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Mrs. G is an 80-year-old white female who has lived in assisted living for several years. She scores 24 on the Saint Louis University Mental Survey (SLUMS), indicating that she has some mild cognitive impairment, and she is independent with bathing and dressing, although she needs encouragement to shower and to change clothes regularly. She is often anxious, as exhibited by her repeated requests for help in the evenings, and she has made multiple complaints of vague pain, shortness of breath, and difficulty sleeping. She asks frequently for medication to help with her symptoms, especially for her difficulty sleeping. Her medications include vitamin C, 500 mg, for anemia in use with iron; vitamin B12, 250 μg daily, for B12 deficiency; vitamin D3, 1,000 units daily, for vitamin D deficiency; clopidogrel, 75 mg daily, as antiplatelet therapy; lisinopril, 20 mg daily, and metoprolol succinate, 50 mg daily, for hypertension; famotidine, 20 mg daily, for gastric acid symptoms; ferrous fumarate, 30 mg daily, for iron deficiency; melatonin, 3 mg at bedtime, for insomnia; fluticasone propionate, 220 μg via inhaler every morning, and albuterol, 90 μg via inhaler as needed, for reactive airway disease; acetaminophen, 650 as needed every 6 hours, for pain; zolpidem, 10 mg at bedtime, also for insomnia; and buspirone, 10 mg by mouth as needed, for anxiety.
Mrs. G has been falling two times per week, usually during the night around 1:00 a.m. She is found on the floor by the nursing assistants; she states that the she simply slid off the bed or slipped on a wet surface when trying to go to the bathroom. She denies dizziness, and her vital signs are consistently stable. The nursing assistants also report that she tends to drink alcohol during the evening, although they are not certain how much is consumed.
The delegating nurse and the nurse practitioner spoke with Mrs. G about cutting back on her drinking to help her sleep and decrease her risk of falling. The staff have tried to limit the amount of alcohol by encouraging Mrs. G to purchase single servings of bourbon, her preferred drink, which the staff make available to her daily. Mrs. G is adamant that she does not want to stop drinking. She insists that she only consumes one drink daily, but there is evidence in her apartment that she orders bourbon and wine directly from a local liquor store. The family has been informed and is aware of the staff’s concerns about her alcohol consumption and its possible correlation with falling. The family members have said they do not think they can do anything to change the situation.
This situation is brought to the IDT to figure out how to best manage it.
Barbara Resnick, PhD, CRNP
Dr. Resnick is a geriatric nurse practitioner with over 30 years of experience working across a variety of settings.
Seeing Mrs. G for a primary care visit related to her insomnia, I spoke with her about her daily routine and cutting back on the alcohol to facilitate sleep. She informed me that she generally gets up about 9:30 a.m., bathes and dresses and has breakfast before returning to bed for a rest. Sometimes she goes to activities either within or outside the facility, and then she takes an afternoon nap. She attends dinner in the dining room or has it delivered to her room. Her naps vary in length from 1 to 2 hours. Regarding her alcohol intake, she reports she has one ounce of bourbon daily before dinner, and wine with dinner if she eats with others. Sometimes she has more bourbon just before she goes to bed, and she was adamant that the alcohol actually helps her sleep. I explained how the alcohol worked and the impact on her sleep cycle. Further, I talked with her about the combined risk of using zolpidem with alcohol, and I recommended some behavioral interventions. Specifically, we discussed good nighttime regimens, including going to sleep at a consistent time, which for her was around midnight; not spending a lot of time in the bed when she was not there for sleeping; limiting her naps to fewer than 30 minutes; and increasing her physical activity and spending time out of the apartment and not in the bed. We made an activity schedule and ordered individual bourbon samplers to control her daily intake. The interventions were reviewed with the nursing assistant who works with her on the unit to ensure consistent application.
To rule out any medical causes contributing to Mrs. G’s insomnia, behavioral issues, or falls, she was evaluated for orthostatic blood pressure and arrhythmias, and a neurologic examination was performed, including a mental status examination. A comprehensive metabolic panel, complete blood count, and thyroid-stimulating hormone, vitamin B12, and folate levels were evaluated. All laboratory results were within the normal limits as were the clinical findings with the exception of mild cognitive impairment noted on a Saint Louis University Mental Status Examination.
