Mrs. S is an 85-year-old woman who moved into the nursing home five years ago when her husband could no longer provide care for her due to her progressive weakness and failure to thrive. She has a history of Barrett’s esophagus and significant reflux and subsequent dysphagia, a long history of depression, allergic rhinitis, dementia with a Brief Interview for Mental Status (BIMS) score of 12, basal cell carcinoma, insomnia, iron deficiency anemia, and a pneumonitis due to aspiration. She is oxygen dependent.
Her medications include mirtazapine, 30 mg daily; nortriptyline, 80 mg daily; melatonin, 3 mg daily; omeprazole, 40 daily; ferrous sulfate, 325 mg daily; vitamin D3, 2,000 units daily; and polyethylene glycol 3350 and senna daily. Over the years her diet has decreased to include mostly just soft or liquid intake such as supplements, ice cream, yogurt, and milkshakes. She has generally maintained her weight. A month ago, she was noted to have loose stools, and the nurses immediately stopped the polyethylene glycol 3350 and senna. The loose stools continued, and she was noted to have less appetite and started to lose some weight.
A complete blood count and comprehensive metabolic panel were obtained, and a stool was sent for Clostridioides difficile testing. Her white cell count was up to 17.3 x 109/L, hemoglobin down to 9.6 g/dL; hematocrit 32.9%, total protein 5.5 g/dL, and albumin 2.3 g/dL. All other tests were within normal limits. The stool specimen tested positive for Clostridium difficile, and she was started on vancomycin, 125 mg orally four times a day for 10 days.
At the end of the 10-day period she was still having at least a few episodes of loose stools daily, and she had a 14-pound weight loss over the past 6 weeks. The team is asked to discuss best ways to facilitate care for Mrs. S.
Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD
Dr. Hector is a Tucson-based physician with over 30 years of medical director experience.
Medically it should be recognized that Mrs. S’s risk factors for acquiring C. difficile include her advanced age, the communal setting, chronic use of a proton pump inhibitor (PPI) such as omeprazole, and a history of pneumonitis and presumptive prior treatment with a course of antibiotic therapy for same. She represents an increased risk of infection for her peers, which is why she needs to be placed on gown-and-glove isolation, with staff assistance with her personal hygiene and a deep cleaning of her room once the infection is deemed treated.
Evaluating whether she continues to manifest symptoms of C. difficile is not always easy. If her white blood cell count has normalized, if she is having some form to her stools, if she is having fewer than three stools per day, and if she is symptomatically better in terms of nausea and anorexia, she is likely over this episode. She has an obvious risk for recurrence. Retesting of her stool may still give a positive result because of Clostridioides colonization, so it does not answer the question of whether she needs treatment again. Because she has already acquired the Clostridioides bacteria, it is not clear whether her PPI still represents a risk.
There has been a lot of discussion about probiotic replacement of the gut microflora, which might be easily achieved in this resident by the use of one of her chosen foods: yogurt with live culture (i.e., unpasteurized yogurt) or any of several probiotic regimens. Any future contemplated use of antibiotics with this resident — or indeed in any resident — must be weighed against the risk of recurrence of this serious and potentially life-threatening infection.
She seems to have a justifiable need for her PPI and unfortunately is already colonized with C. difficile. Otherwise, in terms of deprescribing, perhaps her nortriptyline dosage could be tapered off, given that she is taking mirtazapine; the latter could be reduced to 15 mg or even 7.5 mg, with an inquiry into how the diagnosis of iron deficiency anemia originally was made. Her diet is possibly low in iron (with iron replacement), and she has a history of Barrett’s esophagitis, so we should reconsider the source of her iron deficiency and the extent to which the treatment is necessary in this patient. Vitamin C might be added to enhance her iron adsorption and minimize her dosing of iron.
Nicole Brandt, PharmD, 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.
A review of this interesting case presents many potential medication-related concerns. For instance, Mrs. S’s loose stools and suppressed appetite may be associated with her low hemoglobin levels. Anemia is linked to loss of appetite as well as diarrhea and may be improved with iron supplementation. Although Mrs. S is taking an iron supplement it may be less effective due to the PPI, omeprazole. Iron requires an acidic environment to be absorbed, and PPIs work by blocking gastric acid secretions.
It is unclear what her iron studies/panel findings are, but to minimize this interaction I would recommend separating the two medications by at least four hours: moving the iron to bedtime and keeping the omeprazole for mornings before breakfast. Omeprazole is most effective after a prolonged period of satiety because this is when the parietal cells are stimulated. Because they block gastric acid secretions, PPIs create an ideal environment for organisms such as C. difficile to grow, which is why PPIs are associated with an increased risk of initial and recurrent C. difficile infections.
