JAMDA 18 (2017) 928e940

JAMDA

journal homepage: www.jamda.com

Updates from the AMDA meeting

Clinical Update on Nursing Home Medicine: 2017

Barbara J. Messinger-Rapport MD, PhD, FACP, CMD a, Milta O. Little DO, CMDb,John E. Morley MB, BCh b,*, Julie K. Gammack MD, CMDb

a Section of Geriatric Medicine, Cleveland Clinic, Cleveland, OHbDivision of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO

Keywords:Hypertension after SPRINTCOPDbreathlessnesscognitive impairmentdementiawound carepressure ulcers

* Address correspondence to John E. Morley, MBMedicine, Saint Louis University School of Medicine,Louis, MO 63104.

E-mail address: john.morley@health.slu.edu (J.E. M

https://doi.org/10.1016/j.jamda.2017.09.0011525-8610/� 2017 AMDA e The Society for Post-Acut

a b s t r a c t

This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered arehypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary diseaserisk factors, diagnosis and management including end-of-life planning, and the difficulties with exac-erbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; andwound care and pressure ulcer management.

� 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Hypertension After Systolic Blood Pressure Intervention Trial

Hypertension guidelines do not reflect the heterogeneity of theolder population. A robust 80-year-old woman living in the commu-nity may play tennis and cycle daily, and have a life expectancy ofmore than 12 years.1 Another 80-year-old woman in the lowestquartile of fitness may require substantial care and have a life ex-pectancy less than 5 years.1 The 2017 guideline published by theAmerican College of Physicians and American Association of FamilyPhysicians2 recommends a target systolic blood pressure (sBP) of150 mm Hg, or 140 mm Hg if there is a history of a cerebrovascularevent, in adults 60 years and over. There is no separate recommen-dation for frail elders, or specific recommendations for elders 80 yearsand over, regardless of frailty. Recommendations for adults 60 yearsand over by 8th Joint National Commission3 and Canadian EducationHypertension Program4 are similar. The European Europe5 and theVeterans Administration/Department of Defense6 guidelines offerstatements of caution for the oldest and/or frailest individuals. Clarityregarding heterogeneity of the older populationmay soon be possible,since design of the recently published Systolic Blood Pressure Inter-vention Trial (SPRINT),7 incorporates at least some of the heteroge-neity of the older adult population.

Current hypertension guidelines are driven by the major studiespublished over the past 3 decades preceding SPRINT. The largedouble-blind placebo-controlled legacy trials enrolled older adultswith stage 2 hypertension (sBP >160 mm Hg) and targeted a systolic

, BCh, Division of Geriatric1402 S. Grand Blvd, M238, St

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e and Long-Term Care Medicine.

pressure of 140 mmHg. Interestingly, themean final blood pressure inthe treatment arms of the 3 major trials Systolic Hypertension in theElderly Program (SHEP),8 Systolic Hypertension in Europe trial,9 andHypertension in the Very Elderly Trial,10 studies did not actually reachtarget. Nevertheless, the primary outcome of incident stroke wasreduced 30%e42% among the trials. The incidences of secondaryoutcomes (heart failure and mortality) were also reduced in the SHEPand HYVET trials, which used diuretic antihypertensives. The SystolicHypertension in Europe trial study,9 a calcium-channel blockerintervention, was terminated early on the basis of the primaryoutcome, so secondary outcome events may have been too few todetermine their risks. A nonplacebo controlled trial of antihyperten-sives in older adults suggested a sBP nadir of 130 mm Hg for adversecardiovascular outcomes.11 Based on that finding, the American Col-lege of Cardiology Foundation and the American Heart Associationupdated its 2011 guideline to recommend against lowering sBP anddiastolic BP below 130 mm Hg and 65 mm Hg, respectively,12 forpersons 80 years and over.

The SPRINT trial enrolled 9361 older participants with fewcomorbidities, but tracked important geriatric outcomes such as gaitspeed, cognition, and overall frailty. The research question waswhether a target sBP of less than 120 mm Hg would have superiorcardiovascular outcomes compared with the standard target sBP ofless than 140 mm Hg. Major inclusion criteria were age 50 years andgreater, sBP 130e180 mm Hg, and 1 or more of the following: car-diovascular disease, cardiovascular disease risk of at least 15%, chronickidney disease with estimated glomerular filtration rate (eGFR) of20e59 mL/min; or age of at least 75 years or greater. Major exclusioncriteria were a past cerebrovascular event; diabetes; clinical heartfailure or ejection fraction less than 35%; proteinuria greater than 1 gper 24 hours; eGFR 20 mL/min; dementia or nursing home residencewithout documented dementia; life expectancy of less than 3 years;

B.J. Messinger-Rapport et al. / JAMDA 18 (2017) 928e940 929

and standing sBP less than 110 mm Hg on entry to the study.7,13,14 Theautomated blood pressure cuff used in the SPRINT trial was the sameas used in the Action to Control Cardiovascular Risk in Diabetes15 trial.Blood pressure in both trials was an average of 3 measurements taken1 minute apart after a 5-minute rest.16 One important difference be-tween SPRINT and every other large hypertension trial was that theautomated blood pressures were unattended (ie, the clinician wasoutside the room). Therefore, blood pressures in this trial are likely tobe 5e10 mm Hg lower than the typical community standard.17

The intense blood pressure target was tolerated well with thissubject population; the withdrawal rate from the study was between10% and 11% in both arms and was not different in the older subset. Aswith the legacy hypertension trials, the intense target sBP was notmet. On the average, 3 antihypertensives were required to achieve amean sBP of 121.5 mm Hg, and the control group required 2 antihy-pertensives to achieve a mean sBP of 134.6.7 The trial was dis-continued early after a median follow-up of 3.3 years, because of acumulative hazard ratio for cardiovascular events of 0.75 (95% CI0.64e0.89), and a mortality hazard ratio of 0.73 (95% CI 0.60e0.90).This risk reduction translates to a number needed to treat (NNT) of 61to prevent 1 cardiovascular event and 90 to prevent 1 death. Statis-tically significant serious adverse events included hypotension, syn-cope, electrolyte abnormalities, acute kidney injury or failure.Orthostatic hypotension in the treatment arm was statistically lessthan in the control arm. The most quoted adverse event was a drop ineGFR of at least 30% from a normal baseline occurred in 1.2% of theintense treatment arm, compared with 0.35% in the control treatmentarm. Reversibility of the renal dysfunction is not known.

