Vitamin D is frequently seen as part of the medication list of older adults, particularly those in long-term care (LTC). The LTC population is more at risk of vitamin D deficiency due to factors such as little or no sunlight exposure, malabsorption, frailty, and other comorbidities. Our clinical experience has been that vitamin D supplementation is ordered either because levels were found to be low or simply as a vague expectation that it can’t hurt or that it’s a “best practice.” But is there evidence that truly supports its universal use? Vitamin D deficiency is extremely common, affecting an estimated 50% of the U.S. population, 50% to 60% of institutionalized older persons, and up to 1 billion people worldwide (“Vitamin D Deficiency,” StatPearls, July 27, 2022, https://www.ncbi.nlm.nih.gov/books/NBK532266/). Additional vitamin D offers a plethora of potential benefits; the exhortations to use supplementation are found in both the medical and lay press, including a review in Caring for the Ages (2022;23[3]:11). These benefits include improved bone health, increased muscle strength, decreased falls and fractures, lessening of infections (including COVID-19), and improvements in many disease states such as cancer, diabetes, depression, cognitive decline, and autoimmune disease. Earlier meta-analyses (from 2014) found a link between vitamin D deficiency and all-cause and cardiovascular mortality (BMJ 2014;348:g3656) as well as evidence that D3 supplementation (as opposed to D2) is associated with reduced mortality (BMJ 2014;348:g1903). However, more and more evidence has found no support for the benefits of vitamin D supplementation in community-dwelling older adults, and the evidence in the LTC population has been lacking. In our experience, one major reason many practitioners start older adults on vitamin D supplementation is the belief that it will decrease falls and fractures. Recent studies do not routinely confirm this. For instance, the 2022 Vitamin D and Omega-3 Trial (VITAL), which included only “generally healthy midlife and older adults,” concluded that vitamin D supplementation did not result in a significantly lower fracture risk (N Engl J Med 2022;387:299–309). An accompanying editorial on the VITAL trial said that “providers should stop screening” and stop “recommending Vitamin D supplements” entirely (N Engl J Med 2022;387:368–370). However, for LTC residents the outcomes are mixed. A 2019 Canadian Agency for Drugs and Technologies in Health (CADTH) review of the literature found a statistically significant reduction in falls with vitamin D supplementation, but the 2021 update revealed that reductions were not always statistically significant (S. Banerjee et al., “Vitamin D Supplementation for the Prevention of Falls and Fractures in Residents of Long-Term Care Facilities: A 2021 Update,” Canadian Agency for Drugs and Technologies in Health, 2021, https://www.ncbi.nlm.nih.gov/books/NBK584609/). It is worth noting that this review only included three articles, and the authors concluded that further research is needed. In terms of other health outcomes, our review of the recent literature found only two articles that aim to understand the health impacts of vitamin D supplementation in nursing homes. A 2022 Spanish study looked at differences in depressive symptomatology and in several measures of nutritional status in 100 nursing home patients (Front Aging Neurosci 2022;14:880405). Although not the study’s primary end point, the differences between cognitive status groups were statistically significant with vitamin D use, and the researchers concluded that therapeutic serum levels could protect against cognitive decline. Sixty-six residents from a French nursing home were included in a 2020 study that showed giving a bolus of vitamin D3 either in the week after the suspicion or diagnosis of COVID-19, or the month before, was associated with less severe COVID-19 and a better survival rate (J Steroid Biochem Mol Biol 2020;204:105771. Neither study established recommendations for dosing, normal values, or routine screenings specific to nursing home patients. These two papers suggest that vitamin D supplementation could have some benefits for residents in LTC. However, is universal supplementation necessary? It is commonly known that vitamin D supplementation is not needed in those with normal 25(OH)D levels. However, the current guidelines favor supplementation in those who are vitamin D deficient (“Vitamin D: Fact Sheet for Health Professionals,” National Institutes of Health, Aug. 12, 2022, https://ods.od.nih.gov/factsheets/Vitamind-HealthProfessional/). Deficiency can only be determined through laboratory screening. Recommendations for routine screening of vitamin D levels exist for at least 30 clinical conditions, a list of which can be found in the Centers for Medicare & Medicaid Services Local Coverage Determinations (ID L33771). For all high-risk individuals, the recommendations state to remeasure at three and four months. More than 10 million vitamin D tests are performed in the United States yearly to distinguish between “insufficiency” (levels of <30 ng/mL) and “deficiency” (levels of <20 ng/mL), or as follow up after replacement therapy has been started (N Engl J Med 2022;387:299–309). A standard maintenance dose of 800–2,000 IU/day can be initiated for vitamin D insufficiency without having to recheck a vitamin D level. There is minimal risk associated with this level of vitamin D supplementation. For those being treated for vitamin D deficiency, a repeat screening may be warranted. Some