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The role of the consultant pharmacist in long-term-care

In Geriatric Medicine and Medical Direction – Volume 36 Issue 4 – April 2015 A Peer Reviewed Journal of the Minnesota Medical Directors Association Managing Residents with Parkinson's Disease in Long-Term Care
By: Martha A. Nance MD
Parkinson's disease currently affects up to one Although the diagnostic criteria for PD emphasize million Americans. With increasing longevity as we motor features of the disease, there has been a better manage the complications of conditions of growing awareness over the last 20 years of the middle age such as diabetes, hypertension, and importance of its nonmotor aspects (Seppi et al, hypercholesterolemia, that number is expected to 2011). Loss of sense of smell, constipation, and rapid- double globally over the next 25 years. Until there is a eye-movement (REM) behavioral disorder may cure for the disease, a growing proportion of this precede the onset of motor symptoms by years or increasing number of people with Parkinson's disease decades. And as our "Parkinson's medications" help will live to experience the later stages of their disease, people to maintain mobility for decades after the needing hands-on assistance with activities of daily diagnosis, affected individuals live on to experience living, either in the home or in a care facility. the long-term complications of the neurodegenerative It is useful, therefore, to review the common orthostatic hypotension, and neurogenic bladder. Parkinson's, focusing particularly on the practical In addition to these features that are directly issues that primary care physicians typically address, related to Parkinson's disease, people with this such as medications, rehabilitation team referrals, diagnosis, particularly as they age, often have or prognosis, and end-of-life discussions and care. develop multiple comorbidities (King et al, 2014): heart disease, diabetes, and hypertension; renal, 1. Introduction to late-stage Parkinson's disease
pulmonary, or hepatic dysfunction; sensory input The average onset of Parkinson's disease is issues (hearing or visual loss); orthopedic challenges; between age 60-65, but there is wide variation, with comorbid Alzheimer's disease; mood and behavioral rare individuals as young as 30 developing symptoms issues such as depression and anxiety; and of the disease. The diagnosis is still made primarily by complications related to falls, infections, skin issues, recognition of the core motor features of the syndrome—resting tremor (often unilateral at onset), Several scenarios result in nursing home rigidity, bradykinesia/hypokinesia, and characteristic placement for a person with Parkinson's disease. It is posture and gait changes. Depending on the clinical not usually mobility issues alone, as spouses and presentation, lab work and brain imaging can be used family are usually able to make adaptations that to rule out other conditions that can mimic some of permit continued home management in this situation the features of the disease (e.g., brain CT or MRI to (although a patient who lacks family support may rule out normal pressure hydrocephalus; chronic need nursing home care purely for motor/mobility subdural hematomas; "vascular Parkinsonism," or reasons). Predictors of placement in long-term care other rare conditions; and ceruloplasmin to rule out are the emergence of significant dementia, with or Wilson's disease). A dopamine transporter imaging without hallucinations, greater functional impairment, study, called a "DAT" or "SPECT" scan can be and falls (Aarsland et al, 2000). Long-term care obtained in some centers, and may become a standard placement in some cases is preceded by a diagnostic tool in the future. It is not widely used hospitalization for a fall, a surgery, an episode of delirium from which there is incomplete recovery, so that a short-term rehabilitation stay morphs into MMDA TOPICS in Geriatric Medicine and Medical Direction 1 April 2015 permanent placement. Finally, death or incapacitation preparations 30-60 minutes before or 60 minutes after of a spouse may lead to a need for placement in an a meal for maximum benefit. For some patients this is elderly person with Parkinson's disease. a major issue, and for others, it is not so critical. Individuals with Parkinson's disease who move Several other medications used to address the into long-term care often change health care primary motor features of Parkinson's disease act providers, as they become less able to return to the indirectly through dopaminergic pathways and clinic to see the neurologist. The burden of medication processes: dopamine agonists including pramipexole, management then