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Caring for the Resident with Complex Medical Needs in Assisted Living

      Mr. P is an 89-year-old Black man who transitioned to assisted living after an acute hospitalization for pneumonia and then a short stay in post-acute care for therapy and to stabilize his chronic medical problems. Before that time he had been living independently, but he was hospitalized three times over the past year due to exacerbations of congestive heart failure and his underlying restrictive pulmonary disease (COPD). His additional medical history includes hyponatremia, chronic kidney disease, and anxiety. His current medications include albuterol sulfate HFA 1 inhalation, three times a day; bumetanide at 2 mg daily; carvedilol at 3.125 mg by mouth, twice daily; clonidine 0.3 mg/24 hours as a transdermal patch each week; Eliquis at 2.5 mg by mouth, twice daily; Flomax at 0.4 mg by mouth daily; Lipitor at 80 mg by mouth daily; losartan potassium at 50 mg by mouth daily; mirtazapine at 15 mg by mouth daily; montelukast as a 10 mg tablet taken by mouth daily; Mucinex at 600 mg, two tablets twice daily; pantoprazole at 20 mg by mouth daily; Plavix at 75 mg by mouth daily; and vitamin D, 1,000 units by mouth daily. In addition to primary care, he is followed closely by cardiology and pulmonology providers.
      Mr. P takes his blood pressure (BP) and checks his weight several times a day. For minor fluctuations, including cough, dizziness, and fatigue, he insists on being seen by the nurse and a practitioner. He prefers to remain in his apartment, and he spends time reading and talking with his son and grandchildren on the telephone. He reports enjoying the meals, and his son brings his favorite foods as well. Cognitively Mr. P scores a 30/30 on a Mini Mental Status Exam, and he is able to make all his own medical decisions. He easily engages with staff and expresses appreciation for the care they provide. His medical care is complex and requires frequent oversight, but the staff report that the frequency of his requests has been high, which is making it difficult for them to meet the needs of other residents.

      Attending Provider

      Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD
      Dr. Hector is a Tucson-based physician with over 30 years of medical director experience.
      As part of any geriatric patient’s history, I inquire about their past occupation, their habits when they were younger, and their family, goals, and concerns to learn more about the individual person and what is most important. What are Mr. P’s favorite foods? Does he prefer sweet or savory treats? I also learn about the patient’s immunization beliefs and code status. As a Black man, does Mr. P have fears or concerns about potential bias in his treatment?
      If Mr. P wants to measure his own BP and weight often, teach him that it will vary and give him parameters: for instance, his systolic BP should be >144 more than twice in a row, with longer than 30 minutes between readings, before he should sound an alarm. Give him a job as his own data gatherer and provide specific assignments: BP taken with both feet on the floor, with a BP cuff on his arm and not his wrist, and after resting 5 minutes. Other parameters for when he should notify the staff and his practitioner might include a weight gain greater than two pounds on two consecutive days, measured at the same time each day. Create visual reminders of these parameters, and post them where he will see them. Recognize his success in following the notification parameters as a way to reinforce desirable actions.
      It’s true that information is power, so I would share with him on each visit his “numbers” from the laboratory values and progress notes from the specialists. I would minimize the medical jargon and show him that I’ve received his information. I would inquire whether he has questions or concerns.
      To help diffuse Mr. P’s anxiety, perhaps there are ways to involve him in the community milieu as an organizer, rather than merely as a participant. He could be approached by staff with “I could really use your help with this, Mr. P.” Given his diagnoses and current medication regimen, I would discuss the potential benefits and risks of low-dose clonazepam to help his anxiety and lower the demand on his heart. To anticipate the need and Mr. P’s level of stress, his provider visits should be scheduled for more often than usual in the beginning; the frequency of these visits can be gradually tapered off, along with an explanation of why.
      The 80 mg of Lipitor is too high a dose for someone his age: cut it in half. Explore whether the cardiomyopathy is due to coronary artery disease and whether he benefits from Plavix. Is two 600-mg tablets of Mucinex twice a day too much? Mr. P is at the maximum adult dose on this, and dizziness and fatigue can be side effects of the Mucinex. If we changed his losartan, he might not need Mucinex for his cough — or maybe he just needs less Mucinex.
      Mr. P’s basic metabolic panel may need more frequent monitoring. The hyponatremia may be due to his powerful diuretics, his anxiety, or both. Is he really benefitting from a sodium-restricted diet, considering his congestive heart failure with the low sodium? Consider a chest X-ray if he hasn’t had one recently. With his restrictive lung disease, does he need scheduled albuterol or incentive spirometry? I would review his weights over several months’ time and not just a few data points.
      Certainly, if all of this does not improve Mr. P’s situation (and even if it does), a palliative care consultation might be weighed as an option and an educational opportunity, and discussed with Mr. P and his family.