Margo Kunze, RN, CALA
Ms. Kunze is treasurer and secretary of the American Assisted Living Nurses Association and president of AL Consulting.
I would first discuss with Mrs. G and/or her family the history of her alcohol use, why she is using bronchodilators and what benefits they provide because they might be the cause of some of her agitation, and how long she has been using anxiolytics and hypnotics. I would explore the reasons why her alcohol use might be different now — have there been changes in her life, medical status, medications, living arrangements, or routine? I would recommend that the staff check on her just before 1:00 a.m. as this seems to be her critical hour for falls. I would request that a soft light be left on in her bathroom so she does not have to wait for her eyes to adjust to bright lights.
A capacity assessment would help inform the staff and family of the degree to which Mrs. G is capable of making decisions and demonstrating sound judgment related to alcohol use. If necessary, it might be an option to talk with the family about limiting her access to credit cards, which would curb the amount of alcohol she can purchase. We could talk with the family about removing her credit status at the liquor store and having them refuse to take her orders. It would also be helpful for the pharmacist or medical provider to review Mrs. G’s medications to identify potential contributors to her insomnia and falls.
The IDT should assess her anxiety to identify possible contributing factors and determine potential nonpharmacological interventions. She should be encouraged to attend activities, especially exercise classes, and consider a referral to physical therapy.
The IDT should meet with Mrs. G and the family to discuss the assessments and collaborate on the next steps. If Mrs. G insists on continued alcohol use, I would recommend completing a shared risk agreement to record in-depth documentation of the discussion and the risks and potential outcomes, including the probability of falls with serious injury or death. This discussion would also include reviewing the admission contract with the facility with the rules and regulations that Mrs. G signed when she moved in. At some point, it might become necessary to consider an alternate living arrangement for Mrs. G, which can be initiated with a 30-day discharge notice.
Diane Mockbee, BS, AC-BC
Ms. Mockbee is an activity consultant, educator, and trainer.
I would first assess why Mrs. G is having difficulty sleeping and determine whether it is possible to get her wake/sleep schedule back in synch. Is she napping excessively during the day? Is she in pain? I would explore ideas to get her more involved in activities during the day, such as an exercise program to help strengthen her limbs, decrease her falls, and possibly alleviate her anxiety. Being with others for socialization and similar interests might also decrease her anxiety and reduce her requests for medications. She may require reminders for events and possibly an escort to activities of interest.
I recommend talking with the medical provider about possibly decreasing the zolpidem and increasing the melatonin. Perhaps Mrs. G would enjoy a mug of herbal tea before bed. I would explore relaxation interventions such as aromatherapy (a diffuser with lavender oils is lovely!). Perhaps she would enjoy relaxation music playing softly at bedtime, preferably instrumental or nature sounds.
She may be falling around 1:00 a.m. due to a need to go to the bathroom, so making sure she uses the restroom right before bed could be helpful. If the floor is wet, it could be that she had an incontinence episode and may be too embarrassed to say anything, thus the need to “cover it up.”
If possible, alcohol should be offered to her right after dinner, not at bedtime; the effect may be lessened if it is absorbed with a meal. If she is not amenable to her drink at this time, encourage her to eat a snack when she enjoys the beverage later in the evening. Also consider other strategies such as watering down the drink or serving it with lots of ice.
The key, though, is to tire her out during the day so she will sleep better at night. The Activity Department needs to keep her engaged as much as possible and provide consistent reminders and opportunities to get her out of her room. Caregivers can do the same thing when they are assisting her.
Behavioral Health Specialist
Elizabeth Galik, PhD, CRNP, FAAN, FAANP
Dr. Galik is a professor at the University of Maryland School of Nursing and a nurse practitioner at the Sheppard Pratt Neuropsychiatry Program.
The interplay of Mrs. G’s chronic alcohol use, mild cognitive impairment (MCI), medical comorbidities, and polypharmacy present significant health, safety, and quality of life concerns. From a behavioral health perspective it would be important to obtain additional history from Mrs. G and her family about past patterns of drinking before her move to the assisted living community, about any past complications from her alcohol use and the motivators for her continued alcohol use (social motivator versus coping mechanism), and about past personal psychiatric history for depression, anxiety, and insomnia, and sources of her social support. The behavioral health clinician should also assess her understanding and appreciation of how certain age-related changes (increased permeability of the blood–brain barrier, decreased liver function, and loss of lean muscle mass) may result in higher blood alcohol concentrations compared with when she was younger. Additionally, she may forget the quantity of alcohol that she is consuming due to her MCI and may truly believe that her alcohol intake is moderate.