The Barrett’s esophagus diagnosis limits the opportunities to deprescribe Mrs. S’s PPI, so consideration may be given to initiating a probiotic to aid in the treatment and prevention of the C. difficile infection. Both Saccharomyces boulardii and Lactobacillus mixtures have been studied and have demonstrated mixed clinical results. Although the literature for recommendation of probiotics in this case is not strong, the potential benefits outweigh the risks for Mrs. S, especially in light of her recent treatment with vancomycin.
Approximately 25% of patients treated for C. difficile infection with metronidazole or vancomycin experience recurrent symptoms, typically within four weeks of completing antibiotic therapy. Furthermore, some nuances with oral vancomycin need to be considered such as Mrs. S’s continued loose stools. Oral vancomycin is relatively safe due to its low systemic absorption, but it may have caused prolonged disruption of Mrs. S’s normal gut flora, which may be why she is experiencing persistent loose stools. In addition, oral vancomycin could have added to her reduced appetite as it has known to cause dysgeusia.
In addition to the vancomycin, tricyclic antidepressants such as nortriptyline also affect taste. This is noteworthy in light that she is also taking mirtazapine. The mirtazapine dosage can be optimized to encourage appetite stimulation. At lower doses (7.5–15.0 mg), mirtazapine binds to histaminic sites, leading to sedation and appetite stimulation. At higher doses (30–45 mg), mirtazapine’s norepinephrine properties emerge, resulting in stimulating effects with appetite suppression.
Mrs. S’s mirtazapine dosage is appropriate for the treatment of depression but may be contributing to appetite suppression. Consideration should be given to decreasing the mirtazapine dose to 15 mg at bedtime, which may increase her appetite as well as cause some sedation and allow for removal of her melatonin. Furthermore, her current dosage of nortriptyline, at 80 mg once daily, should be reconsidered. This is greater than the geriatric daily dosing limits, especially in light of her weight loss, and obtaining her nortriptyline levels also should be considered (the specimen should be collected >12 hours after the dose).
Diane Mockbee BS, AC-BC
Ms. Mockbee is an activity consultant, educator, and trainer.
I would review infection control precautions with the staff of the activities department. I would talk with Ms. S to identify what activities would be meaningful for her while she is being isolated for her infection. Possible activities may include playing her favorite music, singing to (or with) her, gentle massage with lotion (the person providing the massage should be wearing gloves), soothing lighting, and reading to her. I would reassess her spiritual needs and preferences and help ensure those are met. The activities department can help support her nutritional needs by offering nutritious snacks such as milkshakes and yogurt. Until the C. difficile infection has resolved, we need to avoid the use of any activity aids or supplies that are difficult to disinfect. Instead, we would encourage her husband to supply such items if she requests them.
Paige Hector, LMSW
Ms. Hector is a social work expert and a coeditor of this column.
Physically, mentally, and emotionally, Mrs. S. has endured significant life challenges, and her current health changes are presenting her with more: declining health, loss of independence, depression, oxygen dependence, and now an illness that impacts her overall well-being, comfort, and appetite. Added to all this is diarrhea, which necessitates frequent pericare and infection control precautions in which she is only touched by staff wearing gloves and gowns. She can only have soft foods or liquids because she chokes. Her cognition is changing as well — either because of depression, dementia, trauma, or a combination of all three. The move from her home where she had created a life with her husband may not be “new,” but the effects of that move and all the other changes have not gone away simply because she has grown older or time has passed. Indirect screening for trauma means that staff need to know the signs and symptoms of delayed (or current) response to trauma. With a trauma-informed lens, we consider the cumulative effect of all these events on Ms. S’s well-being.
Consider that the definition of psychological trauma includes “any situation that leaves you feeling overwhelmed and isolated can result in trauma, even if it doesn’t involve physical harm” (HelpGuide
, Feb. 20, 2020; http://bit.ly/2Po3cWy
). It would be easy to discount the potential impact of trauma because Ms. S’s situation is not uncommon, and staff are accustomed to seeing it regularly in the post-acute and long-term care setting. One of the biggest barriers to incorporating a trauma-informed care approach is an incorrect assumption that “common” events are not traumatic, individually or cumulatively. Another challenge in recognizing trauma is that dementia and post-traumatic stress can make accurate diagnosis difficult and the “behaviors” are often similar.
With Mrs. S’s change in condition, this would be a good time to review her advance directives, but more importantly to engage in advance care planning discussions with her (to the degree she is capable) and her husband to learn what they understand about this current illness and her overall well-being. What are her values and wishes that would inform the type of care she would want should her condition continue to decline? It is also important to educate her husband on C. difficile
infections to help prevent transmission yet still allow compassionate and caring visits with his wife.
