Long Term Care

Seven Tests and Treatments to Question

by
Canadian Society for Long Term Care Medicine
Last updated: March 2021

Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.
1

Transfers to hospitals for assessment and treatment of a change in condition have become customary. However, they are often of uncertain benefit and may result in increased morbidity. In one Canadian study, 47% of hospitalizations were considered avoidable, while a recent US study found 39% to be ‘potentially avoidable’. Transfer often results in long periods in an unfamiliar and stressful environment for the patient. Other hazards include delirium, hospital-acquired infections, medication side effects, lack of sleep, and rapid loss of muscle strength while bedridden. Harms often outweigh benefits. Residents assessed and treated at their care home will receive more individualized care, better comfort, and end-of-life care. If a transfer is unavoidable, give clear prior instructions to the hospital about the patient’s needs. Respect for patient choice is a fundamental consideration in all decisions to transfer to a hospital. A clear understanding of the patient’s goals must be established taking into account current health status, values, and preferences. This will reduce the likelihood of inappropriate transfer. These goals should be discussed earlier and often with the patient and family, including whether comfort, function, and quality of life are their most important goals.

Sources:

Walker JD, et al. Identifying potentially avoidable hospital admissions from Canadian long-term care facilities. Med Care. 2009 Feb;47(2):250-4. PMID: 19169127.

Walsh EG, et al. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. J Am Geriatr Soc. 2012 May;60(5):821-9. PMID: 22458363.
Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.
2

People with dementia can sometimes be disruptive, behaving aggressively and resisting personal care. There is often a reason for the behaviour (pain, for example), and identifying and addressing the causes can make drug treatment unnecessary. When drug treatment is chosen, antipsychotic medicines are often prescribed, but they provide limited benefits and can cause serious harm, including premature death. These medications should be limited to cases where non-drug measures have already been tried and failed and the patients are a threat to themselves or others. When an antipsychotic has been prescribed, frequent reviews and attempts at reduction or discontinuation must be done to reduce harm.

Sources:

Brodaty H, et al. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012 Sep;169(9):946-53. PMID: 22952073.

Schneider LS, et al. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006 Mar;14(3):191-210. PMID: 16505124.

Seitz DP, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review. J Am Med Dir Assoc. 2012 Jul;13(6):503-506.e2. PMID: 22342481.

Relevant Resources:

Patient Pamphlet: Treating Disruptive Behaviour in People with Dementia: Antipsychotic drugs are usually not the best choice

Toolkit: When Psychosis Isn’t the Diagnosis – A toolkit for reducing inappropriate use of antipsychotics in long-term care
Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).
3

Unless there are UTI symptoms such as urinary discomfort, abdominal/back pain, frequency, urgency, or fever, testing should not be done. Testing often shows bacteria in the urine, with as many as 50% of those tested showing bacteria present in the absence of localizing symptoms to the genitourinary tract. Over-testing and treating asymptomatic bacteriuria with antibiotics leads to increased risk of diarrhea and infection with Clostridium difficile. It also increases the risk of failure to consider other causes of change in condition such as SARS-CoV-2. Overuse of antibiotics contributes to increasing antibiotic-resistant organisms.

Sources:

Choosing Wisely Canada. Using Antibiotics Wisely in Long-Term Care. [Internet].

High KP, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jan 15;48(2):149-71. PMID: 19072244.

Kistler CE, Beeber AS, Zimmerman S, Ward K, Farel CE, Chrzan K, Wretman CJ, Boynton MH, Pignone M, Sloane PD. Nursing Home Clinicians’ Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment. Journal of the American Medical Directors Association. 2020 Jan 20;21(5):675-682. PMID: 31974065.

Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, Klein-Fedyshin M, Wessel CB, Mulligan M, Drinka PJ, Crnich CJ. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) consensus guidelines for the diagnosis of uncomplicated cystitis in nursing home residents. Journal of the American Medical Directors Association. 2018 Sep 1;19(9):765-9. PMID: 30037743.

Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.