Exploratory analysis of the SPRINT senior cohort, the 28% of par-ticipants aged 75 years and over, reveals both risk and benefit in thisage group.18 Electrolyte abnormalities occurred in 5% of the inten-sively treated group vs 3.6% of the control; acute kidney injury orfailure occurred 5.9% vs 4.2%. Serum sodium less than 130mmol/L wasfound in 5% vs 3.3%. Interestingly, the rate of injurious falls was lowerin the intensive arm of the oldest adults (12%) compared with thestandard treatment arm (14.6%), with P ¼ .03.18,19 The NNT to prevent1 cardiovascular event was 27 and to prevent 1 death 41. The smallerNNTs in the senior cohort compared with the overall trial reflect theincreased absolute risk in this older population.

Despite recruiting among robust elders by design, deeper inspec-tion of SPRINT senior participant characteristics reveals more het-erogeneity than enrollment criteria suggest. Many subjects hadimpairedmobility, fitness, and cognition. For example, more than one-quarter of the older participants had a gait speed of less than 0.8 m/sand, thus, would be unable to cross a street in the time that it takes alight to change.20 Three-quarters of the participants had at least mildcognitive impairment, with a Montreal Cognitive Assessment score ofless than 26/30.21 One-quarter scored below 19, a cut-off with 77%specificity for mild dementia.22 Finally, almost one-third of the olderparticipants were frail, based on a frailty index cutoff of 0.21.23

Secondary analysis of the senior cohort demonstrated that themost frail benefitted from the intense BP control at least as well as themost fit. Treatment outcomes were similar in the slowest as well asthe fastest walkers.18 The 3-year follow-up of the adults 75 years ofage and over did not demonstrate any treatment differential on gaitspeed or mobility limitation.24 Secondary cognitive outcomes will beexplored in the SPRINT Memory and Cognition in Decreased Hyper-tension (MIND) substudy.13

On theopposite endof themultimorbidity spectrumis thePARTAGEstudy,25 which looked at the relationship between sBP, antihyperten-sive use, and mortality in French and Italian nursing homes. A multi-variate analysis examined mortality for those persons treated withantihypertensives. This subject populationwas on average88years old.Most had hypertension, and a substantial number had diabetes, heartdisease, and heart failure. Mortality was higher in the more intensely

controlledpopulation, thoseparticipantswith sBP less than130mmHgand on at least 2 antihypertensives. The relationship held even whenadjusted for age, sex, body mass index, and other characteristics.

More insight between blood pressure control and function followsa recent propensity study examining the relationship between post-myocardial infarction (MI) use of beta blockers and functional out-comes.26 This large database study queried Medicare Parts A and D, aswell as MDS 2.0, in nursing home residents hospitalized with an acuteMI between 2007 and 2010. Outcomes of interest were 90-day mor-tality and function. The study captured 10,992 older adults, with meanage 84 years. Approximately one-quarter had diabetes or chronicobstructive pulmonary disease (COPD); almost one-half had heartfailure. Approximately 60% had mild to moderate dementia, andapproximately one-third had moderate ADL impairment prior tohospitalization.26 Three months after the acute MI, one-quarter hadbeen hospitalized again, 14% died, and 12% had a functional decline.Not unexpectedly, nursing home residents were less likely to diefollowing an acute MI if they were discharged on a beta blocker.However, those elders with more cognitive and physical impairmentprior to hospitalization were likely to be even more impaired if dis-charged on a beta blocker compared with similar patients not dis-charged on a beta blocker. This study fuels the need to have goals ofcare discussions with residents (or with their families) when signifi-cant functional impairment exists prior to an MI. In addition, theremay be a benefit to deprescription when patients return from thehospital with beta blockers post-acute MI when function is morehighly valued than longevity.

The 3 studies described here, the SPRINT, Predictive Values ofBlood Pressure and Arterial Stiffness in Institutionalized Very AgedPopulation, and beta blockade post-MI, suggest hypertension treat-ment targets for those with minimal morbidities and for those withmultiple morbidities. The Predictive Values of Blood Pressure andArterial Stiffness in Institutionalized Very Aged Population study re-inforces current geriatric practice, as well as current guidelines,discouraging intense blood pressure control with 2 or more antihy-pertensives in a population with multiple morbidities. The beta-blocker study suggests a trade-off between survival and function ina functionally impaired, multimorbid population. On the other hand,SPRINT senior implies that robust elders benefit from and tolerate anintense target of 120 mm Hg, when measured as performed in thestudy, using the mean of serial measurements from a high qualityautomated cuff with the clinician outside the room. This targettranslates to a systolic pressure closer to 130 mm Hg when measuredusing a more typical technique. Elders with a wide range of cognitiveskills and fitness, but without diabetes, heart failure, stroke, or de-mentia, may benefit from this intensive target. These patients must bewilling and able to take, on average, 3 antihypertensives to achievethis target. Frequent reassessment of the risks and benefits would beneeded to manage the hypertensive target. This approach is a novelview of hypertension treatment for very old persons, and differssubstantially from current practice.

An important outcome that is not addressed by current publishedstudies is frailty. The frailty phenotype was originally defined with theFramingham cardiovascular cohort.27,28 Higher cardiovascular riskscores predict development of prefrailty and frailty.29 Would reducingfuture cardiovascular risk by treating hypertension to an intensetarget of 120 mm Hg reduce the risk of prefrailty and frailty? TheSPRINT MIND analysis may shed light on this subject, although theearly termination of SPRINT may limit conclusions. The Intensiveversus standard ambulatory blood pressure lowering to preventfunctional Decline in the elderly study30 relates standard ambulatoryblood pressure lowering to functional outcomes and white matterhyperintensities, which in turn are associated with frailty.31 This 3-year study has not yet been published, but might be one of the mostexciting outcomes to antihypertension therapy.

B.J. Messinger-Rapport et al. / JAMDA 18 (2017) 928e940930

Difficult Issues: COPD and Breathlessness

COPD is the progressive, chronic obstruction of lung airflow thatinterferes with normal breathing and is not fully reversible. Inclusivein the diagnosis are emphysema, chronic bronchitis, refractory(nonreversible) asthma, and some forms of bronchiectasis. It is char-acterized by increasing breathlessness over time and is diagnosedusing spirometry.32

COPD had a global prevalence of 11.7% in 2010, with 384 millionaffected cases and >20% of those affected living in nursing homes.Depending on the year, it is the third or fourth leading cause of deathin the United States and the world. There is an increasing prevalencewith age (particularly in nonsmokers) but is not part of normalaging.33,34

The prevalence of COPD overall does not differ in the postacute andlong-term care (PA-LTC) settings; however, there are some uniqueissues that patients with COPD face when living in these settings. Firstof all, there are high rates of cognitive and functional impairment,which impact whether medications and nonpharmacologic manage-ment techniques will be effective. There are also high rates ofexacerbations possibly because of high rates of under-medication inPA-LTC. One study showed that 17% of residents with COPD(n ¼ 21,000) received no medication, 60% were not prescribed long-acting bronchodilators or inhaled corticosteroids (ICS), and 20% had2 or more exacerbations in 1 year.34 Lastly, nursing home air qualityhas been associated with respiratory outcomes. In homes with higherlevels of pollutants, people with COPD report increased breathless-ness, cough, and obstruction. This is most pronounced in age over80 years and poorly ventilated homes.35

Risk Factors for and Diagnosis of COPD

There are several known risk factors for COPD, including geneticpredisposition, recurrent lung infections, lower socioeconomic status,indoor and outdoor air pollution, occupational exposures, andincreased body mass index.36 The biggest risk factors for COPD aresmoking history (both personal and second-hand exposure) and age.