falls on the primary care provider or ropinirole, rotigotine "act like dopamine" by geriatrician, who may be new to the patient. The need stimulating the postsynaptic receptor directly. for skilled palliative care for Parkinson's disease has Monoamine oxidase (MAO) inhibitors (selegiline, been mentioned, but has been no organized movement rasagiline) prevent the breakdown of dopamine that is at a national level to bridge the gap between outpatient already present in the synapse; and the catechol-O- neurological management and facility-based care by methyl-transferase (COMT) inhibitor entacapone, non-neurologists (Richfield et al, 2013). prevents the breakdown of levodopa, and is therefore always taken with a levodopa product, to enhance its 2. Use of medications in Parkinson's disease
At least ten different medications are commonly Anticholinergic drugs such as trihexyphenidyl or used for the management of the motor symptoms of benztropine are sometimes used to reduce tremor or Parkinson's disease, falling into six categories: dystonia if these are prominent in a particular levodopa (dopamine replacement), dopamine agonists, individual. This class of drugs has a strong potential to anticholinergics, exacerbate problems that many Parkinson patients catechol-O-methyl transferase inhibitors (used as already have: dry mouth, constipation, orthostatic adjunctive therapy along with levodopa), and hypotension, and cognitive impairment. For these amantadine (Connolly and Lang, 2014). Deep-brain reason, they are used sparingly and cautiously. stimulation surgery has been an FDA-approved Finally, amantadine is an unusual drug that therapy for Parkinson's disease since 2002. Finally, a occupies a niche in the management of Parkinson's host of prescription and over-the-counter drugs are disease. It is used sometimes as initial therapy as the used for the many nonmotor aspects of the disease. physician postpones the use of a "stronger" drug in a We will review each of these briefly. patient with mild motor symptoms, and later as adjunctive therapy in a patient who has both "off" a. The ten commonly used "Parkinson's
times as their levodopa wears off at the end of a dose and "dyskinesia" as the next levodopa dose reaches its The most effective medication for Parkinson's peak effects. Amantadine has the potential to reduce disease is levodopa, which, after conversion in the both the "off" times and dyskinesia. brain to dopamine, replenishes the dopamine The scheduling of these medications is quite deficiency that is the root cause of the early motor important, and different medications have different features of Parkinson's disease. Peripheral conversion constraints. Amantadine given too late in the day can of levodopa to dopamine results in nausea or interfere with sleep, while selegiline is metabolized vomiting. Carbidopa, a competitive inhibitor of this into amphetamine and should only be given in the enzymatic pathway, is combined with levodopa to morning. Dopamine agonists, on the other hand, often allow levodopa to more effectively pass into the brain. cause drowsiness and are relatively long-acting, which Levodopa (with carbidopa) comes in a number of can be useful at night but not useful during the daytime. Unless the patient is actively shaking at immediate-acting, bedtime and the tremor interferes with sleep, there is (ParcopaTM) forms, and combined with entacapone in no reason to use an anticholinergic agent at bedtime. StalevoTM. Two new forms of levodopa were approved by the FDA in 2015: Rytary™, a extended- b. Levodopa: "On time, every time"; specify
release oral form of levodopa with carbidopa, and administration times; prn dosing
Duopa®, a gel form administered via an intestinal Virtually all individuals in the mid to late stages infusion pump. Each of these formulations comes in of Parkinson's disease are taking some form of varying dose strengths. Dietary protein can interfere levodopa, as injury to the dopaminergic cells in the with the absorption of orally-administered levodopa, substantia nigra leads those cells to be increasingly so patients are often instructed to take levodopa unable to make dopamine (this is somewhat analogous MMDA TOPICS in Geriatric Medicine and Medical Direction 2 April 2015 to the diabetic who uses insulin injections because the staff to find a strategy that works most safely for the pancreas is no longer able to produce insulin). These same cells also become increasingly unable to store dopamine once it is supplied to them, so that the c. Deep brain stimulation
