Free CCP Clinical Care in Long-Term Care Questions and Answers 1 — Questions and Answers
Question 1: An 85-year-old resident with an indwelling urinary catheter has cloudy, foul-smelling urine. The resident is afebrile, has no new costovertebral angle tenderness, and exhibits no new behavioral changes. A nurse requests an order for an antibiotic. What is the consultant pharmacist's most appropriate recommendation based on antimicrobial stewardship principles?
- Recommend against antibiotic therapy at this time, explaining that the findings represent asymptomatic bacteriuria per the Loeb criteria for catheterized residents. (Correct answer)
- Suggest a broad-spectrum antibiotic, such as a fluoroquinolone, to prevent the development of urosepsis.
- Recommend obtaining a urinalysis and starting empiric antibiotic therapy immediately pending culture results.
- Advise changing the urinary catheter and then reassessing the need for an antibiotic in 24 hours.
Correct answer: Recommend against antibiotic therapy at this time, explaining that the findings represent asymptomatic bacteriuria per the Loeb criteria for catheterized residents.
The Loeb criteria are evidence-based guidelines designed to reduce unnecessary antibiotic use in long-term care. For a resident with an indwelling catheter, clinical signs like cloudy or foul-smelling urine alone are not sufficient to diagnose a UTI. Initiation of antibiotics requires at least one systemic sign or symptom, such as fever, rigors, new-onset delirium, or new costovertebral tenderness. Recommending against antibiotics in this scenario prevents the treatment of asymptomatic bacteriuria, which is a key principle of antimicrobial stewardship.
Question 2: According to CMS regulations for long-term care facilities, for which of the following medication classes is a gradual dose reduction (GDR) attempt required for a resident within the first year of use, unless clinically contraindicated?
- Anticonvulsants used for a diagnosed seizure disorder.
- Antidepressants. (Correct answer)
- Loop diuretics for congestive heart failure.
- Opioid analgesics for chronic pain.
Correct answer: Antidepressants.
CMS defines psychotropic drugs broadly to include antipsychotics, anxiolytics, hypnotics, and antidepressants. Federal regulations (F-Tag 758) mandate that residents receiving any psychotropic medication undergo attempts at a gradual dose reduction. Specifically, for a new psychotropic medication, at least two separate GDR attempts must be made in the first year, unless clinically contraindicated and documented as such. Anticonvulsants for seizure disorders and medications for medical conditions like heart failure or pain are not subject to this specific GDR requirement.
Question 3: A 90-year-old, non-verbal resident with advanced dementia has become increasingly agitated and now grimaces and resists care during repositioning. The facility has a PRN order for lorazepam for agitation. What is the consultant pharmacist's most appropriate initial recommendation?
- Advise increasing the frequency of the PRN lorazepam to better control the agitation.
- Suggest discontinuing the PRN lorazepam and adding a low-dose routine antipsychotic.
- Recommend a trial of scheduled acetaminophen to assess for and treat potential underlying pain as the cause of the behaviors. (Correct answer)
- Document that these behaviors are an expected part of dementia progression and require no intervention.
Correct answer: Recommend a trial of scheduled acetaminophen to assess for and treat potential underlying pain as the cause of the behaviors.
In non-verbal residents with dementia, behavioral disturbances such as agitation are often a primary manifestation of untreated pain. The American Geriatrics Society and other guidelines recommend assuming pain is present and conducting an analgesic trial when new pain-related behaviors emerge. Before escalating psychotropic medications, which can have significant side effects, the standard of care is to first assess for and treat potential underlying causes like pain.
Question 4: A consultant pharmacist is conducting a monthly inspection of a long-term care facility's Emergency Drug Kit (EDK). Which of the following findings represents a significant compliance concern that requires immediate correction?
- The kit contains several single-dose vials of controlled substances for emergency use.
- The medical director, director of nursing, and pharmacist jointly determined the kit's contents.
- A nurse properly documented removing a medication based on a physician's verbal order in an emergency.
- The exterior of the kit is not labeled with the name and expiration date of the earliest-expiring drug inside. (Correct answer)
Correct answer: The exterior of the kit is not labeled with the name and expiration date of the earliest-expiring drug inside.
While specific regulations vary by state, a universal best practice and common requirement is that the EDK be clearly and accurately labeled on the exterior. This labeling must include a list of contents, and often the expiration date of the drug that will expire first. This allows for efficient inspection and replacement of expiring drugs without opening the sealed kit, ensuring it is always ready for an emergency. The other options describe standard, compliant procedures for EDKs in long-term care.
Question 5: An 88-year-old resident with type 2 diabetes, moderate cognitive impairment, and multiple comorbidities has an A1c of 6.8%. The resident is experiencing occasional morning hypoglycemia (blood glucose ~65 mg/dL) on a regimen that includes a sulfonylurea. Based on current geriatric diabetes guidelines, which recommendation is most appropriate?
- Suggest relaxing the glycemic target to an A1c of 8.0-8.5% and de-prescribing the sulfonylurea. (Correct answer)
- Add metformin to the regimen to achieve a more aggressive A1c target of less than 6.5%.
- Maintain the current regimen, as the A1c is close to the standard target of 7.0%.
- Replace the sulfonylurea with a sliding scale insulin regimen for more flexible glucose control.
Correct answer: Suggest relaxing the glycemic target to an A1c of 8.0-8.5% and de-prescribing the sulfonylurea.
For frail, older adults in long-term care with cognitive impairment and multiple comorbidities, glycemic goals should be relaxed to prioritize the avoidance of hypoglycemia. An A1c target of 8.0-8.5% is often considered appropriate for this population. Sulfonylureas carry a high risk of hypoglycemia and are often targeted for de-prescribing. Aggressive targets increase hypoglycemia risk with little benefit on long-term complications in patients with limited life expectancy, and sliding scale insulin as monotherapy is discouraged.
Question 6: A resident is being discharged from a skilled nursing facility (SNF) back to their home. To ensure a safe transition of care and prevent adverse drug events, what is the consultant pharmacist's most critical contribution to the discharge process?
- Calling the resident's outpatient pharmacy to transfer the prescriptions.
- Providing verbal counseling to the resident about the importance of adherence.
- Performing a final medication reconciliation to create a clear, comprehensive, and accurate discharge medication list for the patient, caregiver, and receiving providers. (Correct answer)
- Ensuring the resident has a 7-day supply of all medications from the facility's pharmacy stock.
Correct answer: Performing a final medication reconciliation to create a clear, comprehensive, and accurate discharge medication list for the patient, caregiver, and receiving providers.
Medication discrepancies are a primary cause of adverse events and hospital readmissions during transitions of care. The pharmacist's most vital role is performing a thorough medication reconciliation to create a single, accurate, and up-to-date medication list. This reconciled list is the foundational communication tool that ensures the patient, their family, and all subsequent healthcare providers have a clear understanding of the intended medication regimen, thereby preventing errors of omission, duplication, or incorrect dosing.
Free CCP Clinical Care in Long-Term Care Questions and Answers 1
An 85-year-old resident with an indwelling urinary catheter has cloudy, foul-smelling urine.
The resident is afebrile, has no new costovertebral angle tenderness, and exhibits no new behavioral changes.
A nurse requests an order for an antibiotic.
What is the consultant pharmacist's most appropriate recommendation based on antimicrobial stewardship principles?