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Caring for the Ages
Selected Articles from
September 2004;
Vol. 5, No. 9
Meta Docs Invade LTC
Medicare Beneficiaries Slow to Opt for Drug Discount Cards
No Parallel Gifting Policies
Quality, Access Problems Driving Physicians from LTC
Research 101
The Quality Quandary
NFID Call to Action
Balancing Act
AMDA's Mental Health Workgroup Offers Advanced Workshop
Let's Get Together
ACE Inhibitors Underused in Heart Failure Patients
Palliation Issues in LTC
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Balancing Act

Identify the source of presenting symptoms & prevent further neurologic damage to maximize function in older adults. Second of a two-part series

by Andrea M. Sattinger

A number of neurologic disorders are seen in long-term care patients. In addition to dementia this list includes stroke, Parkinson's disease, progressive supranuclear palsy (Parkinson's disease with additional features), peripheral neuropathies, amyolateral sclerosis and multiple sclerosis. These can result in impairments of cognition, mobility, and other forms of musculoskeletal incompetence (i.e., spasticity, incontinence, and balance and gait disturbances), drooling/difficulties in swallowing (dysphagia), mental health disorders (especially depression), and sleep complications and fatigue. Pain is also a ubiquitous problem.

In older adults, concomitant illness and polypharmacy present risks for reduced quality of life. This patient population rarely--if ever--struggles only with a degenerative neurologic disorder. As a result, they take medications for their primary neurologic disorder, as well as to treat their other conditions. Understandably, concomitant illness can exacerbate a patient's neurologic disorders.

An additional complication is that many drugs commonly prescribed for primary neurologic disorders are contraindicated in older adults. Whether a particular symptom results from the effect of a disease or a drug--or both, identifying the source of the symptom remains paramount to ensure the patient's quality of life.

The specifics of drug dosing and administration for neurologic disorders commonly seen in long-term care have been treated elsewhere.1-10 In this article we address how to identify the source of presenting symptoms--be it disease-related or drug-related--and discuss methods to prevent further neurologic damage and to maximize function in older adults.

Goals of Care

Physicians can explain to patients (if they are able to understand) and their families that because they have multiple illnesses in addition to their neurologic disorder(s), the primary intention is to prevent further damage from their neurologic problem and manage function and quality of life the best way possible. As covered in part 1 of this series (see August 2004 Caring, p. 22), designing care goals for a patient with a neurologic deficit is essential. Evaluating the safety/efficacy profile of any drug must involve taking into account the goals of both patient and provider.

The Disease or the Drugs? Consultants Can Help

Consulting pharmacists and other specialists can help distinguish the cause(s), and therefore the solution, to drug-versus-disease questions.

In long-term care, because so many older patients also have dementia "if they start having hallucinations and delusions, it is hard to tell if it is from the dementia or from the Parkinson's or it could be from a combination of both disorders [or from the drugs they're receiving to treat either or both conditions]," said Marek.

In these cases, he recommends sending patients to see their original neurologists or psychiatrists. "You can reach a plateau with the doses where you're not going to increase the [patient's] physical functioning, but you have a greater increase in side effects or interactions."

The prescribing specialist can help the physician think about drug effects separately from disease effects. This is an excellent resource for those physicians who are locked into a prescribing regimen.

--AS

Symptom Management

Neurologic disorders frequently seen in long-term care have a number of common symptoms. Among them:

Spasticity: This symptom is common to many neurologic disorders and can be a significant cause of disability. If patients suffer from a lack of muscular control and spastic attacks, all other activities of daily living can become difficult and quality of life is severely impaired by a lack of independence. Therefore, drugs to minimize spasticity are critical in a regimen to maximize function.11

Because of the other drugs these patients are typically taking, many drugs commonly used for spasticity cannot be used in long-term care. Drug choices for older adults are more limited than those available for younger adults.12 Most antispasmodics are poorly tolerated by older adults. However baclofen and dantroline can be used as oral agents. While not a curative agent, baclofen can relieve spasticity enough to accommodate physical therapy, which can then greatly affect movement.13 Its risks include drowsiness, nausea, headache, muscle weakness, and light-headedness. Exercise caution when reducing or stopping long-term baclofen treatment.

In long-term care, where many patients already have dementia and impaired cognition, spasticity drugs are often sedating and can lead to agitation, lethargy, falling, and so on. Use spasticity drugs judiciously. Treating physicians must be well informed about side effects of spasticity drugs and about the drugs that their patients are already taking.

