Design We introduced a long-term care facility (LTCF) Infectious Disease (ID) consult service (LID) that provides on-site consultations to residents of a VA LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF. Setting A 160-bed Veterans Affairs (VA) LTCF. Methods Systemic antimicrobial use and the rate of positive C. difficile tests at the LTCF were compared for 36 months before and 18 months after the initiation of the ID consultation service using segmented regression analysis of an interrupted time-series. Results In contrast to the pre-intervention period, total systemic antibiotic administration decreased by 30% (P <.001) with a significant reduction in both oral (32%; P<.001) and intravenous agents (25%; P =.008). The greatest reductions were seen for tetracyclines (64%, P <.001), clindamycin (61%; P <.001), sulfamethoxazole/trimethoprim (38%; P <.001), fluoroquinolones (38%; P <.001) and beta-lactam/beta-lactamase inhibitor combinations (28%; P <.001). Rates of change for positive C. difficile tests at the LTCF declined in the post- vs. preintervention periods (P = .04). Conclusions Implementation of a LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with infectious disease expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

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OBJECTIVE To critically review published articles that have examined the relationship between medication use and functional status decline in the elderly. METHODS The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to December 2010. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors’ article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review. RESULTS Nineteenstudies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, three of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the four studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status while a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (e.g., phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in two community-based studies. Another study of nursing home patients did not report a significant decline in SPPB scores in those taking multiple CNS drugs. Finally, two studies found mixed effects between antihypertensive use and functional status in the elderly. CONCLUSION Benzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.

BACKGROUND/OBJECTIVE Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). In order to develop effective stewardship interventions, there is a need for data on current patterns of unnecessary antimicrobial prescribing among LTCF residents. The objective of this study was to examine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in our Veterans Affairs (VA) LTCF. DESIGN Retrospective chart review. SETTING Cleveland VA Medical Center LTCF. PARTICIPANTS Randomly selected patients receiving antimicrobial therapy from October 1, 2008 to March 31, 2009. MEASUREMENTS Days of necessary and unnecessary antimicrobial therapy determined using Infectious Diseases Society of America guidelines, syndromes treated with unnecessary antimicrobials, and the frequency of development of Clostridium difficile infection (CDI), colonization or infection with antimicrobial resistant pathogens, and other adverse effects. RESULTS Of 1351 days of therapy prescribed in 100 regimens, 575 days (42.5%) were deemed unnecessary. Of the 575 unnecessary days of therapy, 334 (58%) were for antimicrobial regimens that were entirely unnecessary (n=42). Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n=21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer than recommended treatment duration accounting for 226 (94%) unnecessary days of therapy. Within 30 days of completing the antimicrobial regimens, 5 patients developed CDI, 5 had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse drug events. CONCLUSIONS In our VA LTCF, 43% of all days of antimicrobial therapy were unnecessary. Our findings suggest that antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria.

The Richmond Health and Wellness Program (RHWP) is an innovative interprofessional care coordination program that seeks to support the health and wellness of independent-living older adults and educate future practitioners. Since 2012, RHWP has provided community-based interprofessional training to students at Virginia Commonwealth University. The sudden suspension of clinical and communitybased training due to the COVID-19 pandemic created the need to transform the traditional ways students received clinical education and support the vulnerable communities served by RHWP. This paper describes RHWP's rapid transition to a hybrid telephone-based program with a virtual learning component for students which allowed RHWP to continue serving its participants and provide interprofessional training experiences. Since the transition, RHWP has served 111 participants through over 400 telephonic visits, and 12 nurse practitioner and pharmacy students completed clinical hours to fulfill graduation requirements. To meet the needs of learners, interprofessional education models can be adapted to changing circumstances posed by COVID-19.

In community-dwelling older women, peripheral alpha blocker use was associated with UI, and the odds nearly doubled when used with loop diuretics.

This systematic review revealed a high prevalence of dual use of ChIs and UAChs; however, there are mixed results for cognitive and functional outcomes. Results were limited by methodological flaws. Observational or interventional studies assessing dual users are lacking and further study of cognitive and functional risks of dual ChI and UACh use is needed.

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