have advocated for a monthly dose of 50,000 IU, which could reduce the daily pill burden but may affect compliance if the dose is forgotten. Use of bolus dosing is not encouraged (JBMR Plus 2021;5:e10567). Some have gone so far as to recommend vitamin D supplementation in all LTC residents (J Am Med Dir Assoc 2011;12:190–194). However, we do not feel the evidence supports universal vitamin D supplementation. Despite widespread vitamin deficiency in the LTC population and little evidence of harm, there is no clear evidence as to the benefits of universal replacement therapy in this population. There have also been questions about the cost effectiveness of population screening for vitamin D insufficiency compared with universal supplementation, with one study finding screening to be more cost effective than supplementation (J Am Geriatr Soc 2013;61:707–714). However, although testing costs may be low or covered by insurance, they are still a burden on the health care system, with the argument being that laboratory testing shouldn’t be performed if the resulting clinical decision-making isn’t shown to benefit patients. Ultimately, the decision to prescribe or deprescribe vitamin D is left up to the individual practitioner. Given the lack of clear benefit, added pill burden, and costs, we feel that deprescribing vitamin D is a reasonable option in patients who have serious, life-limiting medical conditions and in those who have a lower risk of fracture or fall, such as patients who can no longer leave their bed or are wheelchair confined. Additional studies are needed to justify universal supplementation, to prove the benefits of vitamin D supplementation for LTC residents, and to establish standards for testing and dosing. Dr. Haimowitz is a multifacility medical director and a member of the Caring for the Ages Editorial Board. Carmen Witsken, PharmD is the Executive Fellow in Association Leadership and Management at the American Society of Consultant Pharmacists (ASCP). Emily Cofsky is a 2023 PharmD candidate from Western New England University. Brittany Henault is a 2023 PharmD candidate from Western New England University. Emily Hajjar, PharmD, MS, BCPS, BCACP, BCGP is a professor at the Jefferson College of Pharmacy and clinical pharmacist with expertise in geriatrics and palliative care.

We commend AMDA for “retiring” its 2019 Statement on Stopping Eating and Drinking by Advance Directives “as the official policy of AMDA.”1 Removing this categorical prohibition on requests for Stopping Eating and Drinking by Advance Directive (SED by AD) permits practitioners to consider and evaluate each request for SED by AD under the situational circumstances of each individual case.

Assisted living (AL) has now surpassed nursing homes in terms of the number of long-term care residents who reside there (J Am Med Dir Assoc 2022;23:225–234). Yet as this has happened — and as the comorbidities, frailty, and need for activities of daily living assistance in AL residents have increased — the amount of staffing and medical care in AL communities has not risen proportionally. This issue is fairly well-known among health care professionals but has not been significantly addressed. Could now be the time? The AL industry has historically claimed that it is a “social model,” where older adults live in a homelike setting while receiving limited assistance. However, the AL industry has stressed that a social model is not intended to suggest a lack of health focus, and it would appear that a focus on medical issues would greatly benefit today’s AL residents. Historically, AMDA – The Society for Post-Acute and Long-Term Care Medicine has been cognizant of the need for increased medical care in AL. The Society’s Assisted Living Subcommittee, under the leadership of Sarah Howd, MD, CMD, and now Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, has advocated for increased attention to medical care in AL. AL residents requiring medical care can travel outside to see a provider, may have a visit with a health care provider within the AL community, or can get services via house call programs. Some AL communities contract with providers to offer medical services. Some AL communities may also opt for a medical director, and the Society’s subcommittee has worked on establishing guidance for medical directors’ contracts in AL. They’ve also produced infectious disease guidance, educational materials and podcasts, and a survey for Society membership on AL practice. Much of the subcommittee’s current focus is informed by the “Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel, A Consensus Statement” (JAMA Netw Open 2022;5:e2233872), which was led by Sheryl Zimmerman, PhD, of the University of North Carolina at Chapel Hill. The items most recommended included:•Providing training in person-centered care for staff.•Offering routine toenail care to residents.•Including residents in the assessment/care planning sessions.•Having policies and procedures in place for aggressive or other behaviors.