Stone ND, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965-77. PMID: 22961014.
Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat.
4

Inserting a feeding tube does not prolong or improve the quality of life in patients with advanced dementia. If the resident has been declining in health with recurrent and progressive illnesses, they may be nearing the end of their life and will not benefit from feeding tube placement. Feeding tubes are often placed because of fears that patients may aspirate food or become malnourished. Studies show that tube feeding does not make the patient more comfortable or reduce suffering. Tube feeding may cause fluid overload, diarrhea, abdominal pain, and discomfort/injury (from the tube itself). A tube can actually increase the risk of aspiration and aspiration pneumonia. Helping people eat, rather than tube feeding, is a better way to feed patients who have advanced dementia and feeding difficulties.

Sources:

Hanson LC, et al. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc. 2011 Mar;59(3):463-72. PMID: 21391936.

Palecek EJ, et al. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010 Mar;58(3):580-4. PMID: 20398123.

Sampson EL, et al. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209. PMID: 19370678.

Sorrell JM. Use of feeding tubes in patients with advanced dementia: are we doing harm? J Psychosoc Nurs Ment Health Serv. 2010 May;48(5):15-8. PMID: 20415291.

Teno JM, et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc. 2012 Oct;60(10):1918-21. PMID: 23002947.

Relevant Resources:

Patient Pamphlet: Feeding Tubes for People with Alzheimer’s Disease: When you need them – and when you don’t
Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient.
5

Long-term medications should be discontinued if they are no longer needed (e.g., heartburn drugs, antihypertensives) as they can reduce the resident’s quality of life while having little value for a frail elder with limited life expectancy (e.g., statins, osteoporosis drugs). The use of multiple medications may also affect patient safety. Prescribing medications to meet lab test “targets” that apply to adults living in the community (e.g., blood sugar, blood pressure) may instead have dangerous effects on mobility, function, mortality, and quality of life when applied to a frail elder in care.

Sources:

American Geriatrics Society 2015 Beers Criteria Update Expert Panel, Fick DM, Semla TP, Beizer J, Brandt N, Dombrowski R, DuBeau CE, Eisenberg W, Epplin JJ, Flanagan N, Giovannetti E. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2015 Nov;63(11):2227-46. PMID: 26446832.

Beckett NS, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008 May 1;358(18):1887-98. PMID: 18378519.

Dalleur O, et al. Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria. Drugs Aging. 2012 Oct;29(10):829-37. PMID: 23044639.

James PA, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. PMID: 24352797.

Muntner P, et al. Systolic blood pressure goals to reduce cardiovascular disease among older adults. Am J Med Sci. 2014 Aug;348(2):129-34. PMID: 24978394.

Tinetti ME, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014 Apr;174(4):588-95. PMID: 24567036.
Don’t order screening or routine chronic disease testing just because a blood draw is being done.
6

Unless you are sure treatment can be given that would add to the quality of life, don’t do these tests. “Routine” testing may lead to harmful over-treatment in frail residents nearing the end of their life and lead to misusing healthcare resources that would do more good used wisely.

Sources:

American Medical Directors Association (AMDA). Health maintenance in the long term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2012.

Clarfield AM. Screening in frail older people: an ounce of prevention or a pound of trouble? J Am Geriatr Soc. 2010 Oct;58(10):2016-21. PMID: 20929471.

Gill TM. The central role of prognosis in clinical decision making. JAMA. 2012 Jan 11;307(2):199-200. PMID: 22235093.

Gross CP. Cancer screening in older persons: a new age of wonder. JAMA Intern Med. 2014 Oct;174(10):1565-7. PMID: 25133660.

Moyer VA, et al. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jul 17;157(2):120-34. PMID: 22801674.

Royce TJ, et al. Cancer screening rates in individuals with different life expectancies. JAMA Intern Med. 2014 Oct;174(10):1558-65. PMID: 25133746.

van Hees F, et al. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med. 2014 Jun 3;160(11):750-9. PMID: 24887616.
Don’t hesitate to use virtual care to complement in-person visits in order to meet the needs of residents in long-term care during the COVID-19 pandemic.
7

To reduce the potential of serious outbreaks in long-term care during COVID-19, physicians are encouraged to practice virtual medicine, where appropriate. To be effective, physicians and senior leadership must strive for excellent communication and timely access to physicians. Studies have shown that the use of telemedicine in caring for nursing home residents can facilitate better patient care and overall cost savings through reducing unnecessary hospital transfers to the emergency department and subsequent hospitalizations.

