TO TREAT OR NOT TO TREAT: HOW CLINICAL CONUNDRUMS BECOME OPPORTUNITIES FOR

QUALITY IMPROVEMENTDaniel Bluestein, MD, MS, CMD

Sabine M. von Preyss-Friedman, MD, CMD

Ashkan Javaheri, MD, CMD

Irene Hamrick, MD

Learning Objectives:

By the end of the session, participants will be able to:

1.Articulate a framework for evaluation of weight loss, urinary tract infection, depression, & osteoporosis.

2.Summarize evidence for the pros and cons of double-sided therapeutic options regarding these entities.

3.Examine potential quality improvement opportunities in relation to these entities.

4.Discuss how the interdisciplinary team can be engaged in this process.

QI Caveats• Understand variation: Example; My trip from EVMS to WC• Is variation in rates within statistical limits?• Or did the process change?• Techniques for doing this beyond scope of this talk

• Recc workshop by Matt Wayne & Len Gelman at national meeting

• Understand the process• Flow charts• Fishbone diagrams• Pareto charts• MOST IMPORTANT

• Brainstorm w stakeholders• Don’t rush to judgment (or blame)

WEIGHT LOSS

Daniel Bluestein, MD, MS, CMD, AGSF

Professor & Director, Geriatrics Division

Department of Family & Community Medicine

Eastern Virginia Medical School

Case• On day on rounds, The team leader on 1-A tells me Ms. X

has lost 7 lb. over the past month (she’s 109 years old).• She shows you the dietician progress notes that Mirtazapine be

considered• Or if not Mirtazapine, then Megace or Marinol

My responses (a Parody of Kluber-Ross)• Denial-

• Is this for real

• Anger-• How could you all be so dumb

• Bargaining-• If I put Ms. X on something, maybe they will shut up & leave me alone

• Depression-• I need to go somewhere else

• Adaptation-• Maybe I can make this better

E/M: Like some relationships “It’s complicated”

Rx-able

E/M Overview1. Identify & anticipate at-risk pts (“SNAQ”)2. Are weights accurate?3. Is this fluid loss?

• Vomiting & diarrhea• Diuretics• Osmotic losses (hyperglycemia)• Inadequate access • Physiologic effects of aging

4. How much food is he/she taking in?5. Consider interventional strategies

• Condition specific• Generic

• Dietary supplements• Ambience/Assistance/Appeal• Activity & exercise• Drugs

Contributors: “the Ds”

1. Diseases-a) Hypermetabolic

• Thyroid• Pheochromocytoma• Diabetes

b) Wasting• Cancers• Collagen/vascular• infections• COPD• ESRD• Chronic infections• Pressure ulcers

2. Depression3. Dementia4. Digestive

a) Diarrheab) Dysphagiac) Other GI

5. Dysgeusia6. Dentition7. Drugs

• etoh

8. Deficiency states9. Dysfunction10.Distasteful Diets11.Don’t know

Huffman. Am Fam Physician 2002;65:640-50

The Ds in LTC• Depression• Drugs• Dysfunctions

• Dependent on others to feed (staff turnover, understaffed)• Isolation/poor ambience• Dysmobility

• Dysphasia• Dental/Oral • Dementia/agitation/sedation• Diseases-wounds, COPD, CHF…• Distasteful Diets• Deficiencies• Don’t know

Tamura et al. JAMDA 2013; 14(9):649-55Aoyama et al. JAMDA 2005; 6:566-72

Common Sense Treatment

• Treat underlying disease.• Endocrine, drug, GI disorder, depression most amenable.

• Functional• Dental care/dentures-oral hygiene• OT/PT/Speech/swallowing eval’ns• Hearing aides & glasses• Facilitate Bowel function• Exercise even in frail elders

• Dietary • Ambience• Assistance• Small, frequent meals• Taste facilitators

Supplements-conflicting evidence

• Some studies show 1-2 kg gains in supplement group vs. 1 kg loss in controls• Small sample sizes • 60 day f/u• No real changes in functional status

• Others: supplements substitute for meals, caloric intake the same• Should use between meals, not with

• Cochrane (2009): • Small increase wt• Small mortality reduction

• Morley et al. JAMDA 2010; 11: 391–6, varied JAMDA editorials• More sanguine about leucine-containing supplements in concert with

exercise

Drugs• Mirtazapine-

• small wt gain –up to 7% at best• ? any better than other antidepressants• ? Effect in non-depressed• Hyponatremia, sedation, orthostasis, serotonin syndrome