duration of effect of a dose of medication becomes Deep brain stimulation (DBS) has become a shorter, and the patient is increasingly dependent on standard treatment for a certain subset of symptoms in the correct administration of the medication at the Parkinson's disease (Giugni and Okun, 2014). DBS correct time, in order to be able to move. Patients, does not change the course of the disease, and it does families, and, once medications are no longer under the patient's control, nursing staff, must be strongly dysfunction, or balance problems. It is used most encouraged and repeatedly reminded to give levodopa commonly in two clinical situations. "on time, every time," despite regulations that permit The most common situation is a patient 8-15 years early or late administration of scheduled medications! into the disease, who had tried or is taking several The point of taking Parkinson's medications is to different "Parkinson's medications," including help the patient move better and/or shake less for the multiple doses of levodopa each day, and who is next few hours. Most patients with early Parkinson's fluctuating between periods where the medications disease do not need to take medication at bedtime, as have worn off, and periods, usually when the they are asleep after that. Some patients in the mid- or medication effect is peaking, where there are irregular late-stages of the disease do need to take levodopa at involuntary movements known as dyskinesia. The bedtime. Likely, those patients also are taking their second situation is a patient with medication-resistant daytime levodopa at very specific times or intervals throughout the day. The physician would be wise to After proper programming, a stimulating electrode consult with the patient or family prior to writing placed in either the subthalamic nucleus or the globus levodopa orders, to ensure that the intervals between pallidus in the brain to treat contralateral tremor and doses are optimized, and to specify administration bradykinesia/hypokinesia, and reduces dyskinesia by times. "Carbidopa-levodopa 25/100 1 pill tid" often allowing medication dose reduction. Patients who defaults to an administration schedule of 8 a.m., 2 have had deep brain stimulator placement need to p.m., and 10 p.m., which will not work well for the have the impulse generator voltage checked at 6-12 patient who gets up at 6 a.m., eats breakfast at 7 a.m., month intervals. The impulse generator may work less and goes to bed at 9 p.m. That person will likely effectively as its battery runs out, producing a gradual function much better if the carbidopa-levodopa is worsening of PD symptoms that may be mistaken for given at 6 a.m., 11 a.m., and 4 p.m. Finally, although it is empowering to allow replacement is an outpatient surgical procedure that patients living in the community to "take an extra does not require touching the brain electrode. levodopa pill on a busy, long, active, or shaky day," I Stimulator programming is usually done as an have found the use of prn doses of levodopa in the outpatient in a Parkinson's disease specialty center or long-term care or assisted living facility to be quite a neurologist's office. Battery replacement is done by a neurosurgeon or, in some locations, a general specializing in the management of Parkinson's disease surgeon in a same-day surgical facility. may have the ability to judge, or help the patient judge, if an extra levodopa dose is warranted. But in d. Other medications
most facilities, the challenges of varying staff, the use A person with Parkinson's disease may arrive at a of TMAs to pass medications, the lag time if the TMA long-term care facility with a variety of medications has to consult with an RN before giving a prn dose, for a variety of PD-related symptoms. The following and the presence of dementia or potential for is not an exclusive list, but is meant to suggest the inappropriate medication requests in some patients, kinds of medications to look for on a medication list: make the proper use of prn levodopa orders difficult. Cognition: cholinesterase inhibitor, memantine
On some occasions, it may be possible to order a Depression: a wide range of antidepressants
specific time of the day that an additional dose is Apathy: elevating antidepressant, stimulant
sometimes (but not always) needed: for instance, Emotional incontinence: antidepressant or other
"carbidopa-levodopa 25/100, ½ pill prn at 5 p.m. for anxiety, tremor, restlessness." The prescriber may need to negotiate with the patient, family, and nursing MMDA TOPICS in Geriatric Medicine and Medical Direction 3 April 2015
Hallucinations: neuroleptic agent (any of which
patient ages or has complications, develops dementia could exacerbate the motor symptoms of Parkinson's or hallucinations—or if the person is no longer disease, as all are dopamine blocking agents; ambulatory anyway, it can be advantageous to quetiapine or clozapine are preferred in people with simplify the "Parkinson's regimen" when possible. A complex medication regimen is difficult to manage Anxiety: selective serotonin reuptake inhibitor
