06/15/11

TAMPA – Nursing homes do a balancing act between honoring their demented residents’ autonomy and keeping them safe from some of the consequences of that autonomy, according to three physician-researchers who have studied facilities’ policies for several years.

In a series of nationwide surveys done through the National Association of Directors of Nursing Administration/Long Term Care, Richard Stefanacci, DO, CMD, Paula Lester, MD, and Izchak Kohen, MD, examined how facilities handle smoking by residents, their right to have food and other goods brought into a facility for them, and how to minimize antipsychotic medications while controlling residents’ psychotic symptoms. The researchers presented their findings in the session titled "Autonomy vs. Safety of Nursing Home Policies and Procedures" at the AMDA annual meeting.

Courtesy Craig Huey Photography
At an annual meeting session, researchers described how facilities address resident autonomy and safety issues.

Smoking

"Smoking is still prominent, although there is a downward trend," said Dr. Stefanacci of theInstitute for Geriatric Studies Center for Medicare Medication Management at the University of the Sciences in Philadelphia. "It’s legal, but the consequences can be deadly. Smoking is a major contributor to fires in facilities."

In fact, he said that smoking materials account for 72% of fire-related deaths and 43% of fire-related injuries, he said. Of the 3,600 fires reported in U.S. nursing facilities from 1987-1991, 15% started from residents smoking in bed.

Medicare and Medicaid regulations require that smoking by residents be supervised and controlled. Residents may not smoke in their rooms unless directly observed by staff, and policies must confine smoking to designated areas away from nonsmoking residents. Additionally, facilities must comply with the National Fire Protection Association’s Life Safety Code to restrict smoking by residents with dementia.

Dr. Stefanacci, Dr. Lester, and Dr. Kohen surveyed directors of nursing (DONs) about their facilities’ policies on smoking. In responses from 250 DONs, mostly at facilities with 60-240 beds, nearly all (97%) of said that their facilities had written smoking policies in place. Almost as many (86%) said that cigarettes are distributed by nursing staff, and 68% stated that they require residents to wear fire-resistant aprons when they smoke.

A small minority (14%) said that they let residents control their smoking situation, although Dr. Stefanacci suggested that this response probably meant that a facility has designated smoking area where residents must go if they wish to smoke. Only 31% of the DONs said their facilities require physician orders to allow a resident to smoke.

The survey, Dr. Stefanacci said, left some questions unanswered. "No one seems to have a clear-cut definition as to what they’re describing as smoking," He said. At the same time, he noted that the survey didn’t ask if the DONs themselves are smokers. He suggested that it would be interesting to determine whether the nurses’ status as nonsmokers, current smokers, or ex-smokers affected their feelings about smoking in the facility and how they viewed smoking policies.

Dysphagia

Dysphagia often is seen with Alzheimer’s disease (AD) in long-term care residents and, unfortunately, treated by tube feeding, said Dr. Lester of the department of clinical medicine at Stony Brook (N.Y.) University.

"Contrary to what some people believe, enteral feeding in AD patients does not prolong life, reduce pressure ulcers, or promote weight gain. But it does increase the risk of aspiration pneumonia and restraint use. As clinicians, we need to recognize the goals and benefits of various treatments and make sure that caregivers and others understand what enteral feeding really means."

Managing dysphagia can be challenging because "people have visitors who don’t know what is or isn’t safe to eat. They might think it’s a thoughtful gesture to bring a box of chocolates, but this could cause serious problems for some patients," said Dr. Lester saidof the department of clinical medicine at Stony Brook (N.Y.) University.

In another survey of DONs, only 17% of respondents said that their facilities had the responsibility to restrict residents’ access to outside food; 24% said their facilities have the right to do so.

These are surprisingly low percentages, Dr. Lester noted. For example, much higher percentages of DONs said their facilities have the responsibility to restrict resident access to over-the-counter medications (69%), cigarettes (63%), and alcoholic beverages (55%) brought in from the outside. Similar numbers also said the facility has the right to restrict resident access to these items.

Only 37% of respondents said that their facilities had policies regarding family members bringing outside food to residents. This compares with the 64% who said their facilities have such policies regarding cigarettes and 58% indicating policies about alcoholic beverages. The vast majority of DONs (84%) said that their facilities had formal policies about bringing in over-the-counter medications.

Respondents from only 56 of 299 sites said that they restrict all types of food for all residents, regardless of medical condition. Ninety DONs reported restricting outside food for dysphagia patients. In comparison, 64 said their facilities restrict outside food access for diabetes patients.

Comparing these numbers with the survey data on smoking policies, Dr. Lester noted that, while smoking policies affect only about 10% of residents, 97% of facilities have smoking policies. However dysphagia affects 40%-60% of residents, but only 30% of facilities have food-restriction policies. "This is a concern that needs attention," Dr. Lester said. "Clearly, dysphagia is a much more widespread problem and should be addressed accordingly."

Antipsychotics

The use of antipsychotics in nursing facilities has received much national attention with good reason, said Dr. Kohen, MD, an attending faculty member in clinical psychiatry at Zucker Hillside Hospital, Manhasset, N.Y., said (see page 1). "Since 1999, studies report an increasing use of antipsychotics in nursing home residents. And more recently, antipsychotic use in elderly nursing home residents has increased substantially; primarily because of the use of atypical antipsychotic agents."

He referred to the 2005 Food and Drug Administration black box warning that states, "Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death."

Looking at another set of survey results, nearly 60% of DONs reported that at least 20% of their residents currently are taking antipsychotic agents. While 39% of respondents said that antipsychotic use has decreased since the FDA warning went into effect, another 39% said that usage hasn’t changed, and 3% said that usage actually has increased. Twenty percent of DONs said they did not know if usage has gone up or down.

Of the 250 facilities represented in the survey, 107 reported having policies on antipsychotics. While nonprofit facilities were determined to be no more likely to have such a policy, location did seem to make a difference. Facilities in the West (76.9%) were more likely to have an antipsychotic policy than facilities in the East (35.9%). Also, large nursing homes were more likely than small to have a policy.

Sometimes-overlapping policies included:

--Physician Should Discuss with Family (33% of facilities).

--Physician Required to Discuss Verbally with Family (12%).

--Social Worker Informs Family (22%).

--Nursing Staff Informs Family (57%).

--Family Informed by Written Document (28%).

--Family Must Sign Consent to Allow Antipsychotic Use (64%).

Dr. Kohen concluded that antipsychotics are likely to be increasingly restricted by law and regulation in nursing homes, so facilities should review and strengthen their policies now.

"Nursing facilities have a unique role and responsibility in providing an appropriate assessment and intervention to reduce risks for patients with dementia," he said. This should include a review of how antipsychotics are used and of policies regarding these medications. CfA

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.

 

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