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To Treat or Not to Treat: How Clinical Conundrums become Opportunities for Quality Improvement


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Title: To Treat or Not to Treat: How Clinical Conundrums become Opportunities for Quality Improvement

To Treat or Not to Treat How Clinical Conundrums
become Opportunities for Quality Improvement
  • Daniel Bluestein, MD, MS, CMD
  • Sabine M. von Preyss-Friedman, MD, CMD
  • Ashkan Javaheri, MD, CMD
  • Irene Hamrick, MD

Learning Objectives
  • By the end of the session, participants will be
    able to
  • Articulate a framework for evaluation of weight
    loss, urinary tract infection, depression,
  • Summarize evidence for the pros and cons of
    double-sided therapeutic options regarding these
  • Examine potential quality improvement
    opportunities in relation to these entities.
  • Discuss how the interdisciplinary team can be
    engaged in this process.

QI Caveats
  • Understand variation Example My trip from EVMS
    to WC
  • Is variation in rates within statistical limits?
  • Or did the process change?
  • Techniques for doing this beyond scope of this
  • Recc workshop by Matt Wayne Len Gelman at
    national meeting
  • Understand the process
  • Flow charts
  • Fishbone diagrams
  • Pareto charts
  • Brainstorm w stakeholders
  • Dont rush to judgment (or blame)

Weight loss
  • Daniel Bluestein, MD, MS, CMD, AGSF
  • Professor Director, Geriatrics Division
  • Department of Family Community Medicine
  • Eastern Virginia Medical School

  • On day on rounds, The team leader on 1-A tells me
    Ms. X has lost 7 lb. over the past month (shes
    109 years old).
  • She shows you the dietician progress notes that
    Mirtazapine be considered
  • Or if not Mirtazapine, then Megace or Marinol

My responses (a Parody of Kluber-Ross)
  • Denial-
  • Is this for real
  • Anger-
  • How could you all be so dumb
  • Bargaining-
  • If I put Ms. X on something, maybe they will shut
    up leave me alone
  • Depression-
  • I need to go somewhere else
  • Adaptation-
  • Maybe I can make this better

E/M Like some relationships Its complicated
E/M Overview
  • Identify anticipate at-risk pts (SNAQ)
  • Are weights accurate?
  • Is this fluid loss?
  • Vomiting diarrhea
  • Diuretics
  • Osmotic losses (hyperglycemia)
  • Inadequate access
  • Physiologic effects of aging
  • How much food is he/she taking in?
  • Consider interventional strategies
  • Condition specific
  • Generic
  • Dietary supplements
  • Ambience/Assistance/Appeal
  • Activity exercise
  • Drugs

Contributors the Ds
  • Diseases-
  • Hypermetabolic
  • Thyroid
  • Pheochromocytoma
  • Diabetes
  • Wasting
  • Cancers
  • Collagen/vascular
  • infections
  • COPD
  • ESRD
  • Chronic infections
  • Pressure ulcers
  • Depression
  • Dementia
  • Digestive
  • Diarrhea
  • Dysphagia
  • Other GI
  • Dysgeusia
  • Dentition
  • Drugs
  • etoh
  • Deficiency states
  • Dysfunction
  • Distasteful Diets
  • Dont know

Huffman. Am Fam Physician 200265640-50
The Ds in LTC
  • Depression
  • Drugs
  • Dysfunctions
  • Dependent on others to feed (staff turnover,
  • Isolation/poor ambience
  • Dysmobility
  • Dysphasia
  • Dental/Oral
  • Dementia/agitation/sedation
  • Diseases-wounds, COPD, CHF
  • Distasteful Diets
  • Deficiencies
  • Dont know

Tamura et al. JAMDA 2013 14(9)649-55 Aoyama et
al. JAMDA 2005 6566-72
Common Sense Treatment
  • Treat underlying disease.
  • Endocrine, drug, GI disorder, depression most
  • Functional
  • Dental care/dentures-oral hygiene
  • OT/PT/Speech/swallowing evalns
  • Hearing aides glasses
  • Facilitate Bowel function
  • Exercise even in frail elders
  • Dietary
  • Ambience
  • Assistance
  • Small, frequent meals
  • Taste facilitators

Supplements-conflicting evidence
  • Some studies show 1-2 kg gains in supplement
    group vs. 1 kg loss in controls
  • Small sample sizes
  • 60 day f/u
  • No real changes in functional status
  • Others supplements substitute for meals,
    caloric intake the same
  • Should use between meals, not with
  • Cochrane (2009)
  • Small increase wt
  • Small mortality reduction
  • Morley et al. JAMDA 2010 11 3916, varied JAMDA
  • More sanguine about leucine-containing
    supplements in concert with exercise

