The holistic needs of multi-generational and multi-cultural demographics set the bar for political advocacy in the nursing discipline. Projected populations for LGBTQ demographics in older adults have vacillated dependent upon the resource reporting. Aging LGTBQ adults may have witnessed a social climate where sexual and gender identification led to volatile retribution. LGBTQ awareness has not altered inequalities found woven through state and federal regulations. The USDHHS Healthy People 2020 initiatives recognized the need to improve healthcare outcomes for this vulnerable population; however, LGBTQ adults continue to experience healthcare provider bias. The purpose of this presentation is to identify how current healthcare policies have created legal windows of opportunity for persons to discriminate and create juxtaposition with goals and objectives of Healthy People 2020; promoting barriers in the healthcare continuum for LGBTQ aging adults. Further emphasis will be placed on demonstrating how advanced practice nurses can provide culturally sensitive care for LGBTQ older adults.  

Providing an educational intervention for long-term care facility nursing staff improves knowledge of and prevention of UTIs.

Research summary

Introduction: Urinary tract infections (UTI) frequently occur among residents of long-term care facilities. Early identification of this health condition leads to prompt treatment, which prevents complications.

Objectives: To determine if an educational intervention improved UTI knowledge among nursing staff employed in a long-term care facility.

Methods: Using a longitudinal study design and a previously developed questionnaire, data were collected prior to and after a UTI-specific educational intervention. Data were received from 21 participants, all nursing staff who were direct care providers in a long-term care health facility.

Results: Using paired sample t-test, knowledge of and prevention of UTI scores improved. While not statistically significant, these data reflect a benefit from the educational intervention.

Life expectancy all over the world is increased, and people live longer with chronic illness. The prevalence of chronic, progressive illnesses that lead to terminal conditions brings healthcare system’s attention to have end-of-life discussions. When people anticipate death, their preferences about the care they wish to receive should be communicated clearly to the healthcare providers. Advance directives are the means of communicating end-of-life discussions, and there is an increased need to involve patients and families in end-of-life discussions. Physician order for life-sustaining treatment (POLST) is an advanced care planning document that is used to communicate patient wishes in the form of a medical order. A retrospective chart review of 247 charts was done in a selected long-term care facility to assess the utilization of POLST and the consistency between treatment given and patient wishes. The findings of the study show that patient wishes are honored 100% of the time. 91 patients had completed POLST forms. Cancer was the most common admitting diagnosis of those patients with POLST. Females had the highest number of forms. In regards to race, compared to black patients, white patients had more completed forms. During the study period, there were a total of 162 hospitalizations, and patients with POLST forms had 26 hospitalizations. Data analysis showed that patients with POLST forms had fewer numbers of hospitalizations, and every year there was an increase in the number of active POLST forms. POLST forms helps nurses to direct nursing care towards meeting the end-of-life care needs of patients. Nurses can use POLST interventions in order to minimize unwanted treatment and transfer to hospitals.

Background: Antibiotic misuse contributes to the widespread emergence of antibiotic- resistant bacteria. Inappropriate antibiotic treatments for urinary tract infections (UTI) among nursing home (NH) residents is well documented, but evidence about the accuracy of diagnosis and treatment amongst residents transitioning between hospitals and NHs is lacking. UTI diagnosis differs in NH residents due to widespread presence of asymptomatic bacteriuria (ASB), the colonization of bacteria within the urinary tract. The Infectious Disease Society of America strongly advises against antibiotic treatment of ASB. However, differentiating ASB from UTI has been challenging. Additionally, appropriate care for patients with UTI has been found to be hindered by lack of communication between sites. The purpose of this study is to assess if discharge documents of hospitalized NH residents treated for UTI supported appropriate diagnosis and treatment using signs, symptoms, laboratory results, and prescription reviews.

Methods: A retrospective chart review was conducted with convenience samples in 3 NHs and 4 hospitals in southeast Michigan over a 3-year period. Electronic medical record (EMR) data were abstracted for residents with a diagnosis of UTI. An evidence-based tool and inter-rater agreement were used to determine antibiotic appropriateness.