To learn more about emotional and psychological trauma, go to http://bit.ly/2Po3cWy.
Nursing Home Administrator
Nigel Santiago, MBA
Mr. Santiago is the executive director of Haven of Phoenix in Arizona with 12 years’ experience in long-term care. He holds an MBA from the University of Arizona.
When a resident has a contagious infection like C. difficile, we still must uphold the resident’s rights, but they may have to be temporarily modified under the circumstances to decrease the risk of transmission. Together with the director of nursing, I will review the resident’s care plan and the interdisciplinary documentation to make sure we are following the facility’s policies, meeting the regulations, and providing the best resident care possible. We should identify how staffing responsibilities need to be modified to accommodate the extended time it requires to care for someone with C. difficile and the additional supplies the staff will need to care for Ms. S. Some staff may require education and training on C. difficile. In the morning stand-up meeting, the interdisciplinary team (IDT) will discuss how we are meeting Ms. S’s needs medically, socially, and emotionally and how we can best support her husband so that their mutually supportive visits continue.
Director of Nursing
Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT
Ms. Kulus has been a certified AANAC RAC-CT Master Teacher since 2004. She is Chief Nursing Executive at Lantis Enterprises.
One of the first considerations for a resident diagnosed with C. difficile is to prevent transmission to other residents. Because C. difficile can be spread by direct and indirect contact with the resident and their environment, isolation and contact precautions are necessary.
From a nursing perspective, the focus of care would be to encourage adequate intake to maintain and improve Mrs. S’s weight, monitor her fluid balance due to the diarrhea, continue management of the loose stools, and assess and monitor her depression, which might be exacerbated by the illness and isolation. Additionally, efforts should be made to replenish Mrs. S’s normal gastrointestinal tract flora, which naturally will be depleted from antibiotic therapy and C. difficile infection. Even with a BIMS score of 12 (“moderately impaired”), Mrs. S may be able to participate in her recovery plan and share her food-related likes and dislikes, which may help to increase her appetite and intake.
The Significant Change of Status Assessment (SCSA) Minimum Data Set is required when a resident has two or more changes in condition that will not normally resolve in about two weeks. In the case of Mrs. S, this may apply to the diagnosis of C. difficile, the loose stools, and the weight loss. Staff should monitor her condition to determine whether an SCSA will be necessary.
Rebecca Myrowitz, MHS, RDN, CSOWM, LDN, CPH
Ms. Myrowitz is a registered dietician who currently provides dietary consultation in a continuing care retirement community.
In caring for Mrs. S, the dietitian should perform a physical assessment to determine if fat or muscle losses are evident because these help to classify the severity of malnutrition. Some weight loss may be expected due to lack of appetite, antibiotic therapy, and a prolonged period of loose stools, but I would recommend close monitoring of weekly weights with a goal of no further weight decline. Mrs. S should be encouraged to have small, frequent meals. She may find it easier to incorporate fortified foods to increase energy density. Hydration should be a consideration as well, and she should be encouraged to replete electrolytes with broths, Gatorade, or a clear liquid supplement. Due to the continued loose stools, I would encourage Mrs. S to pick fewer milk-based foods and incorporate more soluble fiber such as oatmeal.
The interdisciplinary approach was important in combining each discipline’s unique perspective in a balanced set of recommendations:
The team was very consistent about the care of Mrs. S and the diagnosis of C. difficile. There were some recommendations across multiple disciplines for medication changes, including deprescribing of her antidepressants, addition of vitamin C to help with iron absorption, careful evaluation of any further antibiotic treatment, and continued use of the PPI, given her Barrett’s esophagitis.
Concerns about her psychosocial status were noted across multiple disciplines including addressing trauma, advance care planning, and engaging her in meaningful activities while managing the isolation required.
The IDT also provided important reviews of facility policy on infection control and the relevant regulations, and ensured that the resident rights of Mrs. S were considered.
Additionally, it is imperative that the team be aware of her advance directives and whether Mrs. S chooses to receive intravenous fluids or enteral nutrition, should it be suggested. She may benefit from a nocturnal meal to help support her oral intake and meet her estimated nutrition needs.
Because Mrs. S has a history of dysphagia and aspiration, and is tending toward softer or liquid foods, the team may consider a speech consultation to assess her swallowing ability. If she has dentures, she may want a dental consultation because weight loss can contribute to ill-fitting dentures. Due to her history of depression coupled with her current lack of appetite and the contact isolation, I would recommend a behavioral health referral.
The team may consider adding a probiotic like Florastor to restore her gut flora, and vitamin C with the ferrous sulfate to aid absorption. If the ferrous sulfate is causing nausea, she may want to take it with food.
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 professional 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.