•Maintaining post-visit practitioner notes and findings for all off-site medical or mental health visits. Many Society members participated in the Assisted Living Workgroup (ALW), a national initiative in 2003 intended to establish best-practices in AL through consensus. The ALW led to the establishment of the national Center for Excellence in Assisted Living (CEAL). CEAL comprises multiple AL organizations, including the Society. CEAL recently transitioned to leadership at the University of North Carolina; it is now called [email protected], with Dr. Zimmerman as its executive director. [email protected], the Society, and other organizations are forming a coalition — named “Be Well in AL” — to develop a framework that will integrate the recommendations from the AL consensus panel to improve resident care. Smaller but equally motivated groups are also helping in the AL world. Early in the pandemic, the California Association of Long Term Care Medicine (CALTCM) established a Delphi group/email discussion list focused on COVID-19 in long-term care. An offshoot of that effort specifically for AL began in the fall of 2020. Their AL project doesn’t meet the strict “Delphi” definition, but it observes similar principles of having multidisciplinary membership (including resident advocates) and deciding on projects from a challengingly large group of topics. This “small but mighty” group has had many accomplishments: working with the California Department of Social Services to develop educational resources on COVID-19 best practices and infection prevention basics in AL, collaborating with the American Society for Consultant Pharmacists (ASCP) for COVID-19 vaccinations in AL, and publishing guidelines and position papers, including “CALTCM Assisted Living Visitation” (Jan. 20, 2022) and “Assisted Living Delphi Medication Optimization White Paper” (Oct. 1, 2022), both available on the CALTCM website (https://www.caltcm.org/). Currently the group is focusing on wider dissemination of the medication optimization paper and working with ASCP to develop a position paper on the ideal role of the consultant pharmacist in AL. (The group meets twice monthly; anyone interested in joining can contact the author.) National advocacy for AL is difficult because there are no federal regulations for AL. AL providers have generally been opposed to federal oversight, fearing burdensome and onerous regulations similar to those in the nursing home industry would ensue (e.g., McKnight’s Senior Living, May 27, 2021, https://bit.ly/3LLTkDZ). Despite this reluctance, AL organizations such as Argentum have federal advocacy initiatives that bring their voices to Capitol Hill (see “Federal Advocacy,” Argentum, https://www.argentum.org/advocacy/federal-advocacy/). A Society resolution has also supported standardizing AL nomenclature nationally (“Streamlining Assisted Living Communities,” resolution A22, April 27, 2022, https://bit.ly/3LMDCbn). The Society’s State-Based Policy and Advocacy subcommittee has further discussed formulating a policy and advocacy plan for AL across states. The goals of national advocacy initiatives for nursing homes often overlap with those of AL. For instance, seven topics are the focus of the National Academies of Sciences, Engineering and Medicine (NASEM) consensus report, The National Imperative to Improve Nursing Home Quality (National Academies Press, 2022, https://bit.ly/3Oa6kBQ), and these same areas inform the goals of the Moving Forward Nursing Home Quality Coalition (https://movingforwardcoalition.org/):1.Person-centered, equitable care2.A well-trained and compensated workforce3.Increased transparency around finance, operations, and ownership4.Creation of better financing systems5.Creation of better systems of quality assurance6.Expanded and enhanced quality measurement and improvement7.Use of health information technology Ideally the next step after “fixing” nursing homes could be to address these same areas in AL. After many years, it appears improved care of residents in AL is getting well-deserved attention. It’s time to call an end to the era of hospital emergency departments only recognizing “nursing homes” or “home” with nothing in between, or arguments that only “social” or “medical” models exist. Health care professionals are an integral part of developing actionable solutions, and for anyone with an interest in AL now is the time to become involved. Dr. Haimowitz is a board-certified internist and geriatrician and a multifacility medical director in Levittown, PA. He serves on the editorial advisory board of Caring for the Ages.

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OBJECTIVES:Nursing homes became epicenters of COVID-19 in the spring of 2020. Due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. Six months into the COVID-19 pandemic, these largely remain in place. The objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors.DESIGN:A modified 2-step Delphi process was used to generate consensus statements.SETTING AND PARTICIPANTS:The Delphi panel consisted of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy.METHODS:State and federal reopening statements were collected in June 2020 and the panel voted on these using a 3-point Likert scale with consensus defined as ≥80% of panel members voting "Agree." The consensus statements then informed development of the visitor guidance statements.RESULTS:The Delphi process yielded 77 consensus statements. Regarding visitor guidance, the panel made 5 strong recommendations: (1) maintain strong infection prevention and control precautions, (2) facilitate indoor and outdoor visits, (3) allow limited physical contact with appropriate precautions, (4) assess individual residents' care preferences and level of risk tolerance, and (5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial well-being of residents.CONCLUSIONS AND IMPLICATIONS:The COVID-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. In the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. The results of this evidence-based Delphi process will help guide policy decisions as well as inform future research.