correctly, confusing to staff and patient, and often (SSRI), benzodiazepine makes it difficult to determine which drug (if any) is Sleep: benzodiazepine, melatonin, other over-the-
providing benefit. All Parkinson's medications counter remedies such as Benadryl promote hallucinations (they are mostly dopaminergic drugs), a complication that becomes increasingly polyethylene glycol (note: bulk agents can worsen likely as the disease progresses. The most effective constipation unless accompanied by enough fluids, drug for the motor symptoms of PD is levodopa, and and are often to be avoided in Parkinson's disease) so I would first consider tapering or discontinuing any Overactive
bladder:
and all other "Parkinson's medications" first, adding additional levodopa pills if the motor symptoms are a Excessive saliva: anticholinergic agents, botox
little worse when another drug is tapered. The order in injections in the salivary glands which to reduce non-levodopa medications may Orthostatic hypotension: fludrocortisone, midodrine,
depend on financial issues, specific side effects that a pyridostigmine, droxidopa person is having, apparent effectiveness of the drug at Seborrhea and dry skin are common in treating PD symptoms, or other issues (e.g., Parkinson's disease, and may require medicated entacapone [ComtanTM] is a large pill that some find shampoos and skin creams. Many people with difficult to swallow). In general, I would first try to Parkinson's disease are taking a variety of vitamins, discontinue medications in the following order: some recommended by the physician, and others on anticholinergic agents (confusion, constipation, dry their own. Some physicians prescribe supplemental B mouth, orthostatic hypotension), then MAO inhibitors vitamins when they prescribe levodopa, as folic acid is (modest benefits, and long list of potential drug used up in the process of metabolizing levodopa. A interactions), amantadine (hallucinations, benefits high proportion of Minnesotans with Parkinson's may wane over time), COMT inhibitors (large pill to disease are Vitamin D deficient, and so might swallow, causes darkening of the urine that can be appropriately be evaluated and treated for this mistaken for dehydration; benefits are often modest), problem. No other vitamins or supplements have been and lastly, dopamine agonists (more effective than the shown to have any significant effect in Parkinson's disease, with the possible exception of Mucuna obsessive/compulsive behaviors, peripheral edema, pruriens, an extract of a particular variety of broad and excessive daytime sleepiness). bean, which contains variable (and small) amounts of There are some general principles to consider levodopa, and is taken by some who want a "natural" when tapering medications: dopamine product.  Change one drug at a time Of note, Vitamin E, creatine, and Coenzyme Q10  Reduce a medication by one pill at a time at have all been proven ineffective in formal large-scale weekly intervals, or no more than a third of the clinical trials in Parkinson's disease (Shoulson, 1998; total daily dose, unless there is an emergency Parkinson Study Group QE3 Investigators, 2014;  Monitor the patient during the drug taper, and if Writing Group for the NET-PD Investigators et al, the motor function becomes noticeably worse, be 2015). Thus, a patient who is taking one of these over- willing to restart the drug at the lowest beneficial the-counter compounds as a treatment for Parkinson's disease should stop taking them. The goal of treatment in Parkinson's disease is to optimize the patient's function, not necessarily to 3. Adjusting Parkinson's medications in late-stage
remove all symptoms at all times. Some patients may Parkinson's disease
not be bothered by their tremors, where others are. There is no published literature to guide the Parkinson's medications generally do not need to clinician in adjusting medications in the late stages of be adjusted significantly in renal, hepatic, or cardiac Parkinson's disease. If a patient is doing well and is failure, or for weight loss, although an aging patient content with his motor function, there may be no may occasionally seem to have altered metabolism of pressing need to change anything. However, as the these medications, among many others. Constipation MMDA TOPICS in Geriatric Medicine and Medical Direction 4 April 2015 can significantly impact on the absorption of levodopa or made safer. When a person with Parkinson's begins from the intestine, leading to worsening motor to fall, it is often appropriate to make