"The antispasmodics cause anticholinergic side effects like dementia, delirium, and confusion," said Joseph G. Marek, RPh, clinical geriatric pharmacist with Omnicare in Perrysburg, Ohio. "So if [a resident is] on one of those, it's a risk versus benefit assessment that we ask of the physicians."

Anticholinergic drugs are contraindicated in patients who have glaucoma, obstructive uropathy, gastrointestinal motility disorders, and myasthenia gravis.14 Because of anticholinergic sides effects, said Marek, it is essential to perform thorough and ongoing assessments.

Difficulty in swallowing (dysphagia): The literature suggests that 40% to 60% of nursing home patients experience some degree of difficulty swallowing.15 Many neurologic disorders produce dysphagia, and many drugs can also cause this problem. These drugs specifically include typical antipsychotics (e.g., clozapine, where the swallowing dysfunction is associated with drug-induced Parkinsonism and tardive dyskinesia--or both).

To differentiate between symptoms from the disorder and those that are drug-induced, carefully check the patient's history and conduct a swallowing evaluation, interview staff familiar with the patient's normal behavior, reduce or eliminate any drugs that can cause swallowing difficulty, regularly watch for symptom progression and, if possible, change prescriptions with careful titration.

Antihistamines and scopolamine are used for dysphagia in older adults due to degenerative neurological disorders. The side effects of these drugs may include urinary retention, blurry vision, rapid heartbeat, raised intraocular pressure, restlessness, irritability, and mental confusion.

Depending on the dose, it may also stimulate or depress the brain. Because the scopolamine patch comes only in one dose and cannot be cut, its use in the frail elderly and in small women may be limited. Side effects include irritated skin surrounding the patch as well as drowsiness, blurred vision, and dry mouth.

Long-term care patients are already at risk for esophageal mucosal damage and dysphagia because they may often be 1) lying down during drug administration, 2) taking multiple medications, or 3) unable to take enough fluid to swallow medication. A nasogastric tube may also cause esophageal spasms or irritability.

In addition, older adults often take certain high-risk medications, such as bisphosphonates and nonsteroidal anti-inflammatory drugs. And esophageal motility and saliva production decline with age. Finally, many older adults with neurologic disorders have pre-existing esophageal or swallowing disorders that may increase the likelihood of iatrogenic esophageal injuries.

In general, patients should be as upright as possible during drug administration and remain so for at least five to 10 minutes afterward. Pharmacists can play a pivotal role by identifying situations where there may be a higher likelihood of drug-induced dysphagia or esophageal injury and can recommend preventive and treatment strategies. (See also, "Evidence-Based Practice in LTC: The Facts about Dysphagia & Swallowing Studies," February 2003 Caring, p. 17.)

Excessive salivation (sialorrhea) & drooling: Drooling presents another distressing complication for people with neuromuscular diseases. In general, "the problem is not that they're making too much saliva, although that is the way it appears to the patient," said Jeffrey Rosenfeld, MD, chief of the division of neurology for the Carolinas Medical Center and director of the Carolinas Neuromuscular/Amyolateral Sclerosis Center in Charlotte, N.C. "They're drooling, and it's pooling. The problem is that they're not moving the saliva that they're making. All of the [available] treatments [cut] down the production of saliva, and it does work, but it works for a secondary reason."

It's important to seek causes of excessive salivation and drooling; for example, medications such as metoclopramide that affect the extrapyramidal nervous system. Treatments commonly prescribed for drooling in other populations include anticholinergic medications, such as glycopyrrolate (Robinul), atropine, and transdermal scopolamine. However, glycopyrrolate is not well tolerated in the elderly because of its anticholinergic side effects. Atropine is rarely used in long-term care because it can lead to dangerous anticholinergic side effects such as delirium and high fever.

Another treatment for drooling in the absence of a treatable cause is L-hyoscyamine (Levsin), which can also serve as an anticholinergic/antispasmodic. Levsin is given for Parkinson's disease to help reduce muscle rigidity and tremors and to help control excess sweating. It is contraindicated in those with kidney disease and has limited use in those with liver disease. Levsin must also be limited to short-term use because it is highly anticholinergic.16

Depression: Depression and anxiety commonly present in neurodegenerative diseases and often result from the diseases themselves. These symptoms are also caused by a number of drugs administered for neurologic and other disorders. Thus, long-term care patients require individually tailored care plans.

"Depression is a chronic disabling disease, and even if a person appears to be coping well--that is, trying their best, generally speaking--life as they live it is not exactly how they envisioned it," said Dr. Rosenfeld, who works with ALS patients. "That dissonance between what they might have hoped for themselves and what they actually are experiencing can result in a depression that I call 'sub-clinical' depression. That's my word. Meaning they're not lying in bed unable to be motivated to do anything or have obvious clinical depression signs, but they have a certain affect that may be under the surface [and that] is most definitely affecting them."