The interdisciplinary approach was important in combining each discipline’s unique perspective in a balanced set of recommendations:
Evaluate daily routines and habits to improve sleep hygiene and reduce or eliminate alcohol use.
Review medications, with suggested changes.
Perform a medical evaluation to rule out contributing factors to the insomnia, falls, and anxiety.
Increase the resident’s daytime activities and involvement in the life of the assisted living community.
Offer the resident assistance with toileting around midnight; leave a soft light on in the bathroom.
Perform a comprehensive psychosocial assessment that emphasizes the resident’s strengths and capacity, and provide trauma and depression screening.
Emphasize the importance of IDT documentation; consider using a shared risk agreement tool.
Stress pursuing healthful and positive goals in the care plan rather than minimizing negative behaviors.
Emphasize with the staff that they should be mindful not to judge or shame the resident.
Review the resident’s advance directives and engage in ongoing advance care planning.
Discuss anticipatory discharge planning options in the event the resident’s care needs change and she requires a higher level of service.
A review of the physical examination and laboratory work done by the nurse practitioner would be performed.
For a treatment plan to be effective, the goals of care and risk avoidance need to be explored with the resident, family, and IDT. Some consensus must be reached on preventing further falls and optimizing Mrs. G’s function so that she can remain in her assisted living apartment. A frank discussion of the risks associated with her current alcohol use must be had with Mrs. G, her family, and the staff. Ideally a plan for a slow, gradual taper of alcohol could be developed, with the staff dispensing and gaining cooperation from Mrs. G and her family to prevent outside ordering of alcohol. Assuming that she will continue to use at least some alcohol, specific pharmacological interventions should be discussed with a pharmacist.
I would suggest tapering off the zolpidem to decrease her risk of delirium and falls, and I would consider pharmacological treatment for her depression and anxiety (mirtazapine), which might also help with her insomnia. Buspirone should either be discontinued or given at 5 mg, twice daily, on a standing basis. Additionally, the continued necessity of clopidogrel should be questioned due to an increased risk of a bleed. As recommended by nursing, brief staff visits before the time of her usual falls (around 12:00 a.m.) to assist with ambulation to the bathroom may decrease her frequency of nighttime falls. Lastly, Mrs. G may benefit from brief cognitive behavioral therapy to address her ineffective coping strategies and develop opportunities for her to engage in meaningful activity that does not involve alcohol.
Paige Hector, LMSW
Ms. Hector has over 25 years’ experience in post-acute and long-term care settings as a social worker and clinical educator.
On an individual basis, cognitive impairment, alcohol use, and falls can be challenging, but when all three are present, it may feel like the perfect storm to the staff and the family. Balancing Mrs. G’s right to self-determination with the responsibility of the assisted living facility to maintain a safe living environment requires collaboration with the IDT, the resident, and the family. This balance occurs through ongoing discussions with Mrs. G and her family about the risks associated with her choices, her medical and cognitive states, the interventions to mitigate the risks, and how the family and staff can work together. Consistent, well-documented entries in the chart by all members of the IDT are critical — all efforts to uphold the plan of care, discuss risk, and keep track of resident outcomes not only demonstrate great resident care but also build a defensible record.
A comprehensive cognitive and psychosocial assessment is key. The information learned may help inform the IDT of how best to collaborate with Mrs. G and the family. The areas to explore include coping mechanisms (past and present), significant relationships, history of mental health treatment and interventions, work and career history, finances, personal goals, past and current functional abilities and challenges, spiritual beliefs, and how Mrs. G defines quality of life. As part of the psychosocial assessment, I would conduct a depression screening such as the Geriatric Depression Scale (GDS) or Patient Health Questionnaire (PHQ-9). Although it is not mandated in the assisted living arena, I would also screen for a history of trauma because this information could be very informative. Transitioning into a new living environment and diminishing functional ability and cognition are all emotionally traumatic, and the staff needs to understand how these experiences inform Mrs. G’s current status and her choices.