Results: A total of 79 hospitalized residents were treated for a diagnosis of UTI. Of those, 18 (22.8%) were appropriately treated. Non-catheterized residents were treated appropriately 13% of the time with catheterized residents appropriately treated 56% of the time. There was a significant difference in lengths of stays between hospitals and NHs. Some findings were impacted by missing communication and documentation between sites.

Conclusions: Appropriate treatment rates amongst hospitalized NH residents appears to be low. The use of a consistent process to facilitate communication and documentation is missing. A comprehensive approach to improve assessment of UTI may improve appropriate treatments. Implementation and further assessments are planned.

Introduction: Early post-operative pain after laparoscopy can be even more severe compared to open surgery1. The insufflation of carbon dioxide into the abdomen can cause cramping, bloating, and shoulder tip pain2. Repeated opioid dosing leads to adverse effects, including sedation, respiratory depression, ileus, opioid-induced hyperalgesia, and nausea or vomiting3, whereas non-pharmacological interventions are non-invasive and associated with minimal risk. Patients prefer to avoid medications if possible4, and opioids should be avoided in older adults whenever possible to avoid side effects and falls.

Methods: A quality improvement project with a pre-/post-design was utilized to implement an evidence-based bundle of non-pharmacological pain management interventions for an abdominal laparoscopic short-stay surgery population at a comprehensive cancer center. The bundle included integrative medicine videos, music, early and frequent in-bed exercises and ambulation, hot packs, and mint or ginger tea. The nurses were educated on the bundle, and it was added to the order set.

Results: Exercise, tea, and hot packs were reportedly the most utilized and beneficial, according to both patients and nurses. Preliminary analysis shows the post-bundle implementation group had a 34% decrease in post-operative opioid use, a 5.35% decrease in pain scores at discharge, and the average number of documented non-pharmacological, pain-relieving interventions increased from 1.04 to 2.23.

Conclusion: Comprehensive postoperative pain management for abdominal laparoscopic surgery patients must include non-pharmacological strategies. Preliminary data analysis shows that adding a bundle of non-pharmacological strategies to the nursing orders can improve pain outcomes.

References
1. Sjovall, S., Kokki, M., & Kokki, H. (2015). Laparoscopic surgery: A narrative review of pharmacotherapy in pain management. Drugs, 75, 1867-1889. doi: 10.1007/s40265-015-0482-y.
2. Blencowe, N.S, Waldon, R., & Vipond, M.N. (2018). Management of patients after laparoscopic procedures. British Medical Journal, 360. doi: 10.1136/bmj.k120.
3. Hah, J.M., Bateman, B.T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic. Anesthesia & Analgesia, 125(5), 1733-1740. doi: 10.1213/ANE.0000000000002458.
4. D’Arcy, Y. (2011). New thinking about postoperative pain management. OR Nurse, 5(6), 29-36. doi: 10.1097/01.ORN.0000406638.19178.07

Heart failure (HF) is a significant chronic medical condition that can significantly impact a patient’s quality of life and the financial stability of a healthcare system. Healthcare organizations are strategically working to identify educational methods that may reduce the burden of HF in the adult population. Ongoing patient education led by multidisciplinary teams remains the backbone of nursing efforts with nurses as key providers of HF education. Patients are stabilized in an acute-care setting and may be transferred to a post-acute care healthcare setting for short-term rehabilitation. This transitional care period is when patient education continues to be an important component for improving patient’s understanding of self-care related to HF. Nurses’ knowledge of HF principles has not been examined in the post-acute care healthcare setting. This four-week descriptive, correlational study assessed knowledge levels of nurses regarding evidence-based HF self-management principles utilizing the Nurses’ Knowledge of Heart Failure Education Principles (NKHFP) survey. This study was designed to determine whether years of nursing experience, educational preparation, and licensure were variables impacting overall knowledge scores. The NKHFP survey was electronically distributed to a group of 125 registered nurses (RNs) and 125 licensed practical nurses (LPNs) who care for patients with HF in a post-acute care healthcare organization. A total of 45 RNs and 47 LPNs completed the electronic NKHFP survey. There was no statistical significance between licensure and knowledge scores (p > 0.05), years of nursing experience (p > 0.36), or educational preparation (p > 0.072). Registered nurses and LPNs demonstrated knowledge deficits in evidence-based practice self-management principles. 