  • Mirtazapine-
  • small wt gain up to 7 at best
  • ? any better than other antidepressants
  • ? Effect in non-depressed
  • Hyponatremia, sedation, orthostasis, serotonin
  • Megestrol Acetate
  • Yeh et al RCT 4 lb wt gain _at_ 25 wks no
    mortality difference
  • DVT, CHF, Adrenal suppression, ?mortality, large
    C/C study
  • Dronabinol
  • Mostly small studies 5-10 ib gain at best
  • MI, delirium, death
  • http//

What I did
  • Read up on Dx Rx of wt loss
  • Went on weight wounds rounds a few times
  • (Usually on a Tuesday AM when I cant easily
  • Some findings
  • Lack of real knowledge
  • Good intentions
  • External pressure
  • Organizational culture other priorities
  • They are really not used to a hands-on medical

My intervention
  • Educate inform
  • Develop implement a rational, step-wise policy,
  • Screen for nutr risk -SNAQ or tool of your
  • When someone triggers on wt loss
  • Med review for new meds
  • PHQ 2/9
  • Note to provider to assess for other treatable
    causes as appropriate in keeping with prognosis
    philosophy of care
  • Implement of non pharmacological interventions
  • Reassess consider
  • Further evaluation on occasion
  • Risk/benefit ratio of drugs
  • In process Goal
  • 1o documentation this process has been followed
  • 2o stabilization/improvement

It remains to be seen
  • Whether this ( other QI measures discussed
    today) improve care remains an open question at
    this time.

To Treat Or Not To Treat How Clinical
Conundrums Become Opportunities For QIUrinary
Tract Infection or Asymptomatic Bacteriuria?
  • Sabine von Preyss-Friedman MD, CMD
  • Associate Clinical Professor, Division of
    Gerontology and Geriatric Medicine, University of

Asymptomatic Bacteruria
  • Prevalence (without catheters)
  • 25-50 for women
  • 15-40 for men.
  • Prevalence (with Catheters)-100
  • Treatment does not improve outcomes
  • Consequence Frequent, unnecessary Abx
  • Cost
  • Resistance
  • C Diff
  • Adverse effects
  • Drug Interactions (cipro-coumadin)
  • Inadvertent nephrotoxic doses (flouroquinolones,
  • Missed the real problem

Nicolle LE. Int J Antimicrob Agents. 1999
On the other hand.
  • Non specific presentation of serious infection
  • Dubious (or no) history in cognitive impairment
  • True UTI Urosepsis are alive well
  • Symptomatic UTI 0.1-2.4 episodes/1000 resident
    days (variation due to differences in
  • Systemic infection 0.49-1.04/10,000
    noncatheterized-resident days.

Problem, continued
  • Serious complications from infections
  • Death from potentially treatable cause
  • Transfers
  • Functional decline
  • LTC
  • More limited diagnostic resources
  • Telephone medicine (e.g. empirical abx)

Grey areas
  • The febrile patient with a positive U/A or
    culture no other focus
  • Only 10 of such patients show rise in serum
    antibodies to infecting urinary pathogens.
  • Corollaries
  • Look hard for other reasons for fever
  • Consider other studies such as a CBC
  • Fever hematuria does point more to UTI
  • The patient who is acting differently
  • Typically more advanced dementia, cant give
  • Lots of other reasons to consider
  • If UTI the cause, will have fever
  • Treatment? Guidelines would say no.

How are Practitioners making decisions?
  • 19 MDs, 3 PAs, 41 nurses.
  • 5 most common triggers for suspect UTI,
    noncatheterized pts.
  • change in mental status (90),
  • fever (76),
  • change in voiding pattern (70),
  • dysuria (65),
  • Change in character of urine (59)
  • MDs, PAs significantly less likely to know or
    apply diagnostic criteria.
  • 55 would treat asymptomatic bacteruria
  • Nurses more likely to urge treating asymptomatic
  • See nonspecific changes in status as symptoms
  • Juthani-Mehta et al. JAGS, 2005.

Why Antibiotic Overuse?
  • Lack of up to date Medical Education
  • Ingrained beliefs of Medical Providers, Nursing,
    patients, families
  • Geropsychiatry Due Diligence
  • Fear of rapid deterioration and poor outcomes in
    frail elderly who have bacterial infection

Prior Criteria less than helpful
  • 2013 study of Loeb criteria (data collected 2011)
  • Often disregarded
  • Even when taking into account, did not curb
    antibiotic use
  • Olsho et al. JAMDA 2013 14(4)309 e1-e7.