a referral not function that doesn't require a higher dose of only to PT, but also to OT, as the reason for the fall is levodopa, but, perhaps, an enema. often an attempt to do some activity of daily living The motor symptoms of Parkinson's disease that is no longer safe. OT can help the patient, family, commonly will be more prominent, as well, when a or staff in the care facility to develop a safer strategy patient develops some other medical issue such as a to accomplish that activity. bladder infection, influenza, or hyponatremia. This Parkinson's disease always has an impact upon transient worsening of symptoms will then resolve the voice, leading to quiet, breathy, strained, with treatment of the medical problem. whispered, or underarticulated speech. As the disease progresses, intelligibility declines, and the speech 4. Use of the rehabilitation team
therapist may be able to teach the patient strategies to improve breath support, head and trunk positioning, occupational, speech, music, recreational therapy) articulation, and voicing so as to improve vocal should be an integral part of the care team throughout quality. It is worth remembering that the same the course of Parkinson's disease. muscles that are used for speech are also used for Unfortunately, despite an explosion of chewing and swallowing—a patient with poorly literature documenting the benefits of specific intelligible or strained speech may also have difficulty interventions in small single-center studies, recent chewing and swallowing certain food textures. The Cochrane reviews have found insufficient data to speech therapist, in conjunction with nutrition support or refute the efficacy of occupational therapy, services, can work to adjust the diet and food textures or of one type of speech therapy or therapeutic to optimize safety and nutritional content. movement strategy over any other, mostly because of the lack of randomized controlled trials for review 5. Disease progression, end-of life and hospice
(Dixon et al, 2007; Herd et al, 2012; Tomlinson et al, The prognosis for a person with Parkinson's As research increasingly supports the role of disease in long-term care is poor. One study found a aerobic exercise both in the maintenance of 3-year mortality rate of 50% among over 15,000 strength/stamina, and perhaps in modifying the people with Parkinson's disease identified through the disease itself (Speelman et al, 2011), we routinely Minimum Data Set (Fernandez and Lapane, 2002), send patients very early in their course to physical and a recent meta-analysis of studies of mortality in therapy to plan out a specific exercise regimen Parkinson's disease found an increased relative risk appropriate for their age, health and activity level, and (2.22) of all-cause death in Parkinson's disease, and a goals. A number of "Parkinson's disease" exercise particularly increased relative risk in those with programs have been developed in the last few years, dementia (3.78) (Xu et al, 2014). including LSVT Big, Parkinson's Wellness and People with Parkinson's disease and their families can Recovery (PWR), RockSteady boxing, Nordic benefit substantially, in the late to terminal stages of walking, and forced exercise such as tandem biking. the disease, from a shift in focus from medical Yoga, Tai Chi, Pilates, and ballroom/tango dancing problem-solving to comfort care that focuses on programs have also been tailored for people with dignity, relief of pain, and planning for and Parkinson's disease. In the later stages, physical management of the medical and psychosocial events therapists assist with posture, gait and balance that accompany death. One recent study of 339 assessments, strategies to manage freezing of gait, patients followed in one center identified two recommendation and training in the use of assistive predictors of hospice eligibility (things more likely to devices such as canes and walkers, and in positioning happen 6-12 months before death compared to 18-24 and seating devices. months before death): body mass index <18, and Occupational therapists evaluate our patients change (reduction) in Parkinson medication use (Goy throughout their course for equipment and strategies to make safer or more convenient the myriad of daily There is no published guideline or literature to tasks that Parkinson's disease has an impact upon. guide the hospice physician, neurologist, or other Everything from tying shoes to shaving, managing practitioner in the use of Parkinson's medicines during urinary urgency, and rolling over in bed, can be the terminal stages. One does have to be careful not to affected by Parkinson's disease, and can be facilitated "stop everything," as abrupt discontinuation of MMDA TOPICS in Geriatric Medicine and Medical Direction 5 April 2015 dopaminergic drugs can lead to the neuroleptic REFERENCES