Providers must be vigilant about detecting depression in long-term care patients. In a two-year study of 3,410 community-dwelling elderly, depressive symptoms were not diagnosed in 50% of them, and depression is even more severe a problem in long-term care, especially with those who are newly admitted. Signs and symptoms may also present differently in older adults.17 Older men are especially at risk for underdetection.

A 2003 study by Watson, et al reported on depression in 2,078 residents from 193 assisted-living facilities in four U.S. states. Residents ranged in age from 65 to 112 years, and 52% were age 85 or older. Investigators measured medical comorbidity by asking residents or their informants to confirm the presence or absence of 31 medical conditions. The Minimum Data Set-Activities of Daily Living (MDS-ADL) scale was used to measure ADLs. Also measured were agitation, social withdrawal, and antidepressant use. Most of the predominantly female sample had multiple medical problems (52% had five or more), with a range from 0 to 15. Thirty-one percent were rated dependent in three or more ADLs, and more than one-half had some level of cognitive impairment.18

Differentiating symptoms of depression stemming from the neurologic disorder as opposed to drug-induced symptoms is a challenge in the elderly. The basic assessment is to check Cognition, Affect, and Psychosis (CAPS). Distinguishing affect involves evaluating for Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor disturbance, and Suicidal intentions (SIG E CAPS is suggested as a mnemonic acronym by Daniel J. Hurley, MD, clinical associate professor of medicine at Indiana University).17 In addition to patient evaluations, physicians should interview staff and family members to evaluate what other factors may be contributing to the patient's mood.

Other conditions that might exacerbate depression in older adults include schizophrenia and other psychiatric disturbances, alcoholism, metabolic disorders, infections, trauma, and medications (including antihypertensive drugs, sedatives, steroids, stimulants, and antipsychotics). It is also important to consider that depression can lead to cognitive impairment and vice versa. This needs to be distinguished from dementia, especially Alzheimer's disease.17

One consideration with antidepressants is that many of them cause dry mouth. If a person is depressed and over-salivating, the answer is not to give them one drug for each problem but to identify a drug that deals with several problems simultaneously. Also, identify a drug that can be used in older adults and that will solve the neurologic symptom without causing another problem.

Example: The drooling could be caused by another agent that the patient is taking. Remain alert for and stop using drugs that may be causing the symptom. Clinicians must look at the big picture regarding whether there is a common cause (e.g., existing medications) of multiple symptoms or if the symptoms are due to the disease itself, in which case effective therapy may be limited.

The challenge when trying to find a drug that helps multiple symptoms (e.g., drooling, depression, and insomnia) without exacerbating the neurologic disorder may be to:

  1. Identify drugs to eradicate symptoms;
  2. Eliminate those drugs that are not approved for use in older adults; and
  3. Carefully check side-effect lists and compare them with those from other comorbidities and therapies; and
  4. In those cases where feasible, talk to the patient or family to discuss where the tradeoffs will lie; a patient may be cognizant enough to choose tolerating one symptom over another (e.g., dry mouth over sedation). Again, consult a pharmacist to help weigh the options.

Sleep problems: Problems with sleep, including fatigue and daytime sleepiness, commonly present in those with neurologic disorders. A variety of causes lead to excessive daytime sleepiness and include the neurologic disease or the neurodegenerative process itself, associated sleep disorders, breathing problems, depression, and medications. Movement disorders may disturb sleep quality and quantity.

Motor limitations such as rigidity and spasticity, which take more energy to overcome, may result in a greater degree of fatigue.19 "It's not so much always that the patient lies awake at night," explained Dr. Rosenfeld. "It's that the quality of the sleep that they obtain is not optimal. As a result, they may sleep lighter or they don't enter the appropriate deeper stages of sleep to get adequate rest, so they may be asleep all night, but not actually asleep at the proper quality."

One study found that somnolence is 25% higher in patients with Parkinson's disease than in those with other neurologic diseases and is often related to the stage of Parkinson's disease, and the use of dopamine agonists such as levodopa.20

Unfortunately, there is a dearth of knowledge about fatigue in poststroke patients or about helpful therapeutic strategies in older adults overall. In one study, poststroke patients listed fatigue as their worst or among their worst symptoms, and myriad factors contribute to this.21 Examination of fatigue in other neurologic populations suggests common characteristics and associated factors that may be useful in the development of potential therapeutic strategies. (For a discussion of evidence-based guidelines for assessing and treating sleep disorders, see "Evidence-Based Practice in LTC: Sleep Management in LTC," January 2004 Caring, p. 30.)

