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Diagnostic advancements in long-term care

March 1, 2011
by Albert L. Riddle, MD, CMD
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Healthcare reform and the Affordable Health Care Act legislation was passed in 2010. Even as components of it are challenged in the courts, we wonder how pending changes in healthcare delivery will affect the long-term care (LTC) industry. One thing is certain: There will be a focus on reducing use of services as a means to lower costs. For LTC, this will require learning ways to reduce hospital readmissions.

Analysis by the Centers for Medicare & Medicaid Services (CMS) has identified 20 medical conditions of particular importance because it is felt that the growth of costs associated with treating these conditions is high. Identified conditions that may be of interest to LTC providers include atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, major depression, and Alzheimer's disease.

Let's consider the impact of atrial fibrillation. It is estimated that 2.4 million people in the United States have atrial fibrillation and that 80% of those with the diagnosis are 65 years of age or older. The cost of the disease exceeds $15 million per year. Furthermore, one of every six ischemic strokes in the United States occurs in patients that have atrial fibrillation as a pre-existing condition. Atrial fibrillation is a condition that is seen in a significant percentage of LTC residents.

The key to preventing complications, such as ischemic stroke, in these residents is to provide adequate anticoagulation, keeping the INR [International Normalized Ratio (for blood clotting time)] lab value between 2.0 and 3.0. New anticoagulant medication that does not require INR monitoring is available; however, most residents continue to be anticoagulated with warfarin while monitoring INRs. A growing number of facilities are using portable devices to do in-house INR testing. These are easy-to-use devices that facilities can purchase for accurate monitoring of INRs, thus avoiding having an outside laboratory come in to provide such service. It would be beneficial for a facility to consider acquiring such a device.

Chronic obstructive pulmonary disease is one of the most common lung diseases managed in the LTC setting. COPD makes it more difficult to breathe and leads to complications such as cough, shortness of breath, wheezing, fatigue, and frequent respiratory infections. Many infections are serious and result in transfer to the acute care setting. Assessing these patients using a stethoscope to listen to the lungs is important and imaging studies such as chest x-rays and CT scans also yield important information. The best test for COPD, however, is a noninvasive test called spirometry. Despite its importance, most facilities do not have the capability of doing the test without seeking a consultation with a pulmonologist. Easy-to-use and reasonably priced handheld spirometers are available and can be very helpful in the management of these patients.

Major depression, caused by chemical imbalances in the brain and/or events such as loss of independence or illness, can present symptoms such as feeling hopeless or sad and can result in behavioral disturbances. In the elderly, untreated depression can accelerate cognitive decline. Worst of all, inadequate treatment can result in suicidal thoughts or attempts. There is a diagnostic tool for depression called the Patient Health Questionnaire (PHQ-9). The PHQ-9 is a tool that has been validated by the World Health Organization as being able to assess symptoms and functional impairment that would allow clinicians to make a tentative diagnosis of depression and allow them to measure severity of symptoms that would assist in both selection of treatment and monitoring response to therapy.

Osteoporosis, a disorder that affects both men and women and results in loss of bone mineral density, not only increases the risk for hip fracture in the elderly, but also results in vertebral fractures that can significantly impact function and quality of life. Several agents are available that can either slow down loss of or stimulate an increase in bone mineral density. The gold standard for evaluating patients with suspected osteoporosis is bone mineral density testing.

Unfortunately, elderly patients don't always easily tolerate having to visit a hospital or diagnostic center to undergo testing. Portable scans are available but do not give results that are as reliable. In situations where it is not possible to get bone mineral density testing done, the 10-year probability of fracture can be calculated using the FRAX tool. The FRAX tool has been validated by the World Health Organization as having predictive value for men and women between the ages of 40 and 90.

Diagnostic tests are frequently requested by healthcare professionals to diagnose disease or assess how a patient is recovering from illness. Some of these tests require the use of simple noninvasive tools that are easily performed in a facility while others involve collection of samples that must be set to a laboratory or require access to complex equipment that necessitate transfer to a hospital or diagnostic center. LTL

Albert L. Riddle, MD, CMD, is President, Riddle Medical Group, LLC, Garnerville, New York. He may be reached by phone at (201) 618-1818 or by e-mail at

riddlemedicalgroup@me.com. Long-Term Living 2011 March;60(3):24-25

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