malignant syndrome, an acute and potentially fatal storm of events that includes severe rigidity, fever, 1. Seppi K, Weintraub D, Coelho M, Perez-Lloret S, Fox SH, Katzenschlager R, Hametner EM, Poewe W, Rascol and delirium. Some patients become very anxious or O, Goetz CG, Sampaio C. The Movement Disorder have escalating tremor if dopaminergic drugs are Society Evidence-Based Medicine Review Update: withdrawn, even in the terminal stages. Others just Treatments for the nonmotor symptoms of Parkinson's gradually slide into a quiet and increasingly persistent disease. Move Disord 2011 Suppl 3: S42-S80. sleep. Once again, the simplest medication to use is 2. King LA, Priest KC, Nutt J, Chen Y, Chen Z, Melnick M, levodopa, which can be given as an oral dissolving Horak F. Comborbidity and functional mobility in persons tablet (ParcopaTM) used in the same dose as immediate with Parkinson disease. Arch Phys Med Rehabil 2014; 95: 2152-2157. release levodopa. The dopamine agonist rotigotine 3. Aarsland D, Larsen JP, Tandberg E, Laake K. Predictors comes in the form of a skin patch, although there is no of nursing home placement in Parkinson's disease. J Am information regarding the transdermal absorption of Geriatr Soc 2000; 48: 938-942. the drug in the terminal patient. Benzodiazepines, 4. Richfield EW, Jones EJ, Alty JE. Palliative care for opiates, and barbiturates can be used for agitation, Parkinson's disease: a summary of the evidence and with caution to avoid precipitating delirium. future directions. Palliat Med 2013; 27: 805-810. 5. Connolly BS, Lang AE. Pharmacological treatment of Parkinson disease: a review. JAMA 2014; 311: 1670- although drugs that can be administered nonorally may be preferred in some situations. 6. Giugni JC, Okun MS. Treatment of advanced Parkinson's disease. Curr Opin Neurol 2014; 27: 450-460. 7. Shoulson I. DATATOP: A decade of neuroprotective The medical management of Parkinson's disease inquiry. Ann Neurol 1998; 44: S1-9. is complex, and often there is a shift in care teams 8. Parkinson Study Group QE3 Investigators, et al. A randomized clinical trial of high-dosage Coenzyme Q10 in early Parkinson's disease: no evidence of benefit. JAMA Neurology 2014; 71: 543-552. Parkinson's disease and the way medications treat 9. Writing Group for the Neuroprotective Exploratory Trials various symptoms of Parkinson's disease is useful for in Parkinson's Diseaase (NET-PED) Investigators, et al. all those involved in treating patients with Parkinson's Effect of creatine monohydrate on clinical progression in disease. Understanding the evolution of disease patients with Parkinson's disease: a randomized clinical symptoms with the progression of disease is also trial. JAMA 2015; 313: 584-593. 10. Dixon L, Duncan D, Johnson P, Kirkby L, O'Connell H, important for those monitoring symptoms and Taylor H, Deane KH. Occupational therapy for patients adjusting medications. This knowledge, along with an with Parkinson's disease. Cochrane Database Syst Rev understanding of the goals of treatment, can help the 2007; July 18; (3): CD002813. practitioner improve the quality of life for these 11. Herd CP, Tomlinson CL, Deane KH, Brady MC, Smith patients throughout their stay. CH, Sackley CM, Clarke CE. Comparison of speech and language therapy techniques for speech problems in Parkinson's disease. Cochrane Database Syst Rev 2012 About the Author
Aug 15; 8: CD002814. Martha Nance, MD is a board certified neurologist 12. Tomlinson CL, Herd CP, Clarke CE, Meek C, Patel S, and clinical geneticist with special interest in Stowe R, Deane KH, Shah L, Sackley CM, Wheatley K, movement disorders such as Parkinson's disease Ives N. Physiotherapy for Parkinson's disease: a Huntington's disease, hereditary ataxias and spastic comparison of techniques. Cochrane Database Syst Rev paraplegias, and other neurogenetic disorders. She 2014 Jun 17; 6: CD002815. has served as the medical director of the Struthers 13. Speelman AD, van de Warrenburg BP, van Nimwegen M, Petzinger G, Munneke M, Bloem BR. How might Parkinson's Center at Park Nicollet since 2000. physical activity benefit patients with Parkinson disease? In addition to the care of patients and families Nat Rev Neurol 2011; 7: 528-534. with neurologic diseases, she is involved in clinical 14. Fernandez HH, Lapane KL. Predictors of mortality research to develop better treatments for Parkinson's among nursing home residents with a diagnosis of disease and Huntington's disease, and interested in Parkinson's disease. Med Sci Monit 2002; 8: CR241-246. education for both patients and medical professionals. 15. Xu J, Gong DD, Man CF, Fan Y. Parkinson's disease and She is also a Clinical Professor of Neurology at risk of mortality: meta-analysis and systematic review. Acta Neurol Scand 2014; 129: 71-79. the University of Minnesota. 16. Goy ER, Bohlig A, Carter J, Ganzini L. Identifying predictors of hospice eligibility in patients with Parkinson disease. Am J Hosp Palliat Care 2015; 32: 29-33. MMDA TOPICS in Geriatric Medicine and Medical Direction 6 April 2015 Minnesota Nursing Home Quality Update- April 2015