• Megestrol Acetate• Yeh et al RCT: 4 lb wt gain @ 25 wks; no mortality difference• DVT, CHF, Adrenal suppression, ↑mortality, large C/C study

• Dronabinol• Mostly small studies: 5-10 ib gain at best• MI, delirium, death

• http://www.uptodate.com/contents/geriatric-nutrition-nutritional-issues-in-older-adults?source=see_link&anchor=H20#H20

What I did• Read up on Dx & Rx of wt loss

• Went on “weight & wounds rounds” a few times • (Usually on a Tuesday AM when I can’t easily attend)

• Some findings:• Lack of real knowledge• Good intentions• External pressure• Organizational culture; other priorities• NO PROCESS• They are really not used to a hands-on medical director

My intervention• Educate & inform• Develop & implement a rational, step-wise policy, Elements:

• Screen for nutr risk -SNAQ or tool of your choice• When someone triggers on wt loss:

• Med review for new meds• PHQ 2/9• Note to provider to assess for other treatable causes as appropriate in

keeping with prognosis & philosophy of care• Implement of non pharmacological interventions• Reassess & consider

• Further evaluation on occasion• Risk/benefit ratio of drugs

• In process: Goal: • 1o: documentation this process has been followed• 2o: stabilization/improvement

It remains to be seen…• Whether this (& other QI measures discussed today)

improve care remains an open question at this time.

To Treat Or Not To Treat: How Clinical Conundrums Become Opportunities For QI

URINARY TRACT INFECTION OR

ASYMPTOMATIC BACTERIURIA?Sabine von Preyss-Friedman MD, CMD

Associate Clinical Professor, Division of Gerontology and Geriatric Medicine, University of Washington

Asymptomatic Bacteruria• Prevalence (without catheters)

• 25-50% for women • 15-40% for men.

• Prevalence (with Catheters)-100%

• Treatment does not improve outcomes

• Consequence: Frequent, unnecessary Abx• Cost• Resistance • C Diff• Adverse effects

• Drug Interactions (cipro-coumadin)• Inadvertent nephrotoxic doses (flouroquinolones, nitrofurantion)

• Missed the real problem

Nicolle LE. Int J Antimicrob Agents. 1999

On the other hand….• Non specific presentation of serious infection

• Dubious (or no) history in cognitive impairment

• True UTI & Urosepsis are alive & well • Symptomatic UTI: 0.1-2.4 episodes/1000 resident days (variation

due to differences in definitions). • Systemic infection: 0.49-1.04/10,000 noncatheterized-resident

days.

Problem, continued• Serious complications from infections

• Death from potentially treatable cause• Transfers • Functional decline

• LTC: • More limited diagnostic resources• Telephone medicine (e.g. “empirical” abx)

Grey areas• The febrile patient with a positive U/A or culture & no other

focus:• Only 10% of such patients show rise in serum antibodies to

infecting urinary pathogens.• Corollaries:

• Look hard for other reasons for fever• Consider other studies such as a CBC• Fever + hematuria does point more to UTI

• The patient who is acting “differently”• Typically more advanced dementia, can’t give History• Lots of other reasons to consider• If UTI the cause, will have fever

• Treatment? Guidelines would say no.

How are Practitioners making decisions? • 19 MDs, 3 PAs, 41 nurses. • 5 most common triggers for suspect UTI, noncatheterized

pts. • change in mental status (90%), • fever (76%), • change in voiding pattern (70%), • dysuria (65%), • Change in character of urine (59%)

• MDs, PAs significantly less likely to know or apply diagnostic criteria.• 55% would treat asymptomatic bacteruria

• Nurses more likely to urge treating asymptomatic bacteruria• See nonspecific changes in status as “symptoms”

• Juthani-Mehta et al. JAGS, 2005.

Why Antibiotic Overuse?

Lack of up to date Medical Education Ingrained beliefs of Medical Providers, Nursing, patients, families

Geropsychiatry ”Due Diligence”Fear of rapid deterioration and poor outcomes in frail elderly who have bacterial infection

Prior Criteria less than helpful• 2013 study of Loeb criteria (data collected 2011)

• Often disregarded• Even when taking into account, did not curb antibiotic use

• Olsho et al. JAMDA 2013; 14(4):309 e1-e7.

