Clinical Care in Long-Term Care Flashcards

A 90-year-old LTC resident with atrial fibrillation and a CHA2DS2-VASc score of 5 is refusing warfarin due to monitoring concerns. Which DOAC is most appropriate given her CrCl of 35 mL/min?

Answer: Apixaban 5 mg BID (or 2.5 mg BID if dose-reduction criteria met)

Apixaban has the most favorable renal dosing flexibility and lowest bleeding risk among DOACs in elderly patients with renal impairment, with dose reduction to 2.5 mg BID if 2 of 3 criteria are met (age ≥80, weight ≤60 kg, SCr ≥1.5).

A LTC resident with COPD is experiencing frequent exacerbations despite using a SABA PRN inhaler. Per GOLD guidelines, the most appropriate next escalation step is:

Answer: Initiate a long-acting bronchodilator (LABA or LAMA)

GOLD guidelines recommend adding a long-acting bronchodilator (LABA or LAMA) as maintenance therapy to reduce exacerbation frequency when SABAs alone provide inadequate control.

Which of the following is an appropriate indication for initiating a proton pump inhibitor (PPI) in a LTC resident without prior upper GI documentation?

Answer: Concurrent NSAID therapy in a patient with prior peptic ulcer disease

PPIs are indicated for gastroprotection in patients taking NSAIDs who have additional risk factors such as prior ulcer history, significantly reducing risk of NSAID-induced GI bleeding.

A consultant pharmacist is reviewing a resident's medication for OBRA compliance. The resident has been on lorazepam 1 mg BID for 6 months with no documented anxiety diagnosis or treatment rationale. The best pharmacist action is:

Answer: Recommend gradual dose taper with documentation of indication and trial of alternatives

OBRA regulations require that benzodiazepines have documented indications, evidence of non-pharmacological trial, and gradual dose reduction attempts; abrupt discontinuation risks seizures and withdrawal.

When counseling LTC staff on recognizing signs of opioid-induced constipation (OIC) in a non-verbal resident, which assessment tool is most appropriate?

Answer: Bristol Stool Form Scale with nursing observation

The Bristol Stool Form Scale combined with nursing observation of stool frequency and consistency is a validated, practical tool to monitor bowel function in residents who cannot self-report.

A LTC resident with Parkinson's disease and hallucinations requires an antipsychotic. Which agent is CONTRAINDICATED due to risk of severe dopamine antagonism worsening Parkinson's motor symptoms?

Answer: Haloperidol

Haloperidol is a high-potency D2 antagonist that severely worsens Parkinson's motor symptoms and is contraindicated; quetiapine and clozapine have lower D2 affinity, and pimavanserin is a 5-HT2A inverse agonist with no D2 activity.

A consultant pharmacist identifies that a LTC resident is receiving duplicate therapy with both escitalopram and venlafaxine. Beyond therapeutic duplication, the primary pharmacodynamic concern is:

Answer: Serotonin syndrome from combined serotonergic activity

Combining two serotonergic agents (SSRI + SNRI) dramatically increases serotonin syndrome risk, presenting as autonomic instability, neuromuscular abnormalities, and altered mental status.