Standardizing House Orders in Long Term Care
Jaclyn R. Guetzko, RN, BSN, DNP Student & Tom Von Sternberg, MD
The Metro Alliance of Geriatric Primary Care Providers is an interdisciplinary group of geriatric primary care providers in the Twin Cities Metro area. Together, the Metro Alliance represents the 12 major Minnesota healthcare organizations and over 345 authorizing providers who practice in long term care, transitional care, and assisted living facilities in our community. The main focus of the Metro Alliance is to focus on common, and when possible, evidence-based approaches to geriatric care. The goal of this collaborative work is to decrease the wide variation and inefficiencies of multiple approaches to common care issues in long term care. The group views this work primarily as promoting increased safety and efficiency for their long term care facility partners. The Metro Alliance has recently developed and endorsed a standardized standing order protocol that is intended for wide distribution in long term care facilities across the state of Minnesota. In doing this, community nursing homes participants and each of the provider group's standing orders were collectively pooled and redesigned into one standardized and universally applicable standing order protocol. All Metro Alliance members were involved in the redesign, with a common goal of creating one homogeneous, practice-approved, and evidence-based standing house order set that is truly relevant in long term care. The new standing order protocol is intended to be a sister document to the standardized Transitional Care Unit standing orders developed by the Metro Alliance in 2013. Evidence-based protocol formats are endorsed by numerous professional organizations including the Centers for Medicare and Medicaid Services, the Institute of Medicine, and the American Medical Directors Association. Existing literature in regards to standing orders has shown that they are a safe way to increase patient access to medical treatment through optimal use of nursing skills. Standardization initiatives that emphasize consistent approaches to care represent an important contribution to improving the quality, safety, and reliability of nursing home care. Nursing home staff experience enough challenges in providing care and assessing changes in status. Adopting one approach to the large number of clinical domains of a patient as they enter a long term care facility is a critical tool for facility staff to provide To access the orders, visit the Metro Alliance of Geriatric Primary Care Providers website at: MMDA TOPICS in Geriatric Medicine and Medical Direction 7 April 2015 Minnesota Medical Directors Association
P. O. Box 24475
Minneapolis, MN 55424
Fax: 612-656-3016
Executive Director: Rosemary Lobeck Editor: Jane Pederson, M.D. E-mail: rlobeck@mnmeddir.org Topics in Geriatric Medicine and Medical Direction is produced and Published bimonthly by the Minnesota Medical Directors Association. Topics in Geriatric Medicine and Medical Direction, the peer reviewed bimonthly publication of the Minnesota Managing Residents with Parkinson's Disease
Medical Directors Association, is committed to publishing quality manuscripts representing scholarly inquiry into all in Long-Term Care
areas of geriatrics and long term care medical direction and practice. We encourage submissions of geriatric and long Minnesota Nursing Home Quality
term care research, best practices, reviews of literature and Manuscripts should be emailed to President's Letter
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Source: http://www.minnesotageriatrics.org/Topics_april_15.pdf

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Strategies for Improving Care :  A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used. B  Treatment decisions should be timely and based on evidence- based guidelines that are tailored to individual patient

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DOCTORADO EN EDUCACION CON ESPECIALIDAD EN MEDIACION PEDAGÓGICA EDUCAR, PARA VIVIR EN PLENITUD -Trabajo de graduación- Por: Daniel Domingo López Guatemala, octubre de 2014 De la eclosión cósmica a la involución humana La eclosión de vida La involución paradigmática La decodificación de la conciencia y la corporalidad del