New McGeer Criteria, 2012• Fever Definition

1. A single oral temperature greater than37.8°C (100°F) or2. Repeated oral temperatures greater than37.2°C(99°F)or rectal

temperaturesgreaterthan37.5°C (99.5°F)or3. A single temperature greater than 1.1°C(2°F) over baseline from any

site.• Acute functional decline in activities of daily living (ADLs)

• A new 3-point increase in total activities of daily living (ADL) score (range, 0-28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence) Bed mobility,   Transfer, Locomotion within LTCF, Dressing, Toilet use, Personal hygiene, Eating

• Use of CAM to define acute change in mental status• Re. UTI-reliance on cx w appropriate symptom

combination (either alone is inconclusive)

UTI (No Indwelling Foley), Criterion 1,Need Both:

At least one of the following s/s: Acute dysuria or acute pain, swelling, or tenderness of testes,

epididymis, or prostate in men Fever or increased WBC and ONE of the following:

○ Acute costovertebral pain or tenderness○ Suprapubic pain○ Gross hematuria○ New or increased incontinence○ New or increased urgency○ New or increased frequency

No fever or increased WBC and TWO from the above list!

Criterion 2. One of the following microbiologic subcriteria:

• At least 100,000 cfu/mL of no more than 2 species of microorganisms in a voided urine sample.

• At least 100 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter

UTI with foley

For residents with an indwelling catheter (both criteria 1and 2 must be present): Criteria1 (at least 1 of the following signs/symptoms):•Fever, rigors, or new-onset hypotension, with no alternate site of infection.•Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis.•New-onset suprapubic pain or costovertebral angle pain or tenderness.•Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate

With foley, continued

Criteria 2. Urinary catheter specimen culture with at least:•100,000 cfu/mL of any organism(s).•Recent catheter trauma, catheter obstruction, or new onset hematuria are useful localizing signs that are c/w UTI but are not necessary for diagnosis.•Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for >14 d).

interventions

Inservices about UTI vs. ASB to nursing staff

Medical Director provides attending physicians with literature and personal education and discussion

Medical Director inservices psychiatric consultants

• “MD compare”

• Protocols based on McGeer Criteria for when it is appropriate to order a U/A

Alternatives to Rx for grey areas• Examples:

• Isolated voiding symptoms, • increased incontinence, • change in urine odor, • change in behavior…

• Watchful waiting for 24 hours• No u/a or c/s• Hydrate• Perineal hygiene• Address constipation• Attend to comfort• Q 8 VS

• Evaluate for UTI if go on fulfill criteria• Look for alternatives if sx persist

It remains to be seen…• We still lack a convincing

marker for UTI vs. colonization in advanced dementia.

• Sx to meet minimum criteria for UTI frequently absent in NH residents w advanced dementia.

• Abx are prescribed for the majority of suspected UTIs that do not meet these minimum criteria

• D’Agata et al. JAGS 2013; 61(1):62-6

To treat or not to treat:How Clinical Conundrums become

Opportunities for Quality Improvement Depression

Ashkan Javaheri, MD, CMDAssistant Clinical Professor- UC Davis School of Medicine

Geriatric Division and Senior Care ProgramDivision Head

Mercy Medical GroupSacramento, CA

Overview• Prevalent

• Treatable

• Often under-recognized

Chronic Medical Illness and Depression

Stroke 30 to 60 %Coronary heart disease 8 to 44 %Cancer up to to 40 %Parkinson’s disease 40 % Alzheimer’s disease 20 to 40 %

Boswell  EB, Stoudemire  A.  Major depression in the primary care setting.  Am J Med.  1996;101:3S–9S

Consequences• Decreased quality of life• Decreased participation in activities• Falls• Malnutrition• Dehydration• Increased risk of intercurrent infections• Behavioral symptoms• Agitation• Rejection of care

04/21/23

Suicide• Elderly 13% of US population; 24% of completed suicides • Less often; more likely successful

• Elderly men highest suicide rate: 28.9/ 100,000.

• Yes it can happen in LTC

04/21/23

Trends-LTC (1999-2007)• Diagnosis of depression and antidepressant therapy in

residents diagnosed increased rapidly.

• By 2007, 51.8% of residents diagnosed with depression, 82.8% of whom received an antidepressant.