If the home needs to be physically attended to, physicians are encouraged to do targeted on-site visits and consider charting remotely. Telemedicine in long-term care can contribute to the delivery of high-quality medical care reducing avoidable hospitalizations. Utilizing virtual care where appropriate can ensure the protection of healthcare workers while still maintaining effective communication with staff and residents’ families. Appropriate systems-level optimization can be created so that physicians can effectively advocate for older residents who are especially vulnerable to contracting COVID-19. The pandemic has further illustrated the need to provide timely access to care to assess acute changes in status including respiratory complaints and hypoactive delirium.

Sources:

Collins R, Charles J, Moser A, Birmingham B, Grill A, Gottesman M. Improving medical services in Canadian long term care homes. Canadian Family Physician. 2020 Oct 7.

Dosa D, Jump RL, LaPlante K, Gravenstein S. Long-term care facilities and the coronavirus epidemic: Practical guidelines for a population at highest risk. Journal of the American Medical Directors Association. 2020 May 1;21(5):569-71. PMID: 32179000.

Grabowski DC, O’Malley AJ. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for medicare. Health Affairs. 2014 Feb 1;33(2):244-50. PMID: 24493767.

Grant KL, Lee DD, Cheng I, Baker GR. Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review. Canadian Journal of Emergency Medicine. 2020 Nov;22(6):844-56. PMID: 32741417.

Gillespie SM, Handler SM, Bardakh A. Innovation Through Regulation: COVID-19 and the Evolving Utility of Telemedicine. Journal of the American Medical Directors Association. 2020 Aug 1;21(8):1007-9. PMID: 32736843.

Gillespie SM, Moser AL, Gokula M, Edmondson T, Rees J, Nelson D, Handler SM. Standards for the use of telemedicine for evaluation and management of resident change of condition in the nursing home. Journal of the American Medical Directors Association. 2019 Feb 1;20(2):115-22. PMID: 30691620.

Heyworth L, Kirsh S, Zulman D, Ferguson JM, Kizer KW. Expanding access through virtual care: The VA’s early experience with Covid-19. NEJM Catalyst Innovations in Care Delivery. 2020 Jul 1;1(4).

Jnr BA. Use of telemedicine and virtual care for remote treatment in response to COVID-19 pandemic. Journal of Medical Systems. 2020 Jul;44(7):1-9. PMID: 32542571.

Landi F, Barillaro C, Bellieni A, Brandi V, Carfì A, Cipriani C, D’Angelo E, Falsiroli C, Fusco D. The geriatrician: the frontline specialist in the treatment of COVID-19 patients. Journal of the American Medical Directors Association. 2020 Apr 23. PMID: 32674823.

Low JA, Toh HJ, Tan LL, Chia JW, Soek AT. The Nuts and Bolts of Utilizing Telemedicine in Nursing Homes–The GeriCare@ North Experience. Journal of the American Medical Directors Association. 2020 Aug 1;21(8):1073-8. PMID: 32576435.

Public Health Association of Canada. Interim guidance: Care of residents in long term care homes during the COVID-19 pandemic – Canada [Internet]. 2020 [cited 17 August 2020].
How the list was created

The Canadian Society for Long Term Care Medicine (formerly the Long Term Care Medical Directors Association of Canada) established its Top 6 recommendations under the leadership of their Director. CSLTCM members were invited to participate in the list development by email. Two physician volunteers came forward to join the Director and form the Choosing Wisely Canada working group. To represent the patient voice, an articulate patient leader and Patients for Patient Safety Canada “champion” joined the working group. The American Medical Directors Association and Canadian Geriatric Society lists were reviewed as a starting point. None of these lists was specific to the frail elderly in residential care. The process aimed for recommendations that were valid and relevant for Canadian patients and our health care system. By small group discussion amongst the working group, the 6 recommendations were proposed. The document was then circulated to the members of the Board of the CSLTCM for feedback and approval.