by Jay Luxenberg, MD 

As many as half of all nursing home admissions have either subsyndromal or full-blown delirium. If they manage to avoid having delirium during their first six months in a SNF, still the majority of residents will demonstrate delirium symptoms at least once over the rest of their long term stay in a SNF. In SNFs, nurses identify delirium only about half the time it is present. The is no data on how often assisted living staffs identify delirium. Although nursing home staffs have been shown to be open to delirium reduction programs, no such program has shown proven efficacy in reducing delirium incidence, duration or severity. At our CALTCM meeting I will review the data from other settings – acute hospitals, ICUs, etc, that we are forced to extrapolate from to make decisions about delirium management in the skilled nursing. I will also review the AGS Clinical Practice Guideline for Postoperative Delirium in Older Adults and other recent clinical practice guidelines that can help us in the absence of site-specific research. Just for the fun of it, we will also discuss strategies to minimize delirium occurrence in hospitals by using newer sedative agents compared to usual practice. As always, the aim is to give you useful take-home information to improve the care you provide in long-term care environments.

Tim Gieseke MD, CMD

How often have you received this call from a facility nurse after a patient with dementia has hurt a staff member or another resident?  As I reflect back on my long career in older adult medicine, the focus of my training, and of the nurses in all settings of care has been on controlling dementia problem behaviors with drugs.  In a sense, nurses, NPs, PAs, and physicians have focused on a medication response during a crisis and have not reflected enough on how to minimize their development.  

Dr. Debra Bakerjian is senior director for nurse practitioner and physician assistant clinical education and practice, as well as an associate adjunct professor, at the Betty Irene Moore School of Nursing at UC Davis. Previously, Dr. Bakerjian was a Betty Irene Moore School of Nursing Postdoctoral Fellow with specialties in health policy and system change.

CALTCM: What is the background of your training, practice setting and how many years have you been in practice?

Dr. Bakerjian:  I started as a medical assistant, and worked as a CNA while going through nursing training.  I received an AND degree, went on to get a BS in Health Services Administration.  I obtained my FNP and PA certificate from UC Davis, then went to UCSF for a Masters in Family Nursing.  In 2002 got a doctoral degree from UCSF in Gerontology and Health Policy. I worked in primary care as a nurse practitioner for 5 years and then went on to develop a practice with 2 collaborating physicians seeing nursing home patients, which I did for 20+ years.

CALTCM: What are you passionate about in long term care?  How are you pursuing your passion?  

Dr. Bakerjian:  I am passionate about improving the education of NH staff in order to provide exceptional-person-centered, high-quality and safe care to older adults and to establish a culture that focuses on collaborative, interprofessional team care.  Now, I teach graduate nurses, NP and PA students about quality and safety along with interprofessional competencies. 

CALTCM:  What advice would you give to a new graduate contemplating a career in long term care?

Dr. Bakerjian: Caring for older adults is extremely fulfilling – it challenges you to think about complex chronic diseases and the social and psychological needs of older adults and families.  It requires the best diagnosticians and clinicians who are dedicated to providing high quality care.

CALTCM: What additional training do you wish you had that may help with your current practice?    

Dr. Bakerjian: Learn how to be a member of a team – it is essential in geriatric care.  Learn about the regulatory environment associated with long term care.  Hone your diagnostic skills, you will need those skills daily as you care for this complex population.

CALTCM:  How has CALTCM impacted your practice?

Dr. Bakerjian:  CALTCM has provided the opportunity to work with and learn from some of the best geriatric minds in the nation who are passionate about the work that they do.   

A hospitalist friend recently moved from that “Silo” of care to the Post-Acute/Long-Term Care (PA/LTC) “Silo” of care in my community.  He rather quickly saw things in the new setting of care likely not apparent to his hospitalist colleagues.  While I readily agreed, he decided to routinely provide feedback to referring hospitalist by cc of his dictated admission H&P and Discharge Summaries to them.  I had previously given up on doing that since the hospital EHRs in my community (Meditech & EPIC) haven’t a place for post discharge records in their EHRs.  However, by sending it to specific hospitalists, they will initially get feedback on what occurred on their PA/LTC patient referrals.  I’m now including that strategy in my dictated reports.