Nursing management review: Parkinsonism, hypertension, pneumonia - interview with Dr. Dennis W. Jahnigen and Dr. David Thomas - Nursing Care

Nursing Homes, April, 1993

Managing nursing home residents is becoming ever more clinically demanding. Due to the triple impact of OBRA, the rapid growth of the over-85 population and hospitals' "quicker and sicker" discharges, nursing staffs are under the gun. Their responsibilities for monitoring and managing residents are deepening in clinical sophistication. Recently NURSING HOMES asked two physicians with long experience in the nursing home setting to offer updated nursing care guidelines for conditions commonly experienced by nursing home residents. Consulted were:

Dennis W. Jahnigen, MD, Chief, Division of Geriatrics, The Cleveland Clinic Foundation, Cleveland, OH, and David Thomas, MD, Associate Professor of Medicine at the Bowman Gray School of Medicine and Medical Director of the Oak Summit Nursing Home, Winston-Salem, NC.

They addressed specific concerns with Parkinsonism, hypertension and pneumonia, as follows:

Parkinsonism

Dr. Jahnigen: "Of primary concern with Parkinsonism is its impact on resident autonomy and self-care. It is important to be aware of the psychological impact of this disorder and how demoralizing it is. Nursing should be supportive of self-care, such as bathing or brushing teeth, even if it takes more time than having the nurses simply do it themselves.

"Physical activity is very important to these patients, because they tend to be hypoactive and even vegetative. Programs of walking, assisted walking or wheelchair activities are all part of a good nursing care environment.

"As for monitoring anti-Parkinson medications, it's worth noting that, as a group, they rank second or third in incidence of psychiatric side effects. They have a major impact, for example, on incidence of delirium in the nursing home. The OBRA regulations have recommended drug holidays for all drugs that effect the central nervous system, and it might be helpful to apply that to anti-Parkinsonian medications, as well. Then it becomes the nurse's primary responsibility to report on all changes, or lack of change, observed in the resident with respect to onset of tremor, rigidity or bradykinesia, or psychiatric side effects."

Dr. Thomas: "Observing for the effects of the anti-Parkinsonian medications is a most important issue. At our facility we have special charting arrangements to track for the off-on phenomenon or the wearing-off effect, both of which occur particularly toward the terminal stages of the disease. We then monitor, of course, for the effects of any drug adjustments.

"While it is true that we tend to get the most severe cases of Parkinsonism in the nursing home, we also very frequently find ourselves initiating treatment for this disease. Either the diagnosis hasn't been made yet or drug therapy has been inadequate. This is largely because the physician and the family have not been in a position to monitor the patient closely enough. This is where the nursing home is superbly equipped to provide optimum care. Because of the opportunity it presents for close observation by professionally-trained nurses, we are able to prescribe and adjust drug therapy more accurately than was ever possible in the physician's office."

Hypertension

Dr. Thomas: "The critical issue here is the potential side effects of the antihypertensives, with orthostatic hypotension and dehydration being of particular concern. This assessment tends to take more nursing skill in the nursing home setting than in other settings, because residents' basic physical condition is so often compromised. Nursing home residents on antihypertensives need constant reassessment for side effects, and changes of drug are very common. Totally stopping drug therapy is also not uncommon in these patients.

"This may occur because of the physiology of aging. For example, some antihypertensives work by dilating the peripheral vasculature, but with the increasing autonomic dysfunction of aging, this tends to occur anyway, and may justify a therapeutic trial off the medication.

"In any event, you have to try to fit the drug therapy to the particular patient and his or her associated diseases. If, for example, there is associated angina, a calcium-channel blocker might be tried. If diabetes is present, there may be some benefit from an ACE-inhibitor because of its renal effects. In general, drug selection is keyed to associated diseases and vulnerability to specific side effects.

"Nurses have to be thoroughly familiar with the important side effects of all the antihypertensives and be ready to communicate these to the physician, because they have the closest personal contact with these patients of all health care professionals."

Dr. Jahnigen: "Aside from monitoring therapy with antihypertensive medications, nurses need to be alert for the possible usefulness of ancillary care, such as a low-salt diet or exercise to reduce systolic hypertension. They should be ready to recommend these if the physician hasn't already.

"An important consideration with the use of antihypertensives in this setting is that people in the nursing home tend to both reduce activity and to lose weight. Often, due to these factors, their previous drug regimens are no longer needed. Patients can be weaned off antihypertensives, and even cardiac drugs, simply because they've lost 10 to 15 pounds. That's why it is particularly important in the nursing home to be alert for signs of overmedication.