Several of the hot topics in geriatrics are pain management, medication reduction/deprescribing, and use of off-label medications. Best-practice use of gabapentinoids — gabapentin (Neurontin) and pregabalin (Lyrica) — comfortably fits into all three categories. Examination of the evidence may help health care practitioners make better decisions when prescribing these medications. The arguments for using gabapentinoids seem sound, at first glance — these drugs appear to be useful for patients. There has been a strong nationwide push to avoid opioids for pain, so some practitioners consider gabapentinoids to be a common “safe” alternative. (In fact, one of us [D.H.] was told exactly this recently by a consulting psychiatrist colleague.) “Neuropathy” is a very frequent diagnosis in the elderly, and everyone knows — certainly from all the advertising in the media! — that gabapentinoids are the drug of choice. But is this true? In our experience, gabapentinoids are not the wonder drugs they might appear to be. Certainly a geriatrician would use a much lower starting dose and increase with more care than would a practitioner in another specialty. However, we have seen a good number of side effects, such as dulling of the patient’s mental status, and we have not seen particularly good efficacy for either neuropathic pain or chronic generalized pain. This should not come as a particular surprise after looking at the literature. A study several years ago showed that nearly 7% to 10% of the general population has neuropathic pain, and treatment has resulted in only a minimal reduction on the pain scales (JAMA 2015;314:2172–2181). Head-to-head data regarding which treatment is best are limited. A systematic review and meta-analysis looked at the number needed to treat (NNT) for 50% pain relief with a variety of medications, and found a lower NNT for tricyclic antidepressants than for gabapentinoids (Lancet Neurol 2015;14:162–173). A much more in-depth review of off-label use of gabapentinoids was published this year by Christopher W. Goodman, MD, and Allan S. Brett, MD, of the University of South Carolina School of Medicine (JAMA Intern Med 2019;179:695–701), and we highly recommend you seek out this article to read for yourself. Its conclusion speaks for itself: “Clinicians who prescribe gabapentinoids off-label for pain should be aware of the limited evidence and should acknowledge to patients that the potential benefits are uncertain for most off-label uses.”Key Points•The evidence does not support gabapentinoid use for many common disease states encountered in long-term care other than postherpetic neuralgia and painful diabetic neuropathy.•“Neuropathy” should not be accepted as a valid diagnosis for use of gabapentinoids.•Gabapentinoids, like many other medications, may have unrecognized side effects.•A careful history may present an opportunity for deprescribing. (For a more general review of deprescribing, we would refer you to a fun video on the subject at https://paltc.org/deprescribing-dr-daniel-haimowitz-0).•More head-to-head and outcome studies are needed to prove the efficacy of gabapentinoids for the treatment of neurogenic pain. •The evidence does not support gabapentinoid use for many common disease states encountered in long-term care other than postherpetic neuralgia and painful diabetic neuropathy.•“Neuropathy” should not be accepted as a valid diagnosis for use of gabapentinoids.•Gabapentinoids, like many other medications, may have unrecognized side effects.•A careful history may present an opportunity for deprescribing. (For a more general review of deprescribing, we would refer you to a fun video on the subject at https://paltc.org/deprescribing-dr-daniel-haimowitz-0).•More head-to-head and outcome studies are needed to prove the efficacy of gabapentinoids for the treatment of neurogenic pain. The only pain-related indication that is approved by the U.S. Food and Drug Administration (FDA) for gabapentin is for postherpetic neuralgia. For pregabalin, the pain-related indications are limited to postherpetic neuralgia, neuropathic pain associated with diabetes or spinal cord injury, and fibromyalgia. (An additional indication — not related to pain — is partial-onset seizures as an adjunct therapy for both gabapentin and pregabalin.) Drs. Goodman and Brett present several interesting facts. They noted that use of gabapentinoids has tripled over the past fifteen years. Gabapentin was the tenth most commonly prescribed medication in the United States in 2017, and pregabalin ranked sixth in nondiscounted spending for brand-name drugs that same year (with that spending rising from $2.4 to $4.9 billion). For the evidence addressing off-label gabapentinoid use, their noteworthy findings included: 1.The evidence is mixed at best for the use of gabapentin for painful diabetic neuropathy.2.There are few studies of gabapentinoids for nondiabetic neuropathies.3.The evidence does not support gabapentinoid therapy for low back pain or radiculopathy.4.Although pregabalin is FDA approved for fibromyalgia, gabapentin is not. However, gabapentin is frequently prescribed for this indication because of its lower cost. In the only placebo-controlled trial, the use of gabapentin resulted in a mean pain difference of only 0.9 on a 0 to 10 scale. As they also point out, this is similar to the mean differences in the trials that resulted in pregabalin’s FDA approval for fibromyalgia. (Take that for what you will …)5.Both pregabalin and gabapentin are FDA approved