      Pharmacist

      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.
      The following recommendations for Mr. P come from the rounding perspective of a pharmacist:
      • 1.
        Respiratory regimen. Albuterol sulfate HFA 1 inhalation three times a day is not an ideal treatment in light of the fact that it is a beta-agonist and Mr. P is taking a beta-blocker (Carvedilol) — this could be aggravating his anxiety. Furthermore, he has COPD, so he needs to be on a maintenance therapy such as a long-acting muscarinic receptor antagonist (LAMA) tiotropium bromide (Spiriva Respimat), which is administered only once per day. Also, it needs to be clarified why he is taking both montelukast (10-mg tablet by mouth daily) and Mucinex (600 mg, 2 tablets twice daily); both could be increasing his pill burden without much effectiveness. Furthermore, LAMA therapy could reduce the need for Mucinex.
      • 2.
        Heart failure regimen. Mr. P currently takes 2 mg of bumetanide daily; 3.125 of carvedilol by mouth twice daily; clonidine at 0.3 mg/24 hours as a transdermal patch each week; and 50 mg of losartan potassium by mouth daily. Is there a compelling indication for the 80 mg of oral Lipitor daily and at this dose? Also, it might be possible to optimize the losartan and carvedilol to reduce the need for clonidine patches.
      • 3.
        Anticoagulation. It is not clear why Mr. P is taking both 2.5 mg of Eliquis by mouth twice a day and 75 mg of Plavix by mouth daily. This needs to be clarified and /or addressed from the deprescribing perspective.
      • 4.
        Additional medications in need of clarification. The rationale for the use of the following medications needs to be clarified: Flomax, 0.4 mg by mouth daily; mirtazapine, 15 mg by mouth daily; pantoprazole, 20 mg by mouth daily; and vitamin D, 1,000 units by mouth daily. Whether all these are currently indicated must be discussed.
      Reevaluating Mr. P’s medication needs and indications may help to improve his quality of life and function as well as reduce the burden on both him and the staff.

      Director of Nursing

      Judi Kulus, MSN, MAT, RN, NHA
      Ms. Kulus is the Chief Nursing Executive at Lantis Enterprises.
      Mr. P’s care can be challenging if the nursing staff do not take time to organize his care and medication regimen. If the number of times per shift and the timing of his calls for nursing care are difficult to manage, it would be useful to evaluate how the timing of his calls relates to the expression of his symptoms and his medication regimen. It also might be helpful to take a few days to track the times nursing is called to his room and the reason for the calls. Are there are any patterns that could identify gaps in medication effectiveness, increased symptoms, or changes in mood? Does he have increased dizziness after taking a certain medication? Can his fatigue be predicted? Evaluating the timing and nature of his care needs can help nursing anticipate when he is likely to need help, which can then be more effectively planned for.
      Another consideration is how effectively nursing has instructed Mr. P on what to do when he experiences abnormal signs and symptoms. Providing him with clear, written, posted instructions regarding the management of his weight and blood pressure changes is essential to helping him cope with his comorbidities. Because his family is highly involved in his care, enlist their help to encourage Mr. P’s continued independence and self-management of his conditions. Perhaps the family can be encouraged to visit during his times of increased anxiety.
      Finally, have routine care conferences with Mr. P and his family to discuss his health care management and goals. Discuss ways to improve his quality of life and promote his safety while optimizing use of health care services.

