Four times a year, the leadership team at the Gerontological Advanced Practice Nurses Association (GAPNA) highlights the most important published literature that a geriatric practice. This month, GAPNA President Natalie R. Baker, DNP, ANP-BC, GNP-BC, CNE, GS-C, FAANP, discusses the benefits of NP-led transitional care from a nursing care facility to home, a decrease in delirium in hospital patients given melatonin, and how chronically ventilated patients at the start of the COVID-19 pandemic were protected against the SARS-CoV-2 virus.
Transitional care following a skilled nursing facility stay: Utilization of nurse practitioners to reduce readmissions in high risk older adults
Geriatr Nurs. 2021:42(6):1594-1596
This study looks at the importance of transitional care services following a skilled nursing facility stay in older adults who are at high risk for readmission. The researchers, led by Tiffany Rose, DNP, NP-C, identified a number of gaps in care such as medication discrepancies, delays in start of home health services, and lack of follow-up with a primary care provider. However, the study findings indicate there is value in seeing patients in their homes soon after discharge from a skilled nursing facility. Of the patients seen for transitional care visits, none were readmitted to the hospital.1
Commentary by Dr. Baker:
As transitional care models (TCM) evolve, the goals of reducing 30-day hospital readmissions and improving care gaps remain consistent. Most TCMs focus on patients who are being discharged from hospitals to home, yet 28% of those discharged from the hospital go to a skilled nursing facility (SNF) before returning home. These individuals are often frailer, have multiple comorbidities, are taking multiple medications, and have a poorer prognosis. Upon SNF discharge, an estimated 22% of the older adults will seek care in an emergency department (ED) or require rehospitalization within 30 days costing Medicare approximately $17.4 billion annually.
Researchers implemented a quality improvement project to assess the effectiveness of a nurse practitioner (NP)-led TCM for older adults discharged from an SNF to back home. Sixteen high-risk older adults consented to a transitional care visit within 72 hours of their SNF discharge. During the transitional care visits, NPs identified care gaps such as the need to taper narcotics and sliding scale insulin prior to SNF discharge, failure to provide the patient with a list of current medications instead of SNF and hospital transfer medications, and delays in the start of home health services. The NPs also discovered that 68.8% of older adults had transportation difficulties and 12.5% of the cohort could not afford items such as medications, liquid thickeners, and scales for weight monitoring.
None of the participating older adults required hospitalization within 30-days of SNF discharge compared with 13.9% of those discharged from the same SNFs prior to the quality improvement project implementation. Nurse practitioners should consider transitional care visits within 72 hours of SNF discharge.
Melatonin and melatonin-receptor agonists to prevent delirium in hospitalized older adults: an umbrella review
Geriatr Nurs. 2021(6):1562-1568
A review of published literature was conducted to evaluate the effectiveness of melatonin and ramelteon (an FDA-approved melatonin-receptor agonist) for managing insomnia and preventing delirium in hospitalized adults aged 50 years and older. Three meta-analyses with more than 3000 patients met the inclusion criteria. Two meta-analyses showed evidence that melatonergics (melatonin or ramelteon) decreased delirium risk in older adults (odds ratio [OR] ranged from 0.51 [95% CI 0.3-0.85] to 0.63 [95% CI 0.46-0.87]). The third meta-analysis showed statistically significant decreased delirium risk in older adults with medical conditions (OR, 0.25 [95% CI 0.07-0.88]) but not surgical conditions (OR, 0.62 [95% CI 0.16-2.43]). Melatonergic dosages in the studies included melatonin 0.5 mg, 3 mg, 5 mg, and 50 mg/kg or ramelteon 8 mg.
Commentary by Dr. Barker:
Delirium is a common neurocognitive disorder manifested in acutely ill patients and can be difficult to treat. Affecting up to 60% of hospitalized patients, delirium is more common in older adults. Delirium is described as abrupt changes in level of consciousness, attention, and cognitive functioning that fluctuates in intensity. Delirium can predispose the patient to emotional distress and safety concerns.
It is postulated that up to 40% of delirium diagnoses can be prevented. Sleep deprivation is one delirium trigger that may be controlled with medication.
When mitigating delirium triggers, health care providers should consider prescribing melatonergics to help combat circadian rhythm disturbances. Some popular medications used to induce sleep may precipitate delirium and should be avoided when treating older adults: antihistamines, benzodiazepines, and nonbenzodiazepine hypnotics.
Absence of COVID-19 disease among chronically ventilated nursing home patients
J Am Med Dir Assoc. 2021;22(12):2500-2503
The study researchers collected data on death rates among chronically ventilated and unventilated patients living at 3 separate nursing homes on Long Island, NY. Data was collected on 93 chronically ventilated patients and 1151 unventilated patients between March 15, 2020, and May 15, 2020. Since this was the start of the COVID-19 pandemic, polymerase chain reaction (PCR) results and reported illnesses on all patients and staff were reported. For comparison, causes of death during the same timeframe from 2019 were collected. Death rates among chronically ventilated patients in 2020 (9 of 93) were similar to those in 2019 (8 of 100).
Commentary by Dr. Baker:
During the early months of the COVID-19 pandemic, the virus rapidly spread through nursing homes, resulting in high rates of morbidity and mortality among patients and staff. The mortality rate from COVID-19 has been high in older adults and those with significant underlying conditions. Researchers analyzed the medical records of 3 nursing homes comparing COVID-19 diagnoses and associated deaths among patients, including those requiring chronic ventilation.
The study included all patients residing at the 3 nursing homes. None of the deaths among ventilated patients were attributed to COVID-19 despite being the patients being treated by multiple staff who tested positive for the virus. Only 1 chronically ventilated patient tested positive — this person had a mild febrile syndrome and fully recovered.
It was hypothesized that the chronically ventilated patients would have high rates of death and COVID-19 diagnosis due to advanced age, multiple comorbidities, and underlying respiratory conditions. It appears that chronic ventilation blocks the SARS-CoV-2 virus from entering the lower respiratory tract, thereby creating a protective environment.
1. Rose T, Frith K, Zimmer R. Transitional care following a skilled facility stay: utilization of nurse practitioners to reduce readmissions in high risk older adults. Geriatr Nurs. 2021;42(6):1594-1596. doi:10.1016/j.gerinurse.2021.06.024
2. Blodgett TJ, Blodgett NP. Melatonin and melatonin-receptor agonists to prevent delirium in hospitalized older adults: an umbrella review. Geriatr Nurs. 2021;42(6):1562-1568. doi:10.1016/j.gerinurse.2021.10.011
3. Gomolin IH, Krichmar G, Siskind D, Divers J, Polsky B. Absence of COVID-19 disease among chronically ventilated nursing home patients. J Am Med Dir Assoc. 2021;22(12):2500-2503. doi:10.1016/j.jamda.2021.09.019