• Gaboda D et al. JAGS 2011; 59:673–680

04/21/23

Underuse/ Overuse 3692 LT residents in 133 VA facilities 877 depressed 25.4 % did not get treatment underuse 57.5% potential inappropriate use

drug-drug and drug-disease interactions

2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants

Hanlon JT - J Am Geriatr Soc 2011

Not as safe as we once thought

SSRI safer than older drugs, still first choice

SSRIs have side effects; Falls, hip fracture, insomnia, hyponatremia GI bleeding, worsen RLS, serotonin syndrome

Evidence Base

Available evidence offers weak support to the contention that antidepressants are an effective treatment for patients with depression and dementia and at best moderate evidence in non demented patients.

It is not that antidepressants are necessarily ineffective but there is not much evidence to support their efficacy either.

Given that they may produce serious side-effects clinicians should prescribe with due caution.

Cochrane Database Syst Rev. 2002 Hanlon et al, J Am Med Dir Assoc 2012 Boyce et al, J Am Med Dir Assoc 2012

Why-depression a mixed bagMedical causesMajor DepressionMinor Depression (or Subsyndromal)DysthymiaBereavementVascular DepressionPsychotic DepressionDepression in AD

Thakur M, Blazer D, J Am Med Dir Assoc 2008

Medical conditions associated with depression symptomsUncontrolled pain MedicationsAlcohol and substance abuseThyroid disease Anemia (B12)Electrolyte abnormalities & organ failures (Cancers)

Major Depression DSM-IV• Symptoms for > 2 weeks• 5 or more symptoms• At least one should be

• Depressed Mood• Anhedonia (lack of interest or

pleasure)

• Meds retain utility here• Mild; 5% superior to placebo (46-

41%)• If major, severe, or prolonged

depression, 27% superior (58%-31%)

• Nelson et al. Am J Psychiatry, 6-13

• Other symptoms • Significant weight loss or weight gain

(more than 5%)• Insomnia or hypersomnia• Psychomotor retardation or agitation• Fatigue or loss of energy• Feelings of worthlessness or

excessive or inappropriate guilt • Diminished ability to think or

concentrate, or indecisiveness, nearly every day 

• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

AND

Subsyndromal Depression/Dysthymia

One of core symptoms (depressed mood / anhedonia) plus 1 to 3 (other) symptoms

Depression without sadness in elderlyRisk factor for Major DepressionFor > 2 weeks => chronicAssociated with

Poorer health and social outcomes Functional impairment Higher health utilization and treatment costs

Not very responsive to drugs in younger populationsRole for non-pharmacological therapies

Bereavement• Usually time-limited

• Behavioral treatments, support groups treatments of choice• Now indications for meds if bereavement triggers major depression

• Likewise for complex or protracted bereavement

• Simon NM. JAMA 2013; 310(4):416-23.

Psychotic DepressionSubtype of Major DepressionDepression with delusions (somatic and persecutory)/

hallucinationsCommon in elderly

Especially inpatient and long-term setting

ECT

Vascular Depression (subcortical ischemic depression)

Ischemic changes are detected with MRIHigher prevalence in patients with vascular dementia20%- 50% of patients develop depression within 1st year

after strokeLeft hemisphere more chance of depressionAssociated with more cognitive impairment and disability,

more psychomotor retardation, less agitation, less guilt, and less insight into their illness 

Some may have “silent stroke” No consensus of diagnosis Response to drugs?

Apathy

Ishii S et al. Apathy: A Common Psychiatric Syndrome in the Elderly. JAMDA 2009; 10: 381–93.

Other considerations• Short vs. Long-term residents

• Seasonal variation

Screening for depression• The USPSTF recommends screening adults for

depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.Grade: B recommendation.

• The USPTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient.Grade: C recommendation.

ToolsGeriatric Depression Scale (GDS)

www.stanford.edu/~yesavage/GDS.html GDS-15: sensitivity 84%, specificity 85.7%

Limm PP et al, Int J Geriatr Psychiatry 2000

Cornell Depression Scale http://img.medscape.com/pi/emed/ckb/psychiatry/285911-13353

00-1356106-1392041.pdf sensitivity 93%, specificity 97% with a cut-off value of ≥6

for patients with dementia

PHQ-2/9

PHQ-9• Total Score Depression Severity• 0-4 None• 5-9 Mild depression• 10-14 Moderate depression• 15-19 Moderately severe

depression• 20-27 Severe depression

• Score >10 has 88% sensitivity and specificity for major depression diagnosis

• Part of MDS 3.0• May be disconnect between MDS

process & clinical care

Evaluation and Treatment of Depression is team work! CNAs Nursing staff and MDS coordinator Dietary Activity staff Pharmacists Social Workers

MDs, NPs, and PAs Psychologist Psychiatrists Therapy staff (PT/OT/ST) Patients Families

Who should be part of the team?