Aging is physiologically associated with an expected progressivedecline in lung function, which when coupled with lung irritants(smoking, pollution, infection), is the main driver of COPD pathology.With age, dynamic lung volumes [vital capacity (VC), FVC, FEV1]decrease and static lung volumes (residual volume, functional residualcapacity, and closing volume) increase, while total lung capacity re-mains unchanged. However, the major cause of age-related physio-logical changes in respiratory function is the loss of elastic recoil of thelung parenchyma. Progressive lung function deterioration in COPDreflects an amplification of the lung-aging physiologic process.36e38

The diagnosis of COPD is suspected in a person with symptoms ofshortness of breath, cough, and increased sputumwith an exposure toknown risk factors, and confirmed with spirometry that shows aforced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratioof < 0.70. COPD is further classified by severity using the post-bronchodilator FEV1 according to the Global Initiative for ChronicObstructive Lung Disease (GOLD) criteria as follows: GOLD 1: mild,FEV1 > 80% predicted; GOLD 2: moderate, 50% < FEV1 < 80% pre-dicted; GOLD 3: Severe, 30% <FEV1 <50% predicted; GOLD 4: verysevere, FEV1< 30% predicted. Spirometry is often difficult to obtain innursing home settings so the diagnosis is often made clinically. Aclinical prediction tool has been validated in this setting by asking thefollowing 3 questions of a resident with typical symptoms of COPD:(1) Does the resident have a greater than or equal to 19 pack-yearsmoking history? (2) Does the resident have shortness of breath atrest or on exertion? (3) Does the resident have a diagnosis of asthma?If the answer to any of these questions is yes, it is supportive of adiagnosis of COPD with a sensitivity 90.6%; specificity 77.8%.39,40

When evaluating for the presence of COPD in older adults, thereare some diagnostic controversies to consider.33,38,40 First, it is ques-tioned whether one ought to use the fixed FEV1 criteria vs the lowerlimits of normal. Most guidelines recommend using the measuredpostbronchodilator FEV1/FVC ratio at a fixed threshold value of lessthan 0.70. However, age-related physiologic decline in the FEV1/FVCratio may lead to the overestimation of COPD prevalence, up to 23%. Ithas even been shown that 35% of healthy older adults over age70 years and 50% of healthy adults over age 80 years who have neversmoked have an FEV1/FVC ratio<0.7.37 In the absence of symptoms orrisk factors, it is not recommended to make a diagnosis of COPD inolder adults only based on spirometry results. Instead, it has beensuggested to use the lower limit of normal, which is defined as theage-corrected lower 95th percentile of the reference population.37,41

A second diagnostic quandary is separating pure COPD andasthma-COPD overlap syndrome (ACOS), which is the presence ofairflow obstructive where aspects of both asthma and COPD are pre-sent, such as FEV1/FVC <0.70 and evidence of airflow reversibility.42

ACOS has 12%e55% prevalence among people with risk factors,signs, and symptoms of COPD. It is important to distinguish the 2because the presence of ACOS changes the medication managementalgorithm as discussed later in this article. Lastly, it is very importantto consider the co-existence of obstructive sleep apnea (OSA). Prac-titioners should be diligent to check for co-existing OSA when patientpresent with both obstructive air flow and pulmonary hypertension.Treatment of underlying OSA will significantly improve outcomes forpatients.43

Comorbid Conditions in COPD

Coexisting and comorbid conditions are common and significantlyaffect outcomes in people with COPD. COPD has been associated withincreased swallowing difficulties, which may lead to respiratory in-fections and malnourishment. In addition, the presence of comor-bidity negatively affects drug management, functional capability,clinical outcomes, and disease severity. It is critical to understand thatcognitive impairment is the main determinant of adherence so clini-cians must assess cognitive status in all patients and alter educationaland management strategies for those with both mild cognitiveimpairment and dementia. Patients with COPD will also exhibitreduced physical performance with comorbid anxiety, depression,osteoporosis, and obesity.40,44e49 Frailty is an important syndromethat also negatively impacts functional outcomes and survival so it isimperative to assess for frailty at regular intervals. The 6-Meter WalkTest is the standard frailty assessment for people with COPD in clinicaltrials and is easy to perform. Other physical measures can be usedincluding the Short Physical Performance Battery or Berg BalanceScale, as well as well-validated scales, such as the FRAIL and SARC-Fquestionnaires (Figures 1 and 2). When frailty and sarcopenia arediscovered, early and intensive rehabilitation is the best interventionto improve outcomes.41,51

It is very common in aging populations to encounter both COPDand heart disease in the same patient. Studies have shown that car-diovascular death is a leading cause of mortality (20-50%) in patientswith COPD and a significant risk factor for recurrent hospitalization.52

There are 3 drug classes used for the management of coronary arterydisease and cardiomyopathy that may impact outcomes of COPD.These are beta-blockers, HMG-CoA reductase inhibitors (or statins),and angiotensin-converting enzyme inhibitors.

Beta-blockers are used to reduce mortality in people with cardio-vascular diseases, but prescribers are hesitant to use them for peoplewith COPD because of the theoretical risk of bronchoconstriction andworsening dyspnea with the use of beta-blockade in chronic lungdisease. However, recent evidence suggests that cardioselective beta-blockers are not only safe to use in people with COPD without an

The FRAIL Scale: A rapid, validated scale for the detection of frailty

3 or more positive answers – frail

1 or 2 positive answers – prefrail

Fatigue (have felt tired most or all of the time in past 4 weeks)

Resistance (have difficulty or unable to climb a flight of stairs)

Aerobic (have difficulty or unable to walk a block)

Illness (have more than 5 illnesses)

Loss of weight (have lost more than 5% of weight in past 6 months)

Fig. 1. The FRAIL Scale: A rapid, validated scale for the detection of frailty. From:Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predictsoutcomes in middle-aged African-Americans. J Nutr Health Aging 2012;16:601-608.50