Parkinsonism & Falls

Falls are especially common in patients with Parkinson's disease--even when compared with other fall-prone populations. Patients with Parkinson's "are often on meds such as Sinemet that are working on dopamine. They're working on the same things that the antipsychotics are working on," said Marek. "When the doses are too high they can cause hallucinations, delusions, and so on. When those [individuals] get into a nursing home their kidney and liver function may be [impaired]," which exacerbates the effects of the disease and the drug effects.

No treatment can arrest or slow neurodegeneration in Parkinson's disease. The aim is to relieve symptoms and avoid drug complications. An extensive list of agents that may lead to drug-induced Parkinsonism is available in AMDA's publication, Parkinson's Disease in the Long-term Care Setting. 1

Maximizing therapy with carbidopa/levodopa, for example, means being careful to notice symptoms and their subtle changes and working with the resident on management and side effects. "For instance, with tremors," said Tim Oser, RPh, clinical geriatric pharmacist and clinical manager, Omnicare of Northwest Ohio, Perrysburg. "It's important to look at the dose they're on and to determine with the resident whether they are getting effective treatment or if the episodes of tremor are persistent [or returning]."

Different drug combinations and options can mean titrating for effectiveness and safety. "There are so many strengths available now with the carbidopa and levodopa," said Oser. "You have an extended-release and immediate-release form. You have to be very careful and specific and find out what the physician is ordering."

--AS

In general, try to eliminate medications that may contribute to sleep disturbances, treat any associated depression or anxiety, institute regular sleep times and sleep hygiene, and specifically treat any sleep-related respiratory disorders or periodic limb movement disorder to improve sleep quality. Periodically question patients if you can about their comfort when it comes to such things as environmental temperatures (i.e., are they too hot? too cold?) and monitor for other sources of stress that may interfere with sleep.

Falls: The clinical effects of falls are considerable and often elicit an incapacitating fear of additional falls. According to one study of 548 subjects, falls occurred twice as frequently among neurologic inpatients compared with an age-matched population living in the community.22

Falls in neurologic patients are particularly linked to medications and pathologies affecting gait and balance.23 Unfortunately, no recent dramatic breakthroughs have occurred to help design therapeutic strategies in order to alleviate risk.

Remind staff to exercise customary methods for fall prevention and to be especially vigilant around these patients. Pharmacologic risk factors arise from use of antidepressants, neuroleptics, and different cardiovascular medications. (For a discussion of evidence-based guidelines for preventing falls, get a copy of AMDA's Clinical Practice Guideline: Falls and Fall Risk available at www.amda.com.)

Barbara J. Messinger-Rapport, MD, Cleveland Clinic geriatrician and medical director of the Fairfax Health Center, Cleveland, Ohio, recommends referring to the Beers criteria, which addresses potentially inappropriate medication use in adults 65 and older.16 In elderly patients, 30% of hospital admissions may be linked to drug-related problems or toxic drug effects. Besides falls, adverse drug events have been linked to problems such as depression, constipation, immobility, confusion, and hip fractures--all of which are preventable.

Conclusion

Caring for residents in long-term care involves careful attention to managing symptoms of neurologic diseases versus pharmacy symptoms. Proper care involves maintaining suspicion for instances where a drug is the problem instead of the disease; determining the risks and benefits of using drugs in older adults with neurologic disorders; and selecting the fewest number of drugs to address the greatest number of simultaneous problems but that elicit the fewest number of side effects. Also, using consulting pharmacists familiar with drug effects in the elderly will help accomplish this objective in the least amount of time.

To maximize function, medical directors and their staff must communicate regularly about such issues as goals of the care plan, symptom management, and--specifically--drug administration and side effects.

Andrea Sattinger is a contributing writer for Caring.

Strategies for Medical Directors

"Medical directors are responsible for overseeing patient care within their facilities and can contribute to the education of all staff members regarding the use of particular psychoactive medications," said Peter A. DeGolia, MD, CMD, geriatrician and attending family physician, MetroHealth Family Practices and Geriatrics, Cleveland. "Monitoring the use of these medications and providing educational literature or seminars to medical and nursing staff can improve the prescription of and monitoring of these medications."