New McGeer Criteria, 2012
  • Fever Definition
  • A single oral temperature greater than37.8C
    (100F) or
  • Repeated oral temperatures greater
    than37.2C(99F)or rectal temperaturesgreaterthan3
    7.5C (99.5F)or
  • A single temperature greater than 1.1C(2F) over
    baseline from any site.
  • Acute functional decline in activities of daily
    living (ADLs)
  • A new 3-point increase in total activities of
    daily living (ADL) score (range, 0-28) from
    baseline, based on the following 7 ADL items,
    each scored from 0 (independent) to 4 (total
    dependence) Bed mobility,   Transfer, Locomotion
    within LTCF, Dressing, Toilet use, Personal
    hygiene, Eating
  • Use of CAM to define acute change in mental
  • Re. UTI-reliance on cx w appropriate symptom
    combination (either alone is inconclusive)

UTI (No Indwelling Foley), Criterion 1,Need Both
  • At least one of the following s/s
  • Acute dysuria or acute pain, swelling, or
    tenderness of testes, epididymis, or prostate in
  • Fever or increased WBC and ONE of the following
  • Acute costovertebral pain or tenderness
  • Suprapubic pain
  • Gross hematuria
  • New or increased incontinence
  • New or increased urgency
  • New or increased frequency
  • No fever or increased WBC and TWO from the above

Criterion 2. One of the following microbiologic
  • At least 100,000 cfu/mL of no more than 2 species
    of microorganisms in a voided urine sample.
  • At least 100 cfu/mL of any number of organisms in
    a specimen collected by in-and-out catheter

UTI with foley
  • For residents with an indwelling catheter (both
    criteria 1
  • and 2 must be present)
  • Criteria1 (at least 1 of the following
  • Fever, rigors, or new-onset hypotension, with no
    alternate site of infection.
  • Either acute change in mental status or acute
    functional decline, with no alternate diagnosis
    and leukocytosis.
  • New-onset suprapubic pain or costovertebral angle
    pain or tenderness.
  • Purulent discharge from around the catheter or
    acute pain, swelling, or tenderness of the
    testes, epididymis, or prostate

With foley, continued
  • Criteria 2. Urinary catheter specimen culture
    with at least
  • 100,000 cfu/mL of any organism(s).
  • Recent catheter trauma, catheter obstruction, or
    new onset hematuria are useful localizing signs
    that are c/w UTI but are not necessary for
  • Urinary catheter specimens for culture should be
    collected following replacement of the catheter
    (if current catheter has been in place for gt14 d).

  • Inservices about UTI vs. ASB to nursing staff
  • Medical Director provides attending physicians
    with literature and personal education and
  • Medical Director inservices psychiatric
  • MD compare
  • Protocols based on McGeer Criteria for when it is
    appropriate to order a U/A

Alternatives to Rx for grey areas
  • Examples
  • Isolated voiding symptoms,
  • increased incontinence,
  • change in urine odor,
  • change in behavior
  • Watchful waiting for 24 hours
  • No u/a or c/s
  • Hydrate
  • Perineal hygiene
  • Address constipation
  • Attend to comfort
  • Q 8 VS
  • Evaluate for UTI if go on fulfill criteria
  • Look for alternatives if sx persist

It remains to be seen
  • We still lack a convincing marker for UTI vs.
    colonization in advanced dementia.
  • Sx to meet minimum criteria for UTI frequently
    absent in NH residents w advanced dementia.
  • Abx are prescribed for the majority of suspected
    UTIs that do not meet these minimum criteria
  • DAgata et al. JAGS 2013 61(1)62-6

To treat or not to treatHow Clinical Conundrums
become Opportunities for Quality Improvement
  • Ashkan Javaheri, MD, CMD
  • Assistant Clinical Professor- UC Davis School of
  • Geriatric Division and Senior Care Program
  • Division Head
  • Mercy Medical Group
  • Sacramento, CA

  • Prevalent
  • Treatable
  • Often under-recognized

Chronic Medical Illness and Depression
  • Stroke 30 to 60
  • Coronary heart disease 8 to 44
  • Cancer up to to 40
  • Parkinsons disease 40
  • Alzheimers disease 20 to 40
  • Boswell  EB, Stoudemire  A.  Major depression in
    the primary care setting.  Am J Med.