B.J. Messinger-Rapport et al. / JAMDA 18 (2017) 928e940 931

increase in mortality but can also reduce exacerbations. Therefore, astrong consideration should be made for starting or continuing car-dioselective beta-blockers in people with concomitant COPD andheart disease.36,49,53

Statins have been shown to have many pleiotropic effects,including anti-inflammatory and antioxidant activity, which havebeen shown to reverse the effects of cigarette smoke in animal modelsand may help ameliorate lung function decline, reduce exacerbations,and prevent hospitalizations in humans. In addition, there is someevidence of reduced mortality, breathlessness, and lung cancer risk inpeople with co-existing COPD and cardiac disease, but themost recenttrial of people with COPD alone failed to confirm theseassociations.36,49,53

A strong consideration for the use of angiotensin-convertingenzyme inhibitors is warranted in people with coexisting coronaryartery disease and COPD as they have been shown to reduce recurrentcardiovascular events, pulmonary-related morbidity, and all-causemortality following revascularization.36,49,53

COPD Management

The GOLD and AMDAeSociety for Post-Acute and Long Term CareMedicine have created guidelines to assist the healthcare team in themanagement of COPD. Generally speaking, the management of COPDdoes not markedly differ for the elderly or PA-LTC patient. The overallgoals of COPD management are to reduce mortality, hospitalizations,and lung function decline, prevent exacerbations, relieve dyspnea,improve exercise tolerance and health-related quality of life, andpreserve functional independence.40,49 In the PA-LTC setting, it isimportant to follow a care process and individualized care plan, whichis outlined in the AMDA clinical practice guideline on COPD man-agement. There are 4 phases to a care process: recognition (identifyingthe presence of a risk or condition), assessment/root cause analysis(clarifying the nature and causes of a condition or situation andidentifying its impact on the individual), treatment (selecting andproviding appropriate interventions for that individual), and moni-toring (reviewing the course of a condition or situation as the basis fordeciding to continue, change, or stop interventions).54 The interpro-fessional team will use this care process to design the individual careplan, which may include the following: (1) Education of resident andfamily; (2) stop cigarette smoking and avoid aggravating factors; (3)reduce symptoms and complications associated with COPD; (4)maximize exercise tolerance; (5) reduce acute exacerbations; (6)prevent and treat any infections; (7) use evidence-based treatment

options to optimize drug therapy; and (8) avoid or minimize therapy-related adverse events.

Integrated, interprofessional disease management of at least3 months duration was shown to decrease hospital admissions andhospital days. It also improved disease-specific quality of life and ex-ercise capacity, as measured by the 6-MWT.49,55

Pharmacologic Management of COPD

The mainstay of the management of COPD is done throughpharmacologic treatment. When prescribing and overseeing medi-cations in people with COPD, it is important to remember thefollowing key points: (1) Age-related physiologic changes potentiallydecrease responsiveness to drugs and increase susceptibility toadverse drug reactions. (2) Knowledge of medication efficacy in PA-LTC and elderly populations is mostly extrapolated from dataderived from younger or community-dwelling populations. (3)Overall, similar efficacy has been shown within drug classes soconsideration should be made to use the cheapest and easiest toadminister medications. (4) Drug delivery and number of requiredadministrations per day are important considerations in the PA-LTCpopulation. (5) Most of the people living in the LTC setting havesignificant frailty, disability, and cognitive impairment, which limitthe use of inhalers with complicated propelling mechanisms. Simi-larly, complicated regimens increase the chance of administrationerrors when nurses and medication technicians have a large numberof residents. Table 1 outlines some of the challenges and advantagesof different inhaler types. Studies have shown that metered doseinhaler (MDI) efficacy is affected in people with impaired hand-breath coordination, fine motor control, hand or finger musclestrength, and cognition.40 One study found that a day after MDItraining, 50% of people with mild cognitive impairment and 100%with dementia could not operate the device correctly.56 Dry powderinhalers (DPI) tend to be even more complex. Once the capsule isloaded, DPIs often require 8 additional steps, commonly associatedwith errors. However, 1 study showed that nursing home residentswith mild to moderate dementia can be successfully educated on theproper use of DPI.57 Overall, meta-analyses of studies, that excludedpeople with cognitive impairment and neurologic deficits, comparingthe clinical efficacy of the various delivery methods have failed toshow a difference in outcomes.40,58 It is, therefore, important forprescribers to consider on an individual basis, based on care goals,the least complicated regimen that will maximize absorption andminimize adverse effects. While following treatment algorithms isuseful, it is critical to understand that these are based on younger,more robust populations and may not be appropriate as sole man-agement tools in the PA-LTC population. The various drug classes fortreatment of COPD are briefly reviewed here.

Short-Acting Bronchodilators

Short-acting bronchodilators are indicated to treat intermittentsymptoms in all GOLD stages and are the main-stay of treatment foracute exacerbations. The nebulized form may also be indicated formaintenance therapy in nursing home residents with cognitive andmotor impairments who cannot properly use inhalers.41,49

Long-Acting Muscarinic Antagonists

Long-acting muscarinic antagonists (LAMA) are first line therapyfor GOLD stages IIeIV. The best evidence is available for tiotropium 18mcg once-daily. Other choices include aclidinium bromide 400 mcgtwice-daily, glycopyrronium bromide 50 mcg once-daily, and ume-clidinium bromide 62.5 mcg once-daily.41,49,59 Multiple trials haveshown LAMA to be effective and all agents were better than placebo at

SARC-F Screen for Sarcopenia

Component Question Scoring_________

Strength How much difficulty do you have in None = 0

lifting and carrying 10 pounds? Some = 1

A lot or unable = 2

Assistance in How much difficulty do you have None = 0

walking walking across a room? Some = 1

A lot, use aids, or unable = 2

Rise from a How much difficulty do you have None = 0

chair transferring from a chair or bed? Some = 1

A lot or unable

without help = 2

Climb stairs How much difficulty do you have None = 0

climbing a flight of ten stairs? Some = 1

A lot or unable = 2

Falls How many times have you None = 0

fallen in the last year? 1-3 falls = 1

4 or more falls = 2

___________________________________________________________________________

Fig. 2. SARC-F Screen for Sarcopenia. *SARC-F scale scores range from 0 to 10 (ie, 0e2 points for each item; 0 ¼ best to 10 ¼ worst) and represent no sarcopenia (0e3) andsarcopenia (4e10).

B.J. Messinger-Rapport et al. / JAMDA 18 (2017) 928e940932

improving FEV1, improving quality of life, decreasing dyspnea scores,and reducing rescue inhaler use.36,59e61 Studies also found no differ-ence in efficacy between different LAMA so consideration should bemade to use the most cost effective medication. The combination oftiotropium and long-acting beta-agonists (LABA) has been shown tosignificantly improve FEV1 and health-related quality of life and wasmore effective than doubling the dose of a single agent. Interestingly,exacerbations were reduced when a LAMA was added to a LABA butnot when a LABA was added to a LAMA.