So often in health care settings we tend to focus on what a person is “doing wrong” or on behavior the staff perceives as frustrating or irritating (and sometimes it really is!). From a person-centered care perspective, Mrs. G is much more than her diagnoses and choices. As the IDT works with her and the family, it is important to identify and incorporate her strengths. Ask about things she does (or used to do) for enjoyment (other than alcohol), what she used to do well, and her values and beliefs around quality of life. As the care plan is developed, use those strengths as a focal point.
So instead of setting a goal to stop or decrease alcohol use, we would approach it from a different perspective: identify what she would be doing instead. If she were drinking less (or not at all), what would she be doing with her time? The care plan should emphasize increasing that activity or state of being as a positive goal. Another important aspect is to consider the times during the day when the problem isn’t happening. What is she doing at those times of the day? How are those times different from when she is drinking? Is it possible to create more of that atmosphere/circumstance?
And it is important to be aware of the human tendency to judge, especially in those situations in which a person is making choices that might be perceived as “wrong” or “inappropriate.” As a social worker, I would be attuned to staff attitudes and how they approach Mrs. G around the alcohol issue. If necessary, I would help them find ways to engage with her without shame or judgment.
I would also review her advance directives and code status in light of her diagnoses, prognosis, and risk of injury due to a fall. I would engage Mrs. G and the family (if she agrees) in a more comprehensive discussion of advance care planning, beyond just the completion of directives. What challenges might she and the family expect should she sustain a fall with injury or if her other medical conditions progress? How would her quality of life, treatment decisions, and living situation be affected?
Finally, I would explore the discharge planning possibilities in the event Mrs. G’s needs can no longer be accommodated in the assisted living setting.
Nicole Brandt, Pharm D, MBA
Dr. Brandt is a professor and the executive director of the Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.
From a medication safety and risk perspective, there are many notable considerations that need to be discussed with the resident, family, and staff to reduce Mrs. G’s alcohol consumption as well as her falls.
With respect to medications, the use of 10 mg of zolpidem in an 80-year-old woman increases her risk of falling (higher dose); when used in conjunction with alcohol, her risk of falls further increases. Her medication regimen suggests that she is experiencing complications from chronic alcohol use, as indicated by her famotidine use as well as her possible iron deficiency anemia and vitamin B12 deficiency. Furthermore, her use of clopidogrel and alcohol together increases her risk of gastrointestinal bleeding. To complicate the picture further, she may be getting hypotensive, especially accompanying positional changes, due to not only age-related implications but also her use of lisinopril, metoprolol, and concomitant use of alcohol.
With respect to the treatment of her chronic conditions, the etiology of her shortness of breath is unclear, so I would recommend determining the benefits of the fluticasone propionate and/or albuterol. Depending on how and by whom the albuterol is being managed, it may be aggravating her anxiety. Buspirone is not effective as an as-needed anxiolytic. We need to explore other agents to manage her sleep and anxiety (the use of mirtazapine might be an option).
With respect to empowering the patient and staff, her alcohol reduction and cessation needs to be a team effort with support from the community. Reducing the alcohol to one drink per day is a good start.
The IDT came up with some very helpful suggestions and approaches for how to manage this challenging case. Given the impact of the alcohol, the team met with the family again to discuss limiting Mrs. G’s ordering of alcohol while still giving her one drink daily in the evening with her dinner. Mrs. G felt the inhalers were of benefit to her, so these were continued. Additional monitoring of her blood pressure for orthostasis was arranged, as well as monitoring of her anxiety with consideration of additional changes in medications. The activities explored included options for daytime and evening activities she would be willing to attend, and staff was committed to help get Mrs. G to those events. She declined physical therapy, but she was willing to participate in a sitting exercise program, which was available a few days a week. An evening routine was planned for her that included aromatherapy per resident preference. The staff instituted a 1:00 a.m. check for toileting, and the team continues to monitor for nighttime falls.
Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
Ms. Hector is a clinical educator and public speaker specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, risk management and end-of-life care, and palliative care, among other topics. She is a member of the Editorial Advisory Board for Caring for the Ages. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.