Advances in Long Term Care Medicine

Guest: Thiruvinva Dharmarajan, MD FACP AGSF Host: Eric Tangalos, MD Patients in hospital settings are often screened and promptly treated for venous thromboembolism, or VTE, but perhaps less commonly in long-term care, even though these patients may be at risk. Dr. T.S. Dharmarajan, clinical director of the division of geriatrics at Montefiore Medical Center (North Division) in the Bronx, New York, discusses the medical conditions in long-term care that put patients at risk for VTE, and ways to assess patients for the condition. What anticoagulation medications and treatments may be used for treating VTE in long-term care? Should long-term care clinicians treat VTE as aggressively as hospitals often do, or are there other unique considerations clinicians should keep in mind for managing patients at risk for VTE in long-term care? Dr. Eric Tangalos hosts.  

Host: Eric Tangalos, MD Guest: Tena Alonzo, MA How can creating a more positive emotional experience for patients with dementia or Alzheimer's diminish behavior issues and improve quality of life? Tena Alonzo, director of research and co-director of the Palliative Care for Advanced Dementia program at Beatitudes Campus in Phoenix, discusses a common-sense approach to creating a comforting environment for those with dementia and Alzheimer's, which focuses on meeting each patient's unique needs. What simple steps can long-term care facilities and caregivers take to enhance the lives of patients with cognitive disorders? Dr. Eric Tangalos hosts.

Guest: Robert Kane, MD Host: Eric Tangalos, MD Deciding between assisted living facilities or nursing homes can be daunting for patients and families. How can healthcare professionals discuss long-term care expectations with patients and families and help with the selection process? Dr. Robert Kane, Minnesota Chair in Long-term Care and Aging at the University of Minnesota School of Public Health and director of the University of Minnesota's Center on Aging, discusses the genesis and evolution of assisted living facilities and nursing homes. What are some of the common precursors to patients and families deciding it is time to choose long-term care, and how can they determine which type of care is best?  Dr. Eric Tangalos hosts.  

Guest: Steven Levenson, MD, CMD Host: Eric Tangalos, MD As healthcare reform evolves, so too do the public policies governing long-term care facilities. How can healthcare professionals stay up-to-date with the latest changes in federal and state regulations? What are the differences between regulations governing assisted living versus skilled care environments? How successful have regulations been at facilitating better quality of care in skilled care and assisted living? Dr. Steven Levenson, medical director of six long-term care facilities in Maryland and past-president of AMDA, says that having a "watchful eye" over long-term care facilities is generally useful in promoting quality of care, but laments the fact that there are some inconsistencies in the ways regulations are applied and implemented. How can healthcare providers aim towards regulatory compliance and better patient care, without getting bogged down with seemingly overwhelming details? Dr. Eric Tangalos hosts.

Guest: Matthew Wayne, MD, CMD Host: Eric Tangalos, MD Regulations regarding nurses as prescribing agents of physicians in long-term care facilities are more restrictive than in the hospital setting, because controlled substance licenses are not currently approved for nursing homes in most states. These restrictions can make it challenging for long-term care patients to receive timely access to narcotics. Dr. Matthew Wayne, medical director, geriatric medicine, University Hospital Richmond Medical Center in Richmond Heights, Ohio, and assistant professor of medicine at University Hospitals Case Medical Center in Cleveland, suggests revisions to some provisions of the Controlled Substances Act in order to ensure long-term care patients have access to pain medications when they need them the most. What hurdles are the most significant impediments to improving patient care with appropriate access to narcotics, and how can medical professionals best navigate the waters until revisions are made to the current law? Dr. Eric Tangalos hosts.

Host: Eric Tangalos, MD Guest: Steven Handler, MD, PhD, CMD Because residents in long-term care facilities often have comorbidities, polypharmacy can be an issue. What are the most common types of adverse drug events that can occur among long-term care patients taking multiple medications? Dr. Steven Handler, assistant professor in the department of biomedical informatics and the department of geriatric medicine at the University of Pittsburgh School of Medicine, and the medical director for long-term care health information technology for the University of Pittsburgh Medical Center, says the current methods for monitoring medications in nursing homes are inadequate for protecting against adverse drug events, and suggests ways to improve medication safety in long-term care. What tools might help practitioners in long-term care better detect and prevent adverse drug events? Dr. Eric Tangalos hosts.

Guest: Peter Winn, MD, CMD Host: Eric Tangalos, MD With palliative and hospice care, there is no one-size-fits-all approach. What differentiates these two types of care and how can physicians decide which approach to palliative or hospice care is best for each patient? Dr. Peter Winn, professor in the department of family medicine at Oklahoma University School of Medicine in Oklahoma City, discusses various types of care at the end of life, and outlines conditions that might require such care. What are some of the challenges to providing effective palliative and hospice care, and how can physicians best discuss realistic expectations with families and patients? Hosted by Dr. Eric Tangalos. 