There are some safety concerns with the use of LAMA, includingpotential anticholinergic effects such as dizziness, blurred vision,acute narrow angle glaucoma, and urinary retention. People withcreatinine clearance <60 are as especially high risk of experiencingan adverse effect. Urinary retention is more likely to occur in thepresence of other risk factors (severe benign prostatic hypertrophy,immobility, other anticholinergics) and early in the treatmentcourse.36,61 There were also concerns that the different forms oftiotropium may place patients at higher risk of adverse

cardiovascular events. Tiotropium Respimat uses a different kind ofpropellant that delivers the medication through a very slow-movingmist that is designed to help patients inhale the medicine easier sothat the amount of medicine the patients take in does not depend onhow fast they are able to inhale. Initial studies showed an increasedrisk of cardiac arrhythmias in the Respimat format vs the HandiHalerformat but cumulative data have found no overall difference in safetyand adverse outcomes between the 2 forms. These trials were notdone specifically in PA-LTC or elderly populations but because theRespimat form is easier to inhale, it may be better for frail elderly andthose living in LTC. One may consider avoiding it in people withbaseline significant arrhythmias.62,63

Long-Acting Beta-Agonists

The most commonly used long-acting beta-agonists (LABA) med-ications are salmeterol and formoterol (administered twice daily) andindacaterol (administered once daily). Indacaterol was found to

Table 1Challenges and Advantages of Inhaler Types

Pressurized MDIs Dry Powder Inhalers Nebulizers

Challenges “The most complex dosage form in medicine”Spacers þ/�

Low force of inspiration / Y drug in the lung, [ drugin mouth or pharynx.

Can contribute to systemic adverse events.

1. Need daily cleaning2. Longer time to admin3. LAMA (tiotropium) not avail as neb

Advantages Cost Do not require� coordination of inhalation with activation� hand strength

Only require normal tidal respiration

Optimizing use Use breath-actuated MDIif strength limitation

Education goes a long way Use for physical and/or cognitive disabilities

B.J. Messinger-Rapport et al. / JAMDA 18 (2017) 928e940 933

improve FEV1, breathlessness, rescue inhaler use, and quality of life aswell as or better than placebo, twice daily LABA, and tiotropium withNO increase in total adverse events, serious adverse events, or adverseevents that led to discontinuation. Side effects of LABA are tremor,tachycardia, and arrhythmias. They tend to be milder than those seenwith short-acting bronchodilators but caution should still be heldwhen using in frail, multimorbid older adults.36,49,64

ICS

ICS are indicated for people with COPD who experience frequentexacerbations. In that group, it has been shown to reduce exacerba-tions and decline in health status and improve health-related qualityof life scores. As with other drug classes, there appears to be no dif-ference in daily vs twice daily dosing so consideration should be madeto use the cheapest and/or easiest to administer.36,65,66 There is alsosome evidence that starting a LABA/ICS combination in drug-naïvepatients older than 65 years with an asthma component (ACOS) de-creases death and hospitalizations.37,41 ACOS is the only time onewould consider an ICS for first-line therapy. For people with pureCOPD (with no overlapping asthmatic component), ICS are reservedfor more severe, refractory disease because of the potential associatedadverse events. People with COPD on ICS have a higher risk of pneu-monia and pneumonia-related mortality.36,37,65 In addition, ICS havebeen associated with decreased bone mineral density, increasedfractures, cataracts, oral candidiasis, and drug-drug interactions sinceICS are metabolized by CYP3A4 enzymes.

Other Therapies

Roflumilast is a phosphodiesterase (PDE-4) inhibitor that has beenshown to significantly improved pre and post FEV-1, breathlessness/dyspnea, and exacerbations. However, this medication is associatedwith significantly higher adverse effects, including diarrhea, nausea,headaches, weight loss, nasopharyngitis, and upper respiratory in-fections. In addition, this medication has not been studied in a PA-LTCpopulation and studies include patient with only a mean age of62e68 years.36,41,67e70 Careful consideration of the risks and benefitsof this medication should be taken before starting in PA-LTC and olderpopulations.

Theophylline is also a PDE-4 inhibitor but is not recommended forthe PA-LTC population because there is a decreased physiologicalresponse to theophylline with aging; it has not been well studied inolder adults; and it has a narrow therapeutic window with high drug-drug/drug-disease interactions. In other words, to achieve a thera-peutic benefit in older adults, theophylline would need to be titratedto a dose that would cause toxic reactions.36,41,67e70

The routine use of macrolide antibiotics in advanced COPD hasbeen studied and shown to decrease exacerbations and improvequality of life. Unfortunately, these benefits come at the cost of anincreased risk of antibiotic resistance. Therefore, it is not recom-mended to routinely prescribe macrolide antibiotics for the treatment

of patients with COPD and this practice is currently limited to researchstudies.36,41,67e70

Oxygen has been associated with a 50% mortality reduction and isindicatedwhen the patient’s PaO2 is less than 55mmHg or SaO2 is lessthan 90%. There is no reported benefit if the PaO2 is above 60 mm Hg.Continuous oxygen therapy is associated with better outcomes thanwith nocturnal use only.41,49

Nonpharmacologic Interventions in COPD

Pulmonary rehabilitation is the mainstay of treatment to be usedalongside medication management and has been incorporated intoall major COPD treatment guidelines. Pulmonary rehabilitation is ahighly effective and safe intervention that has been consistentlyshown to reduce hospital admissions and mortality, and improvefunctional capacity, dyspnea and health-related quality of life.51,71e75

Rehabilitation protocols should include endurance and resistancetraining. Unfortunately, rehabilitation programs are often limited inavailability. In addition, studies often excluded people with severeCOPD and functional limitations and only studied young andoutpatient populations.