      Social Worker

      Paige Hector, LMSW
      Ms. Hector is a social work expert and a coeditor of this column.
      Habitually our instinct is to try to “fix” a situation — to figure out a way to help Mr. P feel comfortable with his care and to shift some of the staff’s time spent with Mr. P to meeting the needs of other residents. We are socialized to react or respond immediately, especially in health care; the traditional medical model with its focus on problems is ingrained in our everyday interactions. Instead, using the principles of nonviolent communication (Caring 2021;22[3]:19), I will approach this situation by focusing on Mr. P’s feelings and needs.
      One of our basic human needs is to connect with other people, which includes being seen, being heard, and being understood. With a lens of curiosity and the intention to connect with Mr. P and the staff, I’ll seek to learn more about everyone’s feelings and needs before we explore solutions.
      I would start by guessing what Mr. P might be feeling and needing by using this sentence: “Are you [insert a guess for a feeling] because you need/want/would like [insert a guess for an unmet need]?” For example, “I’m wondering if you feel scared because your blood pressure and weight vary, and you would like reassurance that you’ll receive prompt medical attention.” Or, “Would you like to feel confident that if your medical condition changes you’ll receive prompt attention?” In this second example, the need might be for trust, reassurance, or predictability.
      Guessing correctly is not important. Take your best guess, and check it out with the individual. If Mr. P doesn’t identify with that feeling and need, he’ll let you know — which will help you both approach clarity.
      In the same way, I would also engage with the staff to better understand their feelings and needs in relation to Mr. P. I could ask a caregiver, “Are you overwhelmed and would appreciate more order in your day so that you can care for all the residents?” Or, “Are you frustrated at the amount of time being dedicated to Mr. P because you need to find balance to care for the other residents?”
      Once there is clarity around what everyone is feeling and needing, the path to a solution (known as a strategy) can be explored. If Mr. P is feeling scared or not confident, and he needs reassurance and trust, and if the staff are feeling overwhelmed and frustrated because they need more order and stability in their daily workflow, how might everyone’s needs be met? It’s not about compromising or negotiating but rather about meeting everyone’s needs. They are not mutually exclusive!
      One of Mr. P’s strengths is the involvement and support of his family. I would involve them in this process because they will likely be instrumental in achieving clarity and implementing a strategy to support everyone. Also consider Mr. P’s other strengths — for example, perhaps his career or work experience could lend itself to his current situation. Was he in a leadership position? If so, how would he have supported an employee who needed reassurance on the job? Is it possible to blend his life experience with his current life situation and build his resilience?
      It may take some practice with this approach to appreciate how the time spent upfront to engage with empathy and to understand everyone’s feelings and needs has the potential to actually save time later on.

      Summary

      Mr. P has a complex medical history that is likely impacting his emotional well-being. He is actively involved in his care, but there are times when the staff find managing the frequency of his requests difficult while meeting the needs of other residents in the community. The interdisciplinary team’s recommendations optimize Mr. P’s complex medication regimen and engage him and his family in structuring his care in a way that meets his needs — both emotional and medical — as well as those of staff and other residents.
      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. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.
      • Enlist Mr. P as a data gatherer and reporter with clearly established parameters for his BP and weight.
      • Review the need for and appropriateness of all his medications to consider options for deprescribing.
      • Explore his feelings, which are directly related to needs and can help clarify possible strategies.
      • Establish a better sense of his daily schedule and care needs to match nursing visits with those needs.
      • Increase his family’s involvement and support.
      • Encourage him to engage in meaningful activities outside of his apartment.