GAPNA Chat: Podcast Highlights
Steven L. Posar, MD, GuideStar CEO and Founder, was recently a guest on a Gerontological Advanced Practice Nurses Association production, the GAPNA Chat podcast. He was interviewed by Dr. Cassandra Voness, a Gerontological Nurse Practitioner, who told Dr. Posar, “your mission statement speaks to many of us that are involved in the care of older adults.” The two explored a neurology-forward approach to alleviating suffering in long-term care. They discussed agitation, BPSD, UTIs, diagnoses, and antipsychotic stewardship.
Suffering in long-term care
Dr. Posar explained his background as a medical director for long-term care facilities, where he was moved by the experience of suffering. The suffering “was complex and multidimensional, and it started to move me deeply,” he shared.
One of his patients was a wheelchair-bound man in his late 70s who could not stop screaming. Striving to provide relief, Dr. Posar determined the man had Parkison’s – frozen man syndrome. A prescription for Sinemet ended the screaming. “He became able to talk – it was a seminal event for me,” said Dr. Posar.
Acknowledging how common axis one diagnoses are in long-term care, he concluded that “the psychiatric, the psychological elements of neurocognitive degenerative disease are literally universal and nobody was addressing this.”
The science to address the neuropathology began emerging in about 2007, when studies came out looking at the impact of acetylcholinesterase inhibitors on BPSD, he explained. Research findings continue to emerge. Nevertheless, “We’re in the infancy of the science and it's confusing even to well-developed practitioners,” he said.
Medication to mitigate BPSDs
Medical literature has made it clear that “a simple cocktail of an acetylcholinesterase inhibitor and memantine given to these patients as soon as you get them will significantly mitigate BPSD,” said Dr. Posar. Yet the practice has not caught on widely so far. Recent research published by the GuideStar team found that only 5% of long-term care residents were on this protocol.
Dr. Posar mentioned that some practitioners add an SSRI to the protocol from the outset. “Our approach is we start them on the cocktail immediately and if they start showing BPSD, we add the SSRI. But it's a minor debate.”
Agitation and UTI “urban mythology”
Dr. Posar agreed with Dr. Voness when she said, “Agitation is not a diagnosis.” Agitation is a syndrome with many causes, commented Dr. Posar. A common scenario, he said, is that an older adult is extremely agitated/combative and is diagnosed with a urinary tract infection (UTI).
When someone is agitated, a UTI is difficult to confirm diagnostically due to the challenge of obtaining a clean urine sample and the obstacles to performing a physical exam. A common practice is to prescribe Haldol and Cipro. However, a finding of bacteria in the urine and the UTI diagnosis can become “urban mythology,” said Dr. Posar.
Microvascular strokes can affect behavior
An alternative understanding is that the resident may have had “one in a series of microvascular strokes”. He discovered this through performing CT scans for hospitalized adults presenting with acute agitation and suspected of having UTIs. All of the adults he tested had high-density white matter lesions, he noted.
Pure Alzheimer’s disease, which is much less common than people think (20% or fewer of dementia cases) is a “gentle disorder,” said Dr. Posar. “It’s slow; it’s predictable,” he said. When a resident diagnosed with Alzheimer’s disease develops severe symptoms, there is typically more going on. Up the three-quarters of people living with Alzheimer’s may have active beta amyloid microangiopathy. This can lead to a series of microvascular strokes. Depending on the locations of such strokes, the effects can be minor or behaviorally profound, he explained.
Quality of life
Tragically, Alzheimer’s and other forms of dementia are incurable and will progress, said Dr. Posar. This shifts the focus of care: “Anything we can do for these folks that will make a significant difference in their quality of life is absolutely worth exploring—and working aggressively to implement.”
Antipsychotic stewardship
Antipsychotic stewardship plays a role in reducing suffering. There are two key elements to this approach, said Dr. Posar:
- BPSD is a neurologic manifestation, not a psychiatric one, for 95% of patients. Treat neurology and see what’s left.
- You’ve got to make an investment in diagnosis (not just “dementia”). Each diagnosis will likely have a unique treatment approach and a different need for supportive measures. Then sometimes there are also secondary diagnoses.
Dr. Posar explained that the GuideStar team devotes intensive focus to deprescribing. This is especially important because older adults can be uniquely sensitive to certain medications, such as anticholinergics. Practitioners may not always have an awareness of what medications have anticholinergic action. An example, he noted, is quetiapine, which has been linked to sudden cardiac death.
Dr. Posar explained the concept of a paradigm shift in the face of emerging science. Lagging adoption, he explained, is typical with a paradigm shift. In his practice, his research, and his teaching for Nurse Practitioners through Saint Mary’s College, he is committed to transferring knowledge to the bedside, rooted in the understanding that we can—and must—open new clinical avenues in order to alleviate suffering.