There is limited data on the impact of pulmonary rehabilitation inthe PA-LTC setting but a couple of recent studies suggest that there ispositive impact of incorporating a pulmonary rehabilitation programinto the care plan of this population. The Geriatric-COPD (GR-COPD)research group created an individually tailored rehabilitation programwith a palliative care component. There were 12 interprofessionalmodules that covered (1) optimizing pulmonary medication use andinhalation techniques; (2) Chronic use of oxygen; (3) smoking cessa-tion; (4) control of symptoms; (5) physiotherapy (endurance andstrength training, inspiratory muscle training, relaxation techniques,breathing regulation skills and mucus evacuation techniques); (6)occupational therapy (regulation of pace, use of walking aids); (7)nutritional status and dietary supplementation; (8) speech, breathing,and swallowing techniques; (9) Psychosocial management; (10) self-management strategies and peer support contact; (11) spiritualneeds; and (12) advance care planning. People with COPDwere placedinto 2 different groups. The GR-COPD 1 group was comprised of pa-tients with a stable disease course whose goals were to regain pre-hospitalization functional status. For this group, the programmaticfocus was exercise, medication optimization, nutritional advice, andpatient education. The GR-COPD2 group included patients withfrequent exacerbations and hospitalizations, multiple comorbidities,and functional decline or dependency. For this group, the focus was onquality of life and palliation with attempts to slow functional decline.For both groups, this postacute program showed a significant andclinically meaningful improvement in functional capacity and healthstatus.75

Another study of pulmonary rehabilitation in PA-LTC offered anindividualized protocol of 24 sessions over a 6-8 week sessions. Thedescription of the protocol was not different than what is typicallyoffered in the United States postacute setting except that this group

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had 3-hour sessions (longer than the typical skilled nursing facilitysession) 3e4 days a week (less frequent than in the typical skillednursing facility). This is a small study (23 patients in 1 postacute fa-cility) with no placebo group so should be seen as a preliminary andhypothesis-driving study. That being said, the researchers foundimproved 6-MWT and improved quality of life scores. Patients underage 65 years also benefited from improved dyspnea scores.76

Other important nonpharmacologic treatments for COPD includethe following:49 (1) smoking cessation, which reduces mortality andcardiovascular risk; (2) influenza vaccination, which reduces exacer-bations, hospitalizations, and mortality; (3) patient education, whichreduces exacerbations and healthcare utilization; (4) nutritionalsupplements, which when combined with exercise can improvehealth-related quality of life, exercise capacity, and weight loss; (5)noninvasive ventilation (CPAP and BiPAP), which for selected patientsmay improve quality of life and reduce mortality; and (6) lung re-ductions surgery, which has very limited evidence of efficacy in olderadults.

Figure 3 is a pyramid of treatment that helps guide treatment forpractitioners.41

Treatment of Exacerbations

Practitioners in PA-LTCmust be comfortable with themanagementof COPD exacerbations. Early identification and treatment of COPDexacerbations may help to avoid emergency room visits and hospi-talizations. Identification of exacerbations may be more challengingbecause of atypical presentations in the elderly and PA-LTC pop-ulations, including dizziness, extreme weakness, chest pain, andconfusion. Once an exacerbation has been identified, the mainstay of

Fig. 3. The COPD pyramid of treatment. Adapted from the Canadian Thoracic Society and Greduction surgery including endobronchial approaches; OCS, oral corticosteroids; Roflummuscarinic antagonist; Vaccinations, annual influenza, pneumococcal, and pertussis vaccin

treatment are short-acting b2-agonists and systemic steroids, whichshorten recovery time, improve lung function (FEV1) and arterialhypoxemia (PaO2), and reduce the risk of early relapse or treatmentfailure.49 Antibiotics stewardship is important and antibiotics are notneeded for all exacerbations. People who would most likely benefitfrom antibiotic treatment for an acute COPE exacerbation exhibitincreasing dyspnea despite initial treatments with short-acting b2-agonists and systemic steroids, increasing sputum volume, andpurulence.

End-of-Life Care Planning

COPD is a progressive inflammatory disease with a decline tra-jectory that is marked by functional decline following an exacerbationwith return to slightly below pre-exacerbation baseline. Therefore, itis very difficult to accurately prognosticate. Some clinical features thatare more likely to be associated with end-stage (6-months or less tolive) COPD are disabling shortness of breath at rest, progressive res-piratory decline, increased emergency room visits or hospitalizations,low oxygenation at rest (PaO2 <55 mm Hg or SaO2 <88%), progressiveweight loss greater than 10% in last 6 months, and resting heart rategreater than 100 beats/minute.54 Even when these features are pre-sent, 50% of patients will live beyond the expected 6 months. Despitethis, patient may benefit from a comprehensive interprofessionalpalliative care team for symptom management and advanced careplanning.77,78

Treatment of breathlessness in advanced disease is challenging.Opioids can help to reduce air hunger and are particularly useful in thevery terminal stages of COPD. Systemic anticholinergics or anti-muscarinics are also used frequently to reduce excessive secretions

OLD guidelines. Azith, azithromycin; LTS, lungs transplant surgery; LVRS, lungs volume, roflumilast; Theo, theophylline; SABA, short-acting b2-agonist; SAMA, short-actingations.

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and dyspnea associated with end-stage illness. These drugs are notused for long-term bronchodilation in stable disease. Reduction ofpolypharmacy has also been shown to reduce reported breathless-ness. Finally, 10-20 minutes of daily aerobic exercise can improvedyspnea and 6-MWT even in advanced disease.41,79e81 Treatmentsthat do NOT help to reduce breathlessness include benzodiazepines(although these medications may be useful to reduce anxiety that isoften an accompanying condition in advanced COPD) and oxygen inthe absence of hypoxia.

In conclusion, COPD is common in PA-LTC populations but isundertreated. It is recommended that providers follow the estab-lished GOLD and AMDA guidelines for the management of COPD.Non-pharmacologic treatments, including pulmonary rehabilita-tion, are evidenced-based and beneficial for all patients, regardlessof functional status or disease stage. Pharmacologic treatmentstarts with LAMA with the addition of LABA for more moderate orsevere disease. ICS are reserved for patient with frequent exacer-bations or ACOS. Patients should be prescribed the cheapest andeasiest to use inhalers, remembering that MDIs are the mostdifficult for people with functional or cognitive impairments.Nebulizers may be used for maintenance therapy in the presence ofcognitive and functional loss. Practitioners should continuallyevaluate for and manage frailty, OSA, depression, and other co-morbid conditions to improve patient outcomes. Advanced careplanning should begin at the early stages of disease and continuethroughout the disease course.