Dementia-related psychosis (DRP) is common among patients with Alzheimer’s disease (AD), Parkinson’s disease (PD), dementia with Lewy bodies (DLB), fronto-temporal dementia (FTD), and vascular dementia (VaD) and is associated with poor outcomes. HARMONY (NCT03325556) was a phase 3, placebo-controlled, randomized, relapse-prevention study evaluating the efficacy and safety of pimavanserin for treating hallucinations and delusions associated with DRP. Patients with dementia and moderate-severe psychosis received open-label (OL) pimavanserin for 12 weeks. Patients with sustained response (≥30% reduction in scale for the assessment of positive symptoms hallucinations+delusions total score AND clinical global impression-improvement score of much/very much improved) at weeks 8 and 12 were randomized 1:1 to continue pimavanserin or receive placebo for up to 26 weeks in the double-blind (DB) period. The primary endpoint was time from randomization to relapse of DRP. 392 patients enrolled. 217 (61.8%) eligible patients experienced sustained response and were randomized. OL response was similar regardless of dementia subtype (randomization rates: 59.8% AD, 71.2% PDD, 71.4% VaD, 45.5% DLB, 50.0% FTD), baseline disease characteristics, age, dementia severity, or previous drug therapy. The study stopped early for superior efficacy when a prespecified interim analysis revealed >2.8-fold reduction in risk of relapse with pimavanserin (hazard ratio: 0.353; 95% CI: 0.172, 0.727; 1-sided p=0.0023). Adverse event rates were low and balanced (OL: 36.2%; DB: 41.0% pimavanserin, 36.6% placebo). No negative trends for worsening in cognition (mini-mental state examination) or motor function were observed. The HARMONY study demonstrated a robust decrease in hallucinations and delusions and significant maintenance of efficacy with pimavanserin treatment in DRP.

Purpose: To evaluate the safety and tolerability of once-daily opicapone in adults with Parkinson’s disease (PD) and motor fluctuations.

Rationale: Catechol-O-methyltransferase (COMT) inhibitors have been approved in the United States (US) as adjunctive therapies to levodopa, but previously available medications are limited by tolerability and safety issues. Opicapone is a novel and highly-selective COMT inhibitor under development in the US as an adjunct to carbidopa/levodopa for PD fluctuations.

Methods: Data were pooled from two pivotal phase 3 studies (BIPARK-1 [NCT01568073], BIPARK-2 [NCT01227655]) in which participants received once-daily opicapone (5mg [BIPARK-1 only], 25mg, 50mg), entacapone (BIPARK-1 only), or placebo for 14-15 weeks in addition to their levodopa regimen. Entacapone was not included in the pooled analysis. Assessments included treatment-emergent adverse events (TEAEs), laboratory tests, vital signs, and electrocardiograms (ECGs). The Modified Minnesota Impulse Disorders Interview (mMIDI) and TEAEs were used to assess compulsive behaviors.

Results: In this pooled analysis (N=888: placebo=257, opicapone 5mg=122, 25mg=244, 50mg=265]), the TEAE incidence was as follows: any TEAE (placebo=57.2%, 5mg=51.6%, 25mg=62.3%, 50mg=64.2%); serious TEAEs (placebo=4.3%, 5mg=3.3%, 25mg=2.0%, 50mg=4.9%); and TEAEs leading to discontinuation (placebo=7.4%, 5mg=5.7%, 25mg=5.7%, 50mg=9.1%). Dyskinesia was the most common TEAE in all treatment groups, but few participants had dyskinesia leading to discontinuation (placebo=0.4%, 5mg=1.6%, 25mg=0.8%, 50mg=3.0%) or serious dyskinesia (placebo=0%, 5mg=0%, 25mg=0.4%, 50mg=0.4%). No Hy’s law cases or severe/serious hepatobiliary TEAEs were reported in opicapone-treated participants except for 1 case of acute cholecystitis (50mg); two participants (25mg) reported urine discoloration. There were no clinically relevant differences between opicapone and placebo in laboratory parameters, vital signs, or ECGs. The incidence of mMIDI compulsive behaviors during opicapone treatment (combined doses) was comparable to baseline for buying disorder (baseline=9.8%; post-baseline=9.3%), pathological gambling (baseline=2.0%; post-baseline=0.9%), and compulsive sexual behavior (baseline=1.5%; post-baseline=2.2%). Few participants experienced impulse control disorders as a TEAE (placebo=0%, 5mg=0.8%, 25mg=0.4%, 50mg =1.1%).