Who is the champion?

What is done with positive screens?

Process• Create a team• Identify champion• Identify residents with PHQ-9

scores above 5 and 10• Create communication system

• Screener RN clinician RN/ Team

• Clinician may make the diagnosis• Behavioral consultant • Care plan (all team members

should be involved)

• Tailor therapies: Danger to self Prior history of depression Psychotic symptoms Any past treatment(s)

• Monitor PHQ-9 score in response to therapy

• Alternate and adjust you care plan as you move forward

• Meet regularly and review data

Further considerationsAccurate assessment

Match variant to therapy Psychologist or psychiatrist in some cases

May try empirical SSRIs Drug

Safety Side effect profile for therapeutic advantage Avoid drug interactions

Dose Duration Assess response-serial PHQ-9s

How about other disciplines? Activities, …What if treatment fails?

American Medical Directors American Medical Directors Association Association Long Term Care Long Term Care MedicineMedicine

To Treat or not to treat: How clinical conundrums become opportunities for QI

Osteoporosis in Frail Osteoporosis in Frail LTCLTCPatientsPatients

Irene Hamrick, MDIrene Hamrick, MDihamrick@wisc.edu

Your thoughts? Clinical Your thoughts? Clinical & QI& QI 97 year old bedbound patient 97 year old bedbound patient

sustains femur fracture during sustains femur fracture during diaper changediaper change– admitted to Nursing facility area of admitted to Nursing facility area of

CCRC 2 years ago after strokeCCRC 2 years ago after stroke

Family is outraged and demands Family is outraged and demands to know how this could happento know how this could happen

To not treat…To not treat…

Do tools for screening in younger populations apply Do tools for screening in younger populations apply here? here? – Bone Density measures, practical?Bone Density measures, practical?– FRAXFRAX

Side effects of antiresorptivesSide effects of antiresorptives– Esophageal erosionsEsophageal erosions– Renal issuesRenal issues

Safety & practicality of administrationSafety & practicality of administration Paradoxical outcomesParadoxical outcomes

– Jaw necrosisJaw necrosis– Atypical fracturesAtypical fractures

? Benefit during lifetime? Benefit during lifetime Limited evidence for bisphosphonatesLimited evidence for bisphosphonates

Or Treat?Or Treat?

Not doing so can lead to bad Not doing so can lead to bad outcomes as in this instanceoutcomes as in this instance

In LTCIn LTC– Prevalence O/P 85% Prevalence O/P 85% – Rate of osteoporotic fractures 11%/yr in Rate of osteoporotic fractures 11%/yr in

NH vs. 2-3% in community. NH vs. 2-3% in community. – Nursing home residents who suffer Fx, Nursing home residents who suffer Fx,

any site-15 fold increase in any site-15 fold increase in hospitalizationhospitalization

Vertebral FxVertebral Fx

back pain, back pain, dysphagia, dysphagia, kyphosis, kyphosis, reduced pulmonary function, reduced pulmonary function, diminished quality of life. diminished quality of life. Narcotic side effectsNarcotic side effects Vertebroplasty/Kyphoplasty?Vertebroplasty/Kyphoplasty?

Osteoporosis & StrokeOsteoporosis & Stroke

Hip fracture increased 2 to 4 Hip fracture increased 2 to 4 times in stroke patients over age-times in stroke patients over age-matched reference population, matched reference population, especially in 1especially in 1stst year after stroke year after stroke

82% on hemiplegic side82% on hemiplegic side 84% due to falls84% due to falls

Ramnemark A et al. Ramnemark A et al. Osteoporos IntOsteoporos Int. 1998;8:92–95.. 1998;8:92–95.

Kanis J, et al. Kanis J, et al. StrokeStroke. 2001;32:702–706.. 2001;32:702–706.

Chiu KY, et al. Chiu KY, et al. InjuryInjury. 1992;23:297–299.. 1992;23:297–299.