Table 2Common Causes of Dementia in Older Persons

1. Primary age-related tauopathy (PART)2. Hippocampal sclerosis of aging3. Vascular dementia4. Lewy body dementia5. Dementia of diabetes mellitus6. Frontotemporal dementia (Pick disease) and primary progressive aphasia7. Hyperamyloidosis of the brain (Alzheimer disease)

Cognitive Impairment

“Memory is a passion no less powerful or pervasive than love”wElie Wiesel

All Rivers Run to the Sea

Cognitive impairment was one of the major areas identified by theJAMDA article titled, International Survey of Nursing Home ResearchPriorities.82 The International Association of Gerontology andGeriatrics Brain Health consensus conference felt that case finding forcognitive impairment should be done on all persons over 65 years ashealthcare professionals need to be able to recognize whether or notpatients can follow instructions.83 In addition, treatable causes ofcognitive decline need to be treated early,84 and lifestyle interventionsuch as a Mediterranean diet with extra virgin olive oil85e87 and ex-ercise88,89 can slow the rate of cognitive decline. Finally, early diag-nosis allows the development of advance directives.90e92

Between 2000 and 2012, dementia has decreased from 11.6% to8.8% in the USA. Cognitive impairment with no dementia declinedfrom 21.2% to 18.8%.93 This is most probably because of aggressivepreventive therapies for cardiovascular disease (hypertension andhyperlipidemia) in middle-aged persons. This highlights the role ofvascular dementia as a major cause of cognitive decline.94,95 Based onpostmortem studies done by the Seattle-based Adult Changes inThought study, 33% of persons dying with dementia have vascularbased lesions, with 45% having Alzheimer disease and 10% Lewy-bodydementia.96

Overproduction of amyloid precursor protein leads to decreasedmemory by inhibiting the release of acetylcholine and other neuro-transmitters, phosphorylating TAU, activating mitochondria to pro-duce apoptosis and oxidative damage, and creating amyloidplaques.97e99 It is important to recognize that persons with normalcognition can have amyloid-beta plaques.100 While pharmacologicdoses of beta-amyloid given into the hippocampus of mice causesmemory impairment, low doses of beta-amyloid enhance memoryand acetylcholine release from the hippocampus.101 Antibodies tobeta-amyloid or antisense to amyloid precursor protein-inhibitedlearning in young mice. Thus, the physiological role of beta-amyloid

is memory enhancement. This explains why drugs like semagace-stat, a gamma secretase inhibitor, which wipes out beta amyloidsecretion, failed to improve cognitive status. We have suggested that abetter understanding of Alzheimer disease could be obtained bycalling it hyperamyloidosis of the brain. Finally, it should be recog-nized that meta-analyses of cholinesterase inhibitors and Namendahave shown very small effects of these drugs as memory enhancersalong with a clear increase in side effects.102e104

Table 2 lists the common dementia in older persons. It is importantto recognize that persons with diabetes mellitus, in whom cognitiveimpairment is common from the age of 50 years,105 is not due toAlzheimer disease. Metformin may reduce the incidence of cognitivedysfunction in persons with diabetes.106 Table 3 lists the commoncauses of reversible dementias.107

Persons with moderate dementia respond to Cognitive StimulationTherapy, or SAIDO in Japan, at least as well as they do to drugs.108e111

This has also been shown in the nursing home.112 Similarly reminis-cence therapy may improve memory as seen with sports basedreminiscence therapy (eg, soccer or baseball).113,114

Families and physicians have problems recognizing dementia.115

Documented unsafe behaviors in persons with dementia where thehealthcare physician failed to make the diagnosis include self-medication management (49%), driving (23%), handling finances(29%), and visiting the doctor alone (29%).116 Based on recent studies,cognitive decline in early stages is best recognized by the MontrealCognitive Assessment or the St. Louis University Mental Status(SLUMS) examination.117,118 The SLUMS is available in 34 languages atwww.aging.slu.edu. The Rapid Cognitive Screen is derived from theSLUMS and takes under 3 minutes to administer.119 It functions betterthan the Mini-Cog or Mini-Mental State Examination. Our group hasshown that early recognition of mild cognitive impairment can lead to48% of these patients being normal at 6 years when provided appro-priate management by geriatricians.120

Recent evidence has suggested that persons with mild cognitiveimpairment who also have frailty have particularly poor out-comes.121e129 The FRAIL scale represents a rapid, well-validated testfor frailty.130e134 Both the Rapid Cognitive Screen and the FRAIL areincluded as part of the Rapid Geriatric Assessment.135,136

It is clear that the diagnosis and management of dementia isextremely complicated and that appropriate management can slow orreverse its course. This is a clear example where computer assistedpatient centered approach (P4 medicine) will be the appropriateparadigm137 (www.dementiaacademy.co.uk).

Update on Wound Care

Wound Care Societies

In the past 10 years, the emphasis on a standardized and scientificapproach to chronic wound care has greatly increased. Several orga-nizations are leading this charge through education, advocacy, and thedevelopment of practice guidelines to set more rigorous standards ofclinical practice. In many cases, these organizations sponsor reputablepeer-reviewed journals dedicated to wound management. Govern-mental agencies are taking note of these efforts and establishing

Table 3Treatable Causes of Dementia

Drugs e anticholinergicEmotional e depressionMetabolic e hypothyroid, B12 deficiencyEars and Eyes e hearing (eg, wax in ears) and visual deficitsNormal pressure hydrocephalus e “wild, wobbly, and wet”Tumor/trauma and other space occupying lesionsInfectionsAtrial fibrillationSleep apnea

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policies that align with published recommendations and nationaladvisory panels.

The Association for the Advancement of Wound Care is a nationalleader in the field of chronic wound care. This nonprofit organization,established in 1995, offers many educational resources and maintainsa Guideline Task Force that reviews and publishes practice guidelinesfor the US Department of Health and Human Services Agency forHealthcare Research and Quality. The most recent Venous Ulcer andPressure Ulcer guidelines were produced in 2010.138 Association forthe Advancement of Wound Care supports the journal Ostomy WoundManagement.

The National Pressure Ulcer Advisory Panel is another national not-for-profit organization with international collaborations (EuropeanPressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance)that has developed many guidelines and resources for wound care.Most well-known include the Pressure Ulcer Scale for Healing tool andthe 2014 Prevention and Treatment of Pressure Ulcers: Clinical Prac-tice Guideline, which includes 575 recommendations. Most recently,an updated International Pressure Ulcer Guideline was published in2016, with revised staging terminology of “pressure injury” and thecategorization of “deep tissue injury.”139

The Wound Healing Society is a nonprofit scientific organizationfocused on both acute and chronic wound healing. This organizationsupports the journals of Wound Repair and Regeneration and Advancesin Wound Care This society has published updated guidelines fordiabetic foot ulcer, arterial ulcers, pressure ulcers, and venousulcers.140

Educational certification in wound care is possible through severalorganizations and for different medical providers.141 Certificationcourses are of varying length and cost, with some requiring continuingeducation for maintenance of certification. AMDA, The Society forPost-Acute and Long-Term Care Medicine, also offers educationalmaterials in chronic wound care. An updated Pressure Ulcer and OtherWounds Clinical Practice Guideline was just released in 2017 and aClinical Practice Guideline for Nursing Assistants CD-ROM and slideset includes material on pressure ulcers as well as other chronicmedical conditions.142

Wound Biofilm

In the last few years the discussion of biofilm in chronic woundcare has become increasingly common. Biofims are bacterial aggre-gates within a biopolymer matrix that are resistant to antimicrobialtreatment and may impede wound healing. Biofilms are difficult toremove, and it is postulated that debridement of biofilm will improvehealing in wounds that have failed to improve with traditional topicaltreatments. Unfortunately, there is lack of consistent data on thediagnostic criteria for biofilms, how to test for biofilm presence, andthe best type of treatment (duration and frequency) to remove thebiofilm. As many studies assess wounds of mixed etiology, size, andcomorbidities and are of small sample size, the quality of scientificdata is often limited.