for postherpetic neuralgia, defined as pain persisting at least three months after acute herpes zoster. However, there is no evidence to support the efficacy of either drug for acute zoster pain.6.In the small number of placebo-controlled gabapentinoid trials for various other pain syndromes, with few exceptions the drugs were either ineffective or were associated with small analgesic effects that were statistically significant but of questionable clinical importance. The evidence cited to support the general use of gabapentinoids in neuropathic pain is often extrapolated inappropriately, according to Drs. Goodman and Brett. “The wording in many guidelines and review articles reinforces an inflated view of gabapentinoid effectiveness or fails to distinguish carefully between evidence-based and non-evidence-based recommendations,” they state. “One unintended effect of the broad definition [of neuropathic pain] might be to create a mistaken perception that an effective drug for one type of neuropathic pain is effective for all neuropathic pain, regardless of underlying etiology or mechanism.” The 2016 guidelines from the U.S. Centers for Disease Control and Prevention (CDC) on opioid prescribing offer an example of this misapprehension (JAMA 2016;315:1624–1645). The guidelines broadly state that gabapentinoids are a first-line treatment for neuropathic pain — without any further details or specification. Although the two drugs are regarded as interchangeable, published direct comparisons in double-blind studies in patients with chronic noncancer pain are virtually nonexistent. Drs. Goodman and Brett also include six common clinical scenarios involving problematic off-label gabapentinoid use that are encountered “repeatedly” in both inpatient and outpatient settings. These drugs are undoubtedly seen in the post-acute and long-term care setting. In fact, when one of us [D.H.] was recently visited in the office by a representative of Alosa Health, an academic detailing group, to talk about managing chronic pain in the elderly, gabapentinoids were included. The group’s evidence-based approach for drug options included pregabalin as “potentially favorable” for osteoarthritis, diabetic neuropathy, and fibromyalgia, and gabapentin only for fibromyalgia (http://bit.ly/2DOEsAR). They noted that the American Diabetes Association (ADA) guidelines recommend pregabalin or duloxetine as an initial treatment for diabetic neuropathy pain, reserving gabapentin for patients who are unable to afford pregabalin (Diabetes Care 2017;40:136–154). Incidentally, Alosa Health’s two “potentially favorable” nondrug interventions for painful diabetic neuropathy are tai chi and transcutaneous electrical nerve stimulation (TENS), and the only “favorable” drug intervention is duloxetine, with nearly half of patients having a 50% reduction in pain in an older study (Pain 2005;116:109–118). One of us [D.H.] has also favorably (and admittedly anecdotally) seen better results and tolerability with duloxetine as compared with the gabapentinoids. Because gabapentin is FDA approved for the treatment of postherpetic neuralgia in adults and as an adjunct therapy for the treatment of partial-onset seizures, the use of this medication for anything other than these indications is considered off-label. One of us [J.M.] called Pfizer to request copies of the off-label studies for gabapentin and pregabalin for the treatment of neurogenic pain before writing this article and received nine pages worth of articles to review! Kidney function and creatinine clearance (CrCl) must be considered when prescribing gabapentinoid medications. The product labels for gabapentin and pregabalin both recommend the use of the Cockcroft and Gault formula (https://www.kidney.org/professionals/KDOQI/gfr_calculatorCoc) to calculate CrCl in milliliters per minute. Gabapentin is currently available as 100, 300, and 400 mg capsules, as well as 600 and 800 mg tablets and a 50 mg/mL oral solution. Pregabalin generic, which was approved in August 2019, is available as 25, 50, 75, 100, 150, 200, 225, and 300 mg capsules and as controlled-release tablets at 82.5, 165, and 330 mg. Additionally, a 20 mg/mL solution is available. For patients who have normal CrCl, titration to the highest dose of gabapentin — 1,200 mg as two 600 mg tablets, three times a day — adds six pills a day to the patient’s current medication regimen. A swallowing evaluation may need to be completed to ensure there are no issues with the tablet/capsule size. The tablets are scored and can be broken in half to aid in swallowing; unused broken tablets should be disposed of if not used within 28 days. Gabapentinoids must be tapered over at least seven days. Overall, the pharmacokinetic profiles of gabapentin and pregabalin are somewhat similar, as Drs. Goodman and Brett discuss in their review. However, the two drugs also have some significant differences, so they are not interchangeable (Pharmacy Times, Sept. 22, 2015; http://bit.ly/2BynHsg). The common adverse reactions to all gabapentinoids include a variety of specific and nonspecific effects including, but not limited to, seizures, suicidal thoughts, somnolence, dry mouth, edema, blurred vision, abnormal thinking, dizziness, peripheral edema, ataxia, and fatigue. For elderly patients with multiple comorbid conditions who reside in a long-term care facility, these adverse effects may not be recognized or may be mistaken for new conditions — with treatment initiated accordingly, and medications added. Even