Guest: Karl Steinberg, MD, CMD Host: Eric Tangalos, MD "Advance directive" is an umbrella term that encompasses end-of-life documents, including a living will and durable power of attorney for healthcare. Such documents can be scary for many patients, and as such, advance directives are not very common among the general US population. Yet these documents can be powerful tools in ensuring patients receive the type of care they desire. What do physicians need to know about advance directives in caring for patients at the end of life? Dr. Karl Steinberg, associate medical director for skilled nursing care at Scripps Coastal Medical Center in Vista, California, discusses variations, misconceptions and confusion surrounding advance directives, and says there is room for improvement. Many states have enacted Physician Orders for Life Sustaining Treatment (POLST) programs to address end-of-life care issues. What do these programs involve, and how effective are such programs in alleviating confusion with end-of-life care? Dr. Eric Tangalos hosts.

Guest: David Smith, MD, CMD Host: Eric Tangalos, MD Nearly three-quarters of patients in long term care have some form of memory impairment or dementia. And while some forgetfulness is a normal part of the aging process, memory loss can also be overlooked as an early symptom of cognitive impairment. How can physicians distinguish between common memory loss and cognitive impairment? Dr. David Smith, professor of family medicine at the College of Medicine at Texas A&M University, College Station; and president of Geriatric Consultants of Central Texas in Brownwood, Texas, discusses the nuances of different forms of cognitive impairment, and emphasizes the importance of early diagnosis. What activities, medications, environments and other strategies can help physicians slow cognitive decline in these patients? Dr. Eric Tangalos hosts.  

Host: Eric Tangalos, MD Guest: Alexandra Papaioannou, MD Millions of Americans have osteoporosis, but too often, a broken bone is the first indication of this common condition. What osteoporosis screening strategies can help diagnose osteoporosis in its early stages, and what treatment regimens are the most effective? Dr. Alexandra Papaioannou, professor in the department of medicine, and past-director of the division of geriatric medicine with a joint appointment in the division of rheumatology at McMaster University in Ontario, Canada, says it's important to target and prevent both falls and osteoporosis in tandem to reduce fractures. What are optimal amounts of calcium and vitamin D for older, less mobile patients? How can long term care facilities incorporate osteoporosis prevention into their screenings? Dr. Eric Tangalos hosts.

Host: Eric Tangalos, MD Guest: William Schaffner, MD Which infectious diseases are most common at long term care facilities? If there is an infectious disease outbreak at a facility, how can we best protect residents? Dr. William Schaffner, president of the National Foundation for Infectious Diseases, as well as professor and chairman of the department of preventive medicine, and professor of medicine in the division of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tennessee, stresses the importance of influenza and pneumococcal vaccinations for not only long-term care residents and staff, but also the residents' families. What strategies can help increase the vaccination success rates at long term care facilities? Dr. Eric Tangalos hosts.

Guest: Alan Lazaroff, MD Host: Eric Tangalos, MD How different is the population of long term care facilities today than in decades past, and how will these new resident communities impact delivery of care? Dr. Alan Lazaroff, director of geriatric medicine at St. Anthony Hospitals Senior Health Centers, and president of Geriatric Medicine Associates in Denver, Colorado, talks about the changes long term care facilities have made to better serve the needs of shifting resident demographics, including flexible scheduling and activities. What challenges face nursing homes today that care for younger, sicker or shorter-term patients? Dr. Eric Tangalos hosts. 

Guest: Douglas Berkey, DMD, MPH Host: Eric Tangalos, MD A patient's mouth can literally serve as a window to their overall health. Systemic conditions that are common among many older patients, such as diabetes, often have oral manifestations. What are some of the symptoms to look for, and how can we promote and preserve the oral health of vulnerable patients? Dr. Douglas Berkey, professor at the University of Colorado Schools of Dental Medicine and Public Health, where he also serves as co-director of the Center on Aging, discusses some of the most common oral health problems among elderly and long-term care residents, including oral abscesses and periodontal disease, and suggests a proactive approach to dental care for these patients. Dr. Eric Tangalos hosts.

Host: Eric Tangalos, MD Guest: James Galvin, MD, MPH, FANA Early detection of various conditions can help physicians better manage and treat their patients, and Alzheimer's is no exception. What early screening tests of cognitive impairment or dementia should be administered by primary care providers help detect when the disease process is beginning? Dr. James Galvin, professor in the departments of neurology and psychiatry at New York University Langone Medical Center in New York City, joins host Dr. Eric Tangalos to discuss the correlation between higher scores on cognitive impairment screening tests (such as the AD8 dementia screening test) and the presence of biomarkers for Alzheimer's. How effective is second stage confirmation of Alzheimer's with the use of biomarkers, and what role will biomarkers play in development of new therapies for this condition?