  • Decreased quality of life
  • Decreased participation in activities
  • Falls
  • Malnutrition
  • Dehydration
  • Increased risk of intercurrent infections
  • Behavioral symptoms
  • Agitation
  • Rejection of care

  • Elderly 13 of US population 24 of completed
  • Less often more likely successful
  • Elderly men highest suicide rate 28.9/ 100,000.
  • Yes it can happen in LTC

Trends-LTC (1999-2007)
  • Diagnosis of depression and antidepressant
    therapy in residents diagnosed increased rapidly.
  • By 2007, 51.8 of residents diagnosed with
    depression, 82.8 of whom received an
  • Gaboda D et al. JAGS 2011 59673680

Underuse/ Overuse
  • 3692 LT residents in 133 VA facilities
  • 877 depressed
  • 25.4 did not get treatment ?underuse
  • 57.5 potential inappropriate use
  • drug-drug and drug-disease interactions
  • 2,815 residents who did not have depression,
    1,190 (42.3) were prescribed one or more
  • Hanlon JT - J Am Geriatr Soc 2011

Not as safe as we once thought
  • SSRI safer than older drugs, still first choice
  • SSRIs have side effects
  • Falls,
  • hip fracture,
  • insomnia,
  • hyponatremia
  • GI bleeding,
  • worsen RLS,
  • serotonin syndrome

Evidence Base
  • Available evidence offers weak support to the
    contention that antidepressants are an
    effective treatment for patients
    with depression and dementia and at best moderate
    evidence in non demented patients.
  • It is not that antidepressants are necessarily
    ineffective but there is not much evidence to
    support their efficacy either.
  • Given that they may produce serious side-effects
    clinicians should prescribe with due caution.
  • Cochrane Database Syst Rev. 2002
  • Hanlon et al, J Am Med Dir Assoc 2012
  • Boyce et al, J Am Med Dir Assoc 2012

Why-depression a mixed bag
  • Medical causes
  • Major Depression
  • Minor Depression (or Subsyndromal)
  • Dysthymia
  • Bereavement
  • Vascular Depression
  • Psychotic Depression
  • Depression in AD
  • Thakur M, Blazer D, J Am Med Dir Assoc 2008

Medical conditions associated with depression
  • Uncontrolled pain
  • Medications
  • Alcohol and substance abuse
  • Thyroid disease
  • Anemia (B12)
  • Electrolyte abnormalities organ failures
  • (Cancers)

Major Depression DSM-IV
  • Symptoms for gt 2 weeks
  • 5 or more symptoms
  • At least one should be
  • Depressed Mood
  • Anhedonia (lack of interest or pleasure)
  • Meds retain utility here
  • Mild 5 superior to placebo (46-41)
  • If major, severe, or prolonged depression, 27
    superior (58-31)
  • Nelson et al. Am J Psychiatry, 6-13
  • Other symptoms
  • Significant weight loss or weight gain (more than
  • Insomnia or hypersomnia
  • Psychomotor retardation or agitation
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or
    inappropriate guilt
  • Diminished ability to think or concentrate, or
    indecisiveness, nearly every day 
  • Recurrent thoughts of death (not just fear of
    dying), recurrent suicidal ideation without a
    specific plan, or a suicide attempt or a specific
    plan for committing suicide

Subsyndromal Depression/Dysthymia
  • One of core symptoms (depressed mood / anhedonia)
    plus 1 to 3 (other) symptoms
  • Depression without sadness in elderly
  • Risk factor for Major Depression
  • For gt 2 weeks gt chronic
  • Associated with
  • Poorer health and social outcomes
  • Functional impairment
  • Higher health utilization and treatment costs
  • Not very responsive to drugs in younger
  • Role for non-pharmacological therapies

  • Usually time-limited
  • Behavioral treatments, support groups treatments
    of choice
  • Now indications for meds if bereavement triggers
    major depression
  • Likewise for complex or protracted bereavement
  • Simon NM. JAMA 2013 310(4)416-23.

Psychotic Depression
  • Subtype of Major Depression
  • Depression with delusions (somatic and
    persecutory)/ hallucinations
  • Common in elderly
  • Especially inpatient and long-term setting
  • ECT

Vascular Depression (subcortical ischemic
  • Ischemic changes are detected with MRI
  • Higher prevalence in patients with vascular
  • 20- 50 of patients develop depression within
    1st year after stroke
  • Left hemisphere? more chance of depression
  • Associated with more cognitive impairment and
    disability, more psychomotor retardation, less
    agitation, less guilt, and less insight into
    their illness 
  • Some may have silent stroke
  • No consensus of diagnosis
  • Response to drugs?