as this prescribing cascade occurs, the pain symptoms being treated with a gabapentinoid may not be relieved. Because the United States is in the midst of an epidemic opioid crisis, despite the lack of resources or data to support the use of gabapentinoids for the treatment of neurogenic pain, they are being prescribed as an alternative. Again, gabapentinoids are not the answer except in the case of postherpetic neuralgia. Thus, an important issue raised by Drs. Goodman and Brett is that the misuse and abuse of gabapentin has become more prevalent in recent years. It is most often abused by multidrug users who combine it with other substances to increase the desired effects, and its misuse has increased along with the worsening of the U.S. opioid crisis. Use of higher-than-recommended doses of gabapentinoids to achieve euphoric highs is being increasingly reported (Med Lett Drugs Ther 2018;60[1540]). Due to the increasing abuse potential and “high” sensation when opioid users take gabapentinoids, pregabalin is considered a federal Schedule V drug in the United States. Gabapentin is not federally scheduled, and its controlled scheduling differs by state. It is treated as a controlled substance by Kentucky, Michigan, Tennessee, Virginia, and West Virginia (Carlisle Medical, June 10, 2019; http://bit.ly/35TQ9ms). The results of placebo-controlled studies for the gabapentinoids do not provide compelling evidence that they are effective for the treatment of pain, yet payors have been seeing an increase in gabapentin and pregabalin oral use. More recently these drugs are being used as topical compounds, even though there are no gabapentinoid formulations currently approved for topical use. We believe this information will be helpful to you in your practice. It is certainly something you can use in your role as an educator to colleagues and staff. And, importantly, make sure all of your patients get the shingles vaccine — if you never get shingles, you will never have postherpetic neuralgia! Dr. Haimowitz is a board-certified internist and geriatrician and a multifacility medical director in Levittown, PA. Dr. Manzi has been a licensed pharmacist since 1990 and a Board Certified Geriatric Pharmacist since 1998. She is currently a clinical advisor for CVS/Caremark, coordinating with account teams and health plans on the details of their pharmacy benefit offerings, formulary implementation, medication utilization management, and MTM as well as providing clinical information and expertise in geriatrics. The authors serve on the editorial advisory board of Caring for the Ages. The views they express are their own and not necessarily those of the Society, CVS/Caremark, or any other entity.

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Some years ago, my nursing home administrator and I met with the chief executive officer of the local hospital, whose idea was to start directing hospital patients to “preferred” nursing homes. “But, but, but,” I sputtered, “you have to give people choice! That’s illegal!” He replied, “Dan, you’re a fool” (a phrase all too frequently said to me, and unfortunately in many cases appropriately so). It turns out I really didn’t understand — he was talking about informed choice, the hospital’s plan to identify the best homes in the area and partner with them, thereby improving quality and reducing cost. To this end, the hospital formed a Transition of Care committee with the local nursing facilities. Initially we worked on how to improve communication, particularly with the emergency department. But with changes in health care, data availability, and financial pressures, our committee’s mission morphed into how to reduce rehospitalization rates. The nursing homes can’t say that they weren’t warned about what was coming — a few months ago, the hospital released their first set of “tiered” skilled nursing facilities. To almost no one’s surprise, the only data point used for what determined the preferred facilities was … yes, rehospitalization rates. At the roll-out meeting, I spoke up with my concerns about this, and over the past few months many of the problems have become clearer. This is an important issue — if it hasn’t occurred in your region yet, there’s a good likelihood that it will or at least will start to be discussed. To make matters worse for my locale, the hospital’s accountable care organization (ACO) is thinking about using the exact same metrics that the hospital has started to use. Which brings us to our questions: Are rehospitalization rates the sole indicator of quality care in a nursing home? What are some of the problems if you assume they are? What are some of the implications — perhaps some of them unintended — for nursing homes, physicians, patients, and families? And is there anything that can be done about all this? There is no doubt that financial pressures are affecting our industry. We are all judged on data. We may lose money with high rehospitalization rates and with bundled care and ACO models. There also is no question that rehospitalization is not the only measure of quality patient care, but the hospitals may not understand this. Perhaps more importantly, they may not want to understand it — if they save money by demanding a rate below, say, 22%, what do they care what the nursing home thinks? The same principles may apply to the ACO, although other factors might affect a “population health” model that takes other factors into account for costs (such as resource utilization, medication usage, or