicians agree or strongly agree with the statement “physicians

embrace the mandate of the ARP”• 90% of physicians agree or strongly agree with the statement “a

positive difference is being made to patient-centred care”• 100% of physicians agree or strongly agree with the statement

“physicians seek the recommendations of the ATL”

Clinical Indicators (12 months up to April 2011)• 10% reduction in restraint use: 23 to 20.8% (13 patients)• 22% reduction in wounds: 8.5 to 6.6% (11 patients)• 7% reduction in anxiolytic utilization: 23 to 21.5% (9 patients)• 20% reduction in transfers to hospital: 1.8 to 1.4 /1,000 RD (80

transfers)• 49% decrease in hip fractures: 12.9 to 6.6/100,000 RD (13 fewer hip

fractures)• 66% reduction in “other” fractures: 14 to 4.7/100,000 RD (20 fewer

“other” fractures)• 19% decrease in discharges due to death: 0.86 to 0.7 /1,000 RD (34

fewer deaths)• 5% increase in antipsychotic use: 18.8 to 19.8%• 15% increase in patients on ≥9 medications: 60.9 to 62% ARP = Alternative Relationship Plan; ATL = associate team leader; RD = resident days.Sources: Data from minimum data set quality indicator panels, pharmacy providerdata, and routine self-reported indicator data on transfers, fractures, falls, and deaths.

on all clinical and relevant administrative developments. A dashboard

of 11 selected quality indicators is distributed every quarter and on an

annual basis to the physicians for discussion. Two continuing

education initiatives have arisen from the group: a practice-based

small group (PBSG) and a journal club with an emphasis on the

practice of LTC medicine. The Alberta Medical Association and

Alberta Health and Wellness oversee the project, and quarterly and

annual progress reporting are conditions of the agreement (as well as

“shadow billing” the fee schedule). An LTC ARP Intercare Physician

Evaluation report in February 2010 sought to document

improvements in care; these are highlighted in Table 3.

Case History: British ColumbiaResponding to pressures similar to those experienced in Calgary, the

model introduced through Fraser Health was implemented in two

phases. The first phase was introduced in 2007 in the town of Surrey

in response to the relocation of an extended care unit that had been

co-located with acute care and was to be transferred to a new site. In

addition, there was a new build of a contracted facility. The total

number of beds was approximately 300, one third of which were

additional beds to the system.

A group of nine family physicians were engaged in the discussions.

They were all experienced family physicians with an interest and

expertise in residential care.

The features of the model were that this group was to provide care for

all of the residents within the two facilities. They would make regularly

scheduled weekly visits to their residents and attend care conferences

on their own residents, although this could be delegated to the site

medical director where this was not possible. The physicians would

maintain their admitting privileges to the local acute care hospital and

would follow up their residents who were transferred to the acute care

hospital and facilitate an early return to the residential facility. Further,

participating physicians would respond to urgent and semi-urgent

issues in a timely manner and would make site visits where appropriate

in addition to their regularly scheduled weekly site visits. The group

of nine would provide a 24/7 on-call service for all of the residents and

would not delegate this to other physicians. They would meet on a

monthly basis with administrative and clinical staff of the facilities to

discuss areas of common interest and concern, including educational

topics. Two of the nine physicians would serve as site medical directors.

The physicians would be paid a monthly stipend that would recognize

the increased time commitment and support that they were

providing for the individual residents and the facilities.

The success of this enhanced service was to be measured by various

performance and quality indicators, which would include but not be

limited to family/resident/staff satisfaction surveys; a reduction in the

unscheduled transfer rate to emergency rooms; a reduction in the

number of medications per resident; a reduction in the length of stay

of residents who were admitted to acute care; a reduction in the drug-

drug interactions; and improvement in communication between

physicians and staff and among physicians. While most of these

outcome measures are in the process of being collected, a significant

reduction (50% of the health authority average) in unscheduled

transfers to acute care has already been demonstrated!

The second phase was introduced in 2011 and involved two different

geographical locations within the health authority (White Rock and

Abbotsford). Each was linked with the respective division of family

medicine and involved the coverage of approximately 800 beds. It was

an agreement between the Ministry of Health, the health authority,

and the division of family practice.

A group of family physicians from within each division agreed to

provide enhanced coverage for all of the residents within their

geographical location. These physicians were all experienced family

physicians with a prior interest and expertise in residential care. Each

physician undertook to make regularly scheduled weekly visits to one

of the facilities in the area; the group provided a 24/7 backup rotation

for all residents that would operate where the attending physicians

could not be reached within 30 minutes or where they indicated they

were unavailable to make a site assessment. The group would retain

acute care admitting privileges at the local hospital and would arrange

admissions and follow-up while in acute care and discharge back to

the facility. Efforts would be made to ensure that communications

were maintained with the attending physician if that individual was

unable to admit a resident. They would hold monthly meetings to

discuss common issues and provide an educational forum. The

physicians would be paid on a monthly basis that would recognize the

number of residents covered in the geographical area and their on-site

time commitment to individual facilities.

Outcome measures included a reduction in the number of

unscheduled transfers to the emergency department, a reduction in

the number of residents on nine or more medications, and a

satisfaction survey for staff and for family physicians in the

geographical area served. Similar to the model implemented in phase

one, outcome measures are currently being collected; initial feedback

from staff in the participating residential facilities has been very

positive. In addition, early trends point to a significant decrease in

unscheduled transfers to acute care.

ConclusionsThe models described above demonstrate how a change in medical

staff organization can significantly impact care. These improvements

are presumably linked not only to physician attributes (i.e.,

commitment and competence) but also to enhanced communication

between physicians, nurses, and other professionals delivering care

throughout the continuum. Successful physician engagement in the

care team in NHs requires a clear understanding by all of the value


Physician Practice in the Nursing Home

Key Points Nursing homes (NHs) play an increasingly important rolein our health care continuum.Recent declines in age-related disability might slow oreven reverse because of the increase of obesity in oursociety, further increasing the need for NHs.How the NH physician workforce is organized andremunerated can have major impacts on the quality ofcare for residents.

and role of the attending physicians. The support of medical and

facility leadership is essential in articulating such vision and goals of

care. Integration of the physicians into the culture of each facility

guarantees shared priorities and a care delivery system that is truly

patient centred.

It is hoped that future demonstration projects will continue to explore

how to effectively integrate physicians into NHs. Such efforts will not

only enhance overall quality but will also go a long way to garnering

the “respect” that is so clearly needed to cement professional

credibility and attract a dedicated workforce.

This article has been peer reviewed.Conflicts of interest: None declared

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