Dr. DeGolia, medical director for Long Term Care Services of the MetroHealth System and president-elect of AMDA's Ohio chapter, recommended highlighting the following key points for attending physicians:

  1. Start at low doses and advance slowly when prescribing for older adults, but continue to titrate medications until the desired treatment effect is achieved or adverse side effects are noted.
  2. Don't start or adjust multiple medications simultaneously. Start with one medication, adjust the dose as necessary, and then initiate a second medication if appropriate.
  3. Familiarize yourself with the medications you prescribe. Take into account specific drug-drug and drug-disease interactions that may occur.
  4. Take advantage of your pharmacy consultant. Work with them to address concerns of possible side effects.
  5. Use potential side effects to your advantage. Consider time of delivery and common side effects. For example, a medication that tends to cause sedation may be particularly useful in a patient who has insomnia. Consider offering this medication at bedtime.

--AS

References

  1. American Medical Directors Association, Committee on Clinical Practice Guidelines. Parkinson's Disease in the Long-term Care Setting. Clinical Practice Guideline. Columbia, Md: American Medical Directors Association; 2002.
  2. Vance J. Sleuthing out strokes. Caring for the Ages; 2003;9:34-41
  3. Agency for Healthcare Research and Quality. Antithrombotic and thrombolytic therapy for ischemic stroke. In: Sixth ACCP Consensus Conference on Antithrombotic Therapy. Accessed July 27, 2004 at here.
  4. Olanow CW, Watts RL, Koller WC. An algorithm (decision tree) for the management of Parkinson's disease (2001): treatment guidelines. Neurology. 2001;56:S1-S88.
  5. Ezekowitz M. Medical prevention of secondary stroke: a cardiologist's perspective. Clin Cardiol. 2004;27:II36-1142.
  6. Elkind M. Secondary stroke prevention: review of clinical trials. Clin Cardiol. 2004;27:II25-1135.
  7. Goodin D, Frohman E, Garmany GJ, et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines. Neurology. 2002;58:169-178.
  8. Walling AD. Amyotrophic lateral sclerosis: Lou Gehrig's disease. Am Fam Physician. 1999;59:1489-1496.
  9. Agency for Healthcare Research and Quality. Practice parameter: the care of the patient with amyotrophic lateral sclerosis (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology: ALS Practice Parameters Task Force. Accessed July 27, 2004 here.
  10. Miller RG, Rosenberg JA , Gelinas DF, et al. Practice parameter: the care of the patient with amyotrophic lateral sclerosis (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology: ALS Practice Parameters Task Force. Neurology. 1999;52:1311-1323.
  11. Pelletier J. Rationale for the use of structure-modifying drugs and agents in the treatment of osteoarthritis. Osteoarthritis Cartilage. 2004;12:S63-8.
  12. Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology. 2001;47(6):295-299.
  13. Mohammed I, Hussain A. Intrathecal baclofen withdrawal syndrome? a life-threatening complication of baclofen pump: a case report. BMC Clin Pharmacol. 2004;4:6.
  14. Hockstein N, Samadi D, Gendron K, Handler S. Sialorrhea: a management challenge. Am Fam Physician. 2004;69:2628-2634.
  15. Shanley C, O'Loughlin G. Dysphagia among nursing home residents: an assessment and management protocol. J Gerontol Nurs. 2000;26:35-48.
  16. Fick DM, Cooper JW, Wade WE , Waller JL, Maclean R, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US census panel of experts. Arch Intern Med. 2003;163:2716-2724.
  17. Reiter J. A practical update on depression. Accessed July 23, 2004 at http://www.mhsource.com/depression/update.html.
  18. Watson LC, Garrett JM, Sloane P, Gruber-Baldini A, Zimmerman S. Depression in assisted living: results from a four-state study. Am J Geriatr Psychiatry. 2003;11:534-542.
  19. Happe S. Excessive daytime sleepiness and sleep disturbances in patients with neurological diseases: epidemiology and management. Drugs. 2003;63:2725-2737.
  20. O'Suilleabhain P, Dewey Jr, RB. Contributions of dopaminergic drugs and disease severity to daytime sleepiness in Parkinson's disease. Arch Neurol. 2002;59:986-989.
  21. De Groot M, Phillips S, Eskes G. Fatigue associated with stroke and other neurologic conditions: implications for stroke rehabilitation. Arch Phys Med Rehabil. 2003;84:1714-1720.
  22. Grimbergen YA , Munneke M, Bloem B. Falls in Parkinson's disease. Curr Opin Neurol. 2004;17:405-415.
  23. Stolze H, Klebe S, Zechlin C, Baecker C, Friege L, Deuschl G. Falls in frequent neurological diseases: prevalence, risk factors and aetiology. J Neurol. 2004;251:79-84.

This article originally appeared in Caring for the Ages, September 2004; Vol. 5, No. 9, p. 55-59. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission.

The opinions expressed by the authors are their own
and not necessarily those of AMDA or of Elsevier.

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