number of consultants). Already I have seen quality measures that are applicable to young, healthy patients being used in our population. AMDA — the Society for Post-Acute and Long-Term Care Medicine has appropriately recognized the importance of identifying quality in the PA/LTC world, but it’s a difficult nut to crack. Let’s review some of the issues. A focus on rehospitalization sends a message to nursing home staff to keep patients in the SNF as long as possible, perhaps inappropriately so. This is a point strongly made in the Interventions to Reduce Acute Care Transfers (INTERACT) materials. The financial truth, sad to say, is that if a sick patient dies in the nursing home before being sent to the emergency department, that helps the home’s rehospitalization data. The hospital may develop a palliative care team. While stressing that it isn’t “hospice,” the reality is that patients are clearly being driven toward hospice/do-not-hospitalize status, even when it may not be appropriate. End-of-life care is complicated, with many gray areas, and there are definitely staff (physicians included) who can only see black or white. Just because patients are receiving palliative care does not categorically mean they should not be rehospitalized, but that may be the way they get treated. The SNFs that take complicated patients are unfairly discriminated against. A fair assumption can be made that very sick patients are more likely to be readmitted to the hospital than those not as sick. Let’s say an SNF gets 10 highly complicated admissions; despite hospital-level care at the SNF, three of these patients are appropriately returned to the hospital. Another home gets 10 “easy” patients, of whom two are readmitted to the hospital inappropriately. Which home looks better in the data? The data do not show the difference between a potential avoidable hospitalization (PAH) and an unavoidable one. To go back to our previous example, using the current methods the first SNF has a rehospitalization rate of 30%, and the second has a 20% rate. But if you look at it from an adjusted PAH perspective, the first SNF drops down to 0%. Obviously the numbers matter. A smaller number of admissions to the SNF can make a huge difference, and the SNF needs a larger denominator if the patients are high risk. But if the SNF isn’t preferred, it gets fewer admissions — making it far more difficult to achieve the hospital-driven benchmark. A nursing home in a hospital’s 9-1-1 catchment area may not be treated fairly. When the hospital sends a patient to an SNF that directs its emergencies to a different hospital, that data may not be correctly captured. The hospital claims this is seen on the PointRight system (a national data set that is supposed to take into account every hospital that a patient is sent to), but our local homes believe that may not be the case. So apples are not being compared with apples. Hospitals should consider the local SNFs as their partners — they should work with them closely and meet frequently. Once a hospital has developed its SNF preference tiers, who exactly is presenting the information to the patients? Either social workers or case managers are likely informing patients and families of their choices. Do all the SNFs involved feel comfortable with that? How do we know what they are telling the patients and families? For instance, one physician claimed that the hospital’s social worker told a hospitalized Medicare patient that the non-preferred SNF, in addition to not meeting the desired rehospitalization rate, “may not accept your insurance” — which along with not being true, might also be unethical to say. The social workers and case managers work for the hospitals, so they share the hospital’s inherent biases. They also may not know all there is to know about the range of available facilities, even though they have the power to influence referrals. Should patients even be referred to specific facilities? Who assumes the responsibility of having made that choice? For years, I wouldn’t provide specific recommendations to my patients because that would make me responsible for a bad outcome or bad care. Instead I would tell the families to look at the homes themselves and take into consideration many factors, such as their opinion after visiting, how close it was for the family to visit, its community reputation, the available reviews of prior stays and survey results, and the doctors who attended the residents. With the hospital now using only one measure for recommendations — readmissions — none of those other factors matter. Now, if the hospital refers to a home where the family is unhappy, the hospital’s to blame. If the family chooses a different home and has a good outcome, the hospital was wrong. If the family chooses a different home and there’s a bad outcome, the family must deal with the guilt of going against the hospital’s recommendation. What’s more, every facility not on the preferred list is being subtly accused of giving poor care by the hospital, which isn’t a good message to send to the community. How often the data are assessed can also be a major problem point. If the SNF has even one bad month, which can occur for a variety of reasons either preventable or not, their rehospitalization rate may go above the “accepted” level. They are then dropped off the preferred list, and boom, financial peril ensues. In general this is an example of many people not understanding data — one fixed data point does not establish a trend. The implications