A recent consensus panel of experts was convened to developrecommendations for the management of biofilms but identified noclinical, therapeutic, or diagnostic randomized controlled trials toinform the consensus document.143 Using basic science evidence, thispanel deemed “investigation for presence of biofilm” a “stronglyrelevant” recommendation for diabetic foot ulcers and dehisced sur-gical wounds. The panel strongly recommended mechanicaldebridement for pressure ulcers, venous ulcers, and diabetic foot ul-cers when biofilm presence was suspected. Adjunctive use of anti-microbial dressings and topical antiseptics were stronglyrecommended in arterial, pressure, and diabetic foot ulcers but notvenous stasis ulcers.

Another consensus panel, from the European Society for ClinicalMicrobiology and Infectious Diseases, had a more reserved view instating that,

“There is no evidence to support the use of systemic antimi-crobial agents to prevent biofilm infections in the treatment ofwound-associated infections. While the rationale for debride-ment seems logical, the evidence to support its use to enhancehealing is scarce. There is more evidence in the literature on theeffectiveness of debridement for diabetic foot ulcers than forvenous ulcers and pressure ulcers. After debridement, topicalantimicrobial agents may be more effective in the treatment ofthe infected wound and in avoiding the re-establishing of mi-crobial biofilm.”144

Although debridement of biofilm is recommended, the evidence islimited. A small but well-designed randomized controlled study of 14chronic wounds with biofilm was recently published. Use of sharpversus hydrodebridement of chronic wounds failed to demonstratesignificant reduction in bacterial tissue load after the intervention, or adifference in bacterial reduction between the 2 debridementmethods.145

Debridement for removal of slough or necrotic tissue (not biofilm)has a more established clinical evidence base. A study of 48 diabeticfoot ulcers randomized to sharp vs enzymatic debridement showedgreater improvement in wound healing in the enzymatic group.Enzymatic debridement was more cost effective, as the sharpdebridement required multiple visits to a wound care center incontrast to home administration of the enzymatic product.146 Otherauthors failed to find difference in wound size reduction or closurerates for diabetic foot ulcers (N ¼ 215) randomized to enzymaticdebridement versus topical hydrogel.147 A systematic review ofdebridement methods for diabetic foot ulcer also failed to endorse onemethod of wound debridement over another.148

Device-Assisted Healing

Negative pressure systems may be the most commonly appliedand studied devices used to assist in wound healing. Systematic re-views have looked at negative pressure therapy in a variety of acuteand chronic wound types.149 Study quality remains limited with noconsistent evidence to support meaningful wound healing benefits.Despite limited data on efficacy, negative pressure devices areroutinely used for both acute and chronic wounds.150e152 Both elec-trical and mechanical force can be used to power these negativepressure devices. Mechanical force was found to be noninferior toelectrical force in one study.153

Electrical stimulation for wound healing is another well-studiedtechnology for chronic wound management. It is postulated thatelectrical stimulation works by reducing pathogen load, inducingangiogenesis, and increasing fibroblast proliferation. To reducedchance of skin burning, the current is generally delivered in a pulsed,direct current manner. A systematic review by Kawasaki et al154

identified 7 suitable studies of electrical stimulation for wound

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healing. Overall, electrical stimulation had few adverse effects. Therewas moderate quality evidence to support its use in healing pressureulcers. Another meta-analysis demonstrated significant reduction inulcer size of 24%e62% in 6 trials when compared with controltreatments.155

Unlike electrical stimulation, studies on therapeutic ultrasound forwound healing have not demonstrated significant benefit. Severalmeta-analyses have been performed on a variety of wound typeswithout evidence of improved wound healing. Three studies of ul-trasound vs sham procedure on pressure ulcers failed to demonstratebenefit of this technology.156 Studies of venous ulcer healing showedinitial benefit of ultrasound at 7 weeks; however, sustained results atthe 12 week endpoint were not seen.157

Hyperbaric oxygen therapy in wound care has been used mostsuccessfully for managing diabetic foot ulcers. Most data for treatmentof other wound types have not been positive. A 2015 systematic re-view identified 10 studies (N ¼ 531) of diabetic foot ulcers. Ulcerhealing was improved at 6 weeks [risk ratio (RR) 2.35, 95% confidenceinterval (CI) 1.19e4.62; P ¼ .01], however, this was not sustained at1 year. There was no reduction in rate of limb amputation. One trial ofvenous ulcers and “mixed” ulcers were reviewed with reduction inulcer area at 4e6weeks, however, both studies were very small in size.There were no studies of arterial or pressure ulcerations.158

Topical Wound Treatments

Interventions to reduce wound bed pressure have focused onrepositioning and support surface technologies. A randomized clinicaltrial in nursing homes studied turning intervals of 2, 3, and 4 hours toreduce pressure ulcer development in moderate-high risk individuals.Overall 2% of the populationdeveloped a pressure ulceration, and therewasnodifferent between the groups at different turning intervals.159 Ina treatment trial, nursing home residents with stage 1 pressure ulcer-ations were randomized to 2-hour vs 4-hour turning intervals. Therewas no difference in ulcer progression between the groups.160

In its fourth update, a Cochrane meta-analysis of support surfacesto prevent pressure ulceration was performed. Fifty-nine trials wereidentified, but little high quality data was noted. Studies did supportthe use of foam alternatives to standard hospital mattresses. Themerits of other pressure reducing overlays is unclear.161 Once a pres-sure ulcer has been identified, treatment with specialty mattresses oroverlay product may reduce pressure, but little data demonstratesbenefit of one product type (air vs foam) over another.162

Many skin preparations have been proposed to prevent pressureulcer development. These may include dressings, topical gels orcreams, or barrier products to reduce skin maceration. Althoughquality of studies was poor for pooling of data, there was some evi-dence that topical dressings applied to pressure areas may reducepressure ulcer incidence; RR 0.21 (95% CI 0.09e0.51; P ¼ .0006).Similarly, use of topical agents may reduce the pressure ulcer inci-dence by 36%; RR 0.64 (95% CI 0.49e0.83; P ¼ .0008).163

In treating pressure ulcers, there is insufficient high quality data todetermine whether certain topical antiseptics or antimicrobial agentspromotewound healing.164 Similarly, there is little evidence, includinga 2017meta-analysis, that shows certain classes of topical dressing aresuperior to others for wound healing.165

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