Applicability to APN practice: Opicapone, which is under development in the US as a once-daily adjunct to carbidopa/levodopa, was generally safe and well-tolerated in clinical trials. TEAEs reported with other COMT inhibitors, such as hepatic injury and serious/severe diarrhea, were not observed and the incidence of compulsive behaviors was low.

Purpose: To evaluate the effects of once-daily opicapone on OFF-time in subgroups of patients with Parkinson’s disease (PD) and motor fluctuations.

Rationale: Opicapone is a novel and highly selective catechol-O-methyltransferase (COMT) inhibitor under development in the US as an adjunct to carbidopa/levodopa for PD fluctuations. In two pivotal Phase 3 studies (BIPARK-1 [NCT01568073], BIPARK-2 [NCT01227655]), opicapone 50mg significantly reduced OFF-time relative to placebo (primary endpoint). Additional information regarding the effects of opicapone in various patient subpopulations are warranted.

Methods: Participants were randomized to 14-15 weeks of treatment with opicapone (5mg [BIPARK-1 only], 25mg, 50mg), entacapone (BIPARK-1 only), or placebo, added to their levodopa plus dopa decarboxylase inhibitor (DDCI) regimen. Least squares (LS) mean changes from baseline to Week 14/15 in absolute OFF-time were analyzed in the pooled population and in subgroups defined by the following baseline factors: age, gender, race, modified Hoehn and Yahr (H&Y) stage during ON, DDCI treatment (carbidopa or benserazide), and concurrent use of other PD medications (dopamine agonists [DA] or monoamine oxidase-B inhibitors [MAOBI]). Participants receiving both levodopa/DDCI formulations (carbidopa and benserazide) were excluded from subgroup analyses due to the small number. All analyses were conducted using a mixed model for repeated measures. Results for opicapone 50mg (targeted clinical dose) are presented.

Results: In the overall pooled population (placebo n=255; 50mg n=262), opicapone 50mg significantly reduced (improved) OFF-time versus placebo at Week 14/15 (LS mean change ±standard error [SE], hours): 50mg, -2.22±0.17; placebo, -1.28±0.17; P

Purpose: To explore the impact of possible tardive dyskinesia (TD) in a real-world population of older patients (≥55 years).

Rationale: Older age is a risk factor for developing TD (DSM-5, 2013), a persistent and potentially disabling movement disorder associated with prolonged exposure to antipsychotics. In older patients, TD symptoms may appear after shorter antipsychotic treatment.

Methods: In RE KINECT (NCT03062033), adult psychiatric outpatients with ≥3 months of lifetime exposure to antipsychotics and ≥1 psychiatric disorder were assessed for possible TD based on clinicians’ observation and evaluation (“none”, “some”, or “a lot”) of involuntary movements in 4 body regions: head/face, trunk/neck, upper extremities, and lower extremities. Patients were categorized into cohort 1 (without visible movements or possible TD) or cohort 2 (with visible movements and confirmed by clinician as consistent with possible TD). Baseline outcomes for all patients included demographics, clinical history, patient-reported health status, and the patient-reported EuroQoL 5 dimensional 5-level questionnaire (EQ-5D-5L). Exploratory statistical testing was conducted between older adults (≥55 years) in cohorts 1 and 2.

Results: 739 patients were enrolled in the study; results for those ≥55 years (N=300, 41%) are presented. Within this older subgroup, 114 (38%) had clinician-confirmed possible TD (cohort 2) and 186 (62%) had no visible movements or had non-TD movements (cohort 1). In older cohort 2 patients, severe abnormal movements (rating=“a lot”) were most frequently observed in head/face (25%) and upper extremities (14%). Compared to older cohort 1 patients, fewer cohort 2 patients were married (23% vs 34%), more were living in care homes (22% vs 11%), and lifetime exposure to antipsychotics was longer (19.1 vs 12.2 mean years); all P