of all this can be very profound. For hospitals, one of the risks is that a non-preferred home may not only start sending its patients to a different hospital, but also stop using the other ancillary services that the hospital has been providing (such as home care, labs, hospice, etc.). When a resident’s family asks why they aren’t being sent to the hospital next door, all the SNF has to tell them is that the hospital now sends its patients to facilities many miles away, without respecting the family’s wishes. It takes a careful look at the big picture to see whether that’s a risk worth taking for the hospital, both financially and for its reputation. What can be done about all this? I’m not sure I have the answer, but I have some suggestions: Become involved. Regardless of your discipline, communicate with your hospitals so they know your concerns and know your goal is to provide excellent care. Work together for solutions. In today’s changing medical field, one should proactively address these issues. Encourage your local hospital to work collaboratively with SNFs in their catchment area. Personally I think hospitals should consider the local SNFs as their partners — they should work with them closely and meet frequently. Referring patients elsewhere has too many drawbacks in my opinion. Discuss the issue with all providers. Nursing home administrators may not know the issues and potential solutions from the health care providers’ perspective, and vice versa. Talk to the providers in the hospital. As hospitalists become more common, they may not realize what’s going on in our PA/LTC world. The primary care practitioners in the community may also be unaware. Each group’s involvement may encourage discussion so the patient and family are making a true informed choice. Make sure you are giving the best possible care. Organizations have been working for years to determine who the highest risk patients are. Look at your process to focus your efforts on this highest risk group. Luke Kim, MD, and colleagues at the Cleveland Clinic Health System recently validated a measuring instrument to predict 30-day all-cause readmission rates of SNF residents to hospitals, which may be of use (J Am Med Dir Assoc 2016;17:863.e15–863.e18). Join or form a larger group. Many areas have long-term care alliances and consortiums. There is power in numbers. Identify and implement best practices. If you are a member of a larger group or if the hospital is running a committee involving nursing homes, find out what the best nursing homes are doing to prevent PAHs and also look into how to replicate what they do. Always remember that we can ask the Society to help and we can bring up the issue in our state affiliates (the Society or others). Larger organizations working together is a helpful option as well. This is why we belong to organizations — to call attention to important issues and seek help. Again, never forget that there is power in numbers. The Board Room is an editorial written by members of Caring’s Editorial Advisory Board. Dr. Haimowitz is a multi-facility medical director and physician in Levittown, PA, and a member of the board. The views he expresses are his own and not necessarily those of the Society or any other entity.

Oral hygiene influences taste, affecting appetite and nutrition in older adults. However, the impact of self-administered tongue brushing on their taste perceptions was unclear. This pilot study (N = 44) was aimed to observe the changes in taste thresholds using Filter Paper Disc after tongue brushing in Thai older adults. Based on the results, continuous tongue brushing for 3 months reduced tongue coat (p < 0.01) and improved subjective taste in 74% of participants. Sweet and salty recognition thresholds were reduced in both anterior and posterior tongue, while sour and bitter thresholds were reduced only in posterior tongue. No changes in umami (savory) were observed. Daily brushing was more effective than weekly brushing in improving the sweet and bitter tastes. The data suggested that tongue brushing could improve perception of multiple tastes and daily tongue brushing was recommended as routine personal care for older adults. This study supports further investigation in a randomized-controlled setting.

Appropriate amount of dopant enhances the luminescence intensity of host material. Inspired by the encouraging electrical properties of perovskite materials, we report on some optical features of Eu3+ activated BaZrxTi(1−x)O3(BZT) powders synthesized by solid state reaction technique (SSRT) that usually produces particles with comparatively bigger size. However, we have succeeded in obtaining particles of smaller size with this technique. The effects of adding Eu3+ to BZT phosphor have been studied in terms of XRD, FESEM, HRTEM, and UV–vis absorption spectroscopy. The X-ray diffractograms ascertain the formation of BZT with single phase while FESEM and HRTEM help in morphological analysis of prepared samples. The thermoluminescence (TL) glow curves for BZT:Eu3+are compared with respect to irradiation time and dopant concentration. The TL intensity is observed to be more for samples irradiated for longer time. It implies that irradiation time is an effectual and practical way to enhance TL intensity. The TL glow curves are deconvoluted using computerized glow curve deconvolution (CGCD) method. The kinetic parameters, which play vital role in characterizing a particular phosphor material, have been calculated and presented for BZT:Eu3+.