Host: Eric Tangalos, MD Guest: James E. Galvin, MD, MPH Early detection of various conditions can help physicians better manage and treat their patients, and Alzheimers is no exception. What early screening tests of cognitive impairment or dementia should be administered by primary care providers help detect when the disease process is beginning?nbsp;Dr. James Galvin, professor in the departments of neurology and psychiatry at New York University Langone Medical Center in New York City,...

Guest: Frederick Wendt, RPh Host: Eric Tangalos, MD As medication costs continue rising, what strategies can help long-term care facilities reduce drug expenditures, while still providing the best quality of care for patients? Fred Wendt, RPh, vice president of pharmacy services for Senior PharmaStrategies in Burleson, Texas, says one of the most significant pharmacy issues in long-term care is the Drug Enforcement Administration's current position on the nursing facility staff as agent of the physician, with regard to controlled substances. How is the role of the consultant pharmacist changing in long-term care? What programs can help long-term care facilities reign in drug costs, while maintaining high quality care for patients, particularly in the area of diabetes? Dr. Eric Tangalos hosts.

Host: Eric Tangalos, MD Guest: Christine Dunford, PhD Guest: Mary O'Hara, MA, LCSW Although we remain limited in our options for treating patients with memory loss and Alzheimer's, there are a variety of non-pharmacologic treatments that are showing some promise. Mary O'Hara, social worker at Cognitive Neurology and Alzheimer's Disease Center at Northwestern University Feinberg School of Medicine, and Christine Dunford, cultural anthropologist, ensemble member of Chicago's Lookingglass Theatre, and founding teaching artist with the Chicago Arts Partners in Education (CAPE) program, facilitate an improvisational acting workshop called the Memory Ensemble for patients with Alzheimer's and memory loss. One of improv's principles emphasizes being "in the moment," which can be particularly therapeutic for patients with memory loss. How has the Memory Ensemble program been designed to be both challenging and supportive, and what are some of the program's benefits? What other types of creative programs might have a similar effect on improving the quality of life, as well as building confidence and coping mechanisms for these patients? Hosted by Dr. Eric Tangalos.

Host: Eric Tangalos, MD Guests: Christine Dunford, PhD, Mary OHara, MA, LCSW Although we remain limited in our options for treating patients with memory loss and Alzheimers, there are a variety of non-pharmacologic treatments that are showing some promise.nbsp;Mary OHara, social worker at Cognitive Neurology and Alzheimers Disease Center at Northwestern University Feinberg School of Medicine, andnbsp;Christine Dunford, cultural anthropologist, ensemble member of Chicagos Lookingglass...

Guest: Laurie Jacobs, MD Host: Eric Tangalos, MD Patients who have recently had orthopedic and other types of general surgery, those who have recently had a stroke, and those with an ongoing medical condition (such as heart disease) are at most risk for developing venous thromboembolic disease. Do most long-term care facilities screen for this condition among these patient populations, and when should physicians initiate prophylactic care? Dr. Laurie Jacobs, professor of clinical medicine and vice chairman of clinical and educational programs in the department of medicine at Albert Einstein College of Medicine and Montefiore Medical Center, and director of the Resnick Gerontology Center at Albert Einstein College of Medicine in Bronx, New York, discusses ways to reduce the risk of developing venous thromboembolism among long-term care patients. What is on the horizon in terms of new therapies? Hosted by Dr. Eric Tangalos.

Guest: Bruce Troen, MD Host: Eric Tangalos, MD Vitamin D deficiency has been receiving a deluge of media coverage lately, and physicians are likely to hear many related questions from patients, especially long-term care residents and their families. What are the latest developments in vitamin D research, and how can adequate vitamin D levels help prevent falls among our older patients? Even more fundamentally, how do we define vitamin D insufficiency and deficiency? Dr. Bruce Troen, professor of medicine, research scientist at the Geriatric Research, Education, and Clinical Center, and director of the molecular gerontology program at the University of Miami Miller School of Medicine in Miami, Florida, describes the crucial role that vitamin D plays throughout the body, beyond its well-known role in the musculoskeletal system. How common is vitamin D insufficiency among geriatric and nursing home residents? What is the best regimen and dosage to overcome vitamin D insufficiency or deficiency? When should calcium be supplemented to help prevent fractures? Tune in to hear host Dr. Eric Tangalos and this week's guest sift through the latest information on vitamin D.