QuestionQuestion

How soon after stroke is most How soon after stroke is most bone lost in the paralyzed side?bone lost in the paralyzed side?a)a) 4 weeks4 weeks

b)b) 4 months 4 months

c)c) 1 year1 year

d)d) 4 years4 years

Bone Bone Loss Loss after after StrokeStroke Bone loss most severe in first 3-4 mo.Bone loss most severe in first 3-4 mo.

– Upper extremities Upper extremities ↓↓ by 9.3% (P = 0.01) by 9.3% (P = 0.01) – Lower extremities Lower extremities ↓↓ 3.7% (P = 0.01) 3.7% (P = 0.01) Hamdy 1995 Am J Phys Med Reh 74;351-6

GuidanceGuidance

Consider Rx for Consider Rx for – clinical hip or spine fracture, clinical hip or spine fracture, – radiological evidence of a VF, radiological evidence of a VF, – BMD data if available. BMD data if available.

Since O/P Rx demonstrate Fx Since O/P Rx demonstrate Fx reduction in ~ 1 year, do not use reduction in ~ 1 year, do not use if < 1 year life expectancy.if < 1 year life expectancy.

Greenspan et al. JAGS 2012; 60(4):684-90

CA + DCA + D

Cochrane review-reduction of hip and nonvertebral fractures Cochrane review-reduction of hip and nonvertebral fractures when vitamin D and calcium were taken together.when vitamin D and calcium were taken together.– subgroup analysis benefit most significant in institutionalized subgroup analysis benefit most significant in institutionalized

personspersons– Avenell et al. Cochrane Database Syst Rev 2005;3:Avenell et al. Cochrane Database Syst Rev 2005;3:– CD000227.CD000227.

Feb 2013 USPSTF did not endorse but did not engender LTC Feb 2013 USPSTF did not endorse but did not engender LTC residentsresidents

Ca side effectsCa side effects– ConstipationConstipation– Ca-carbonateCa-carbonate– Ca-citrateCa-citrate– Binding effectsBinding effects

? Vit D levels vs. empirical supplementation? Vit D levels vs. empirical supplementation Uncouple Ca & DUncouple Ca & D

Evidence for Evidence for Bisphosphonates in LTC Bisphosphonates in LTC admittedly thinneradmittedly thinner alendronate (10 mg po qd) vs. placebo in elderly alendronate (10 mg po qd) vs. placebo in elderly

women in LTC w O/Pwomen in LTC w O/P– alendronate increased BMD in both spine and alendronate increased BMD in both spine and

femoral neck femoral neck – good tolerance, good tolerance, – incidence of Fx lower in alendronate group but did incidence of Fx lower in alendronate group but did

not reach statistical significance not reach statistical significance limited # participantslimited # participants short follow-up.short follow-up.

Greenspan et al. Ann IM Greenspan et al. Ann IM 2002; 136(10):742-6.2002; 136(10):742-6.

Extrapolate from less frail pop’nsExtrapolate from less frail pop’ns Bisphosphonates post hip fx reduce recurrencesBisphosphonates post hip fx reduce recurrences

QI ramificationsQI ramifications

Identify patients with a diagnosis of osteoporosisIdentify patients with a diagnosis of osteoporosis Consider 2o causes if appropriateConsider 2o causes if appropriate Look for risk factorsLook for risk factors

Assess if all patients in facility who have Assess if all patients in facility who have osteoporosis are treated or have a documented osteoporosis are treated or have a documented reason for no treatment reason for no treatment

Recognize impact of immobilityRecognize impact of immobility Engage the IDT for suggestions re diet, Engage the IDT for suggestions re diet,

weightbearing, sun exposureweightbearing, sun exposure Pharmacy review Pharmacy review

– Vitamin D and Calcium on MARVitamin D and Calcium on MAR– Minimize interactions Minimize interactions – Correct administration of other Osteoporosis medsCorrect administration of other Osteoporosis meds

ConclusionConclusion

Vitamin D 800-1000 IU daily, Vitamin D 800-1000 IU daily, higher in deficiencyhigher in deficiency

Calcium 500-600 mg twice daily if Calcium 500-600 mg twice daily if inadequate dietary intakeinadequate dietary intake

Discuss high fracture risk, Discuss high fracture risk, additional medication treatment additional medication treatment with familywith family

In parting… Don’t get mad or despair-get creative Keep up with developments & best practices Goals are care processes rather than clinical outcomes Engage the team Be persistent