Ishii S et al. Apathy A Common Psychiatric
Syndrome in the Elderly. JAMDA 2009 10 38193.
Other considerations
  • Short vs. Long-term residents
  • Seasonal variation

Screening for depression
  • The USPSTF recommends screening adults for
    depression when staff-assisted depression care
    supports are in place to assure accurate
    diagnosis, effective treatment, and
    follow-up.Grade B recommendation.
  • The USPTF recommends against routinely screening
    adults for depression when staff-assisted
    depression care supports are not in place. There
    may be considerations that support screening for
    depression in an individual patient.Grade C

  • Geriatric Depression Scale (GDS)
  • GDS-15 sensitivity 84, specificity 85.7
  • Limm PP et al, Int J Geriatr Psychiatry 2000
  • Cornell Depression Scale
  • http//
  • sensitivity 93, specificity 97 with a cut-off
    value of 6for patients with dementia
  • PHQ-2/9

  • Total Score Depression Severity
  • 0-4 None
  • 5-9 Mild depression
  • 10-14 Moderate depression
  • 15-19 Moderately severe depression
  • 20-27 Severe depression
  • Score gt10 has 88 sensitivity and specificity for
    major depression diagnosis
  • Part of MDS 3.0
  • May be disconnect between MDS process clinical

Evaluation and Treatment of Depression is team
  • CNAs
  • Nursing staff and MDS coordinator
  • Dietary
  • Activity staff
  • Pharmacists
  • Social Workers
  • MDs, NPs, and PAs
  • Psychologist
  • Psychiatrists
  • Therapy staff (PT/OT/ST)
  • Patients
  • Families

Who should be part of the team?
What is done with positive screens?
Who is the champion?
  • Create a team
  • Identify champion
  • Identify residents with PHQ-9 scores above 5 and
  • Create communication system
  • Screener? RN ? clinician ? RN/ Team
  • Clinician may make the diagnosis
  • Behavioral consultant
  • Care plan (all team members should be involved)
  • Tailor therapies
  • Danger to self
  • Prior history of depression
  • Psychotic symptoms
  • Any past treatment(s)
  • Monitor PHQ-9 score in response to therapy
  • Alternate and adjust you care plan as you move
  • Meet regularly and review data

Further considerations
  • Accurate assessment
  • Match variant to therapy
  • Psychologist or psychiatrist in some cases
  • May try empirical SSRIs
  • Drug
  • Safety
  • Side effect profile for therapeutic advantage
  • Avoid drug interactions
  • Dose
  • Duration
  • Assess response-serial PHQ-9s
  • How about other disciplines? Activities,
  • What if treatment fails?

American Medical Directors Association Long Term
Care MedicineTo Treat or not to treat How
clinical conundrums become opportunities for
QIOsteoporosis in Frail LTCPatients
  • Irene Hamrick, MD

Your thoughts? Clinical QI
  • 97 year old bedbound patient sustains femur
    fracture during diaper change
  • admitted to Nursing facility area of CCRC 2 years
    ago after stroke
  • Family is outraged and demands to know how this
    could happen

To not treat
  • Do tools for screening in younger populations
    apply here?
  • Bone Density measures, practical?
  • FRAX
  • Side effects of antiresorptives
  • Esophageal erosions
  • Renal issues
  • Safety practicality of administration
  • Paradoxical outcomes
  • Jaw necrosis
  • Atypical fractures
  • ? Benefit during lifetime
  • Limited evidence for bisphosphonates

Or Treat?
  • Not doing so can lead to bad outcomes as in this
  • In LTC
  • Prevalence O/P 85
  • Rate of osteoporotic fractures 11/yr in NH vs.
    2-3 in community.
  • Nursing home residents who suffer Fx, any site-15
    fold increase in hospitalization

Vertebral Fx
  • back pain,
  • dysphagia,
  • kyphosis,
  • reduced pulmonary function,
  • diminished quality of life.
  • Narcotic side effects
  • Vertebroplasty/Kyphoplasty?

Osteoporosis Stroke
  • Hip fracture increased 2 to 4 times in stroke
    patients over age-matched reference population,
    especially in 1st year after stroke
  • 82 on hemiplegic side
  • 84 due to falls
  • Ramnemark A et al. Osteoporos Int. 199889295.
  • Kanis J, et al. Stroke. 200132702706.
  • Chiu KY, et al. Injury. 199223297299.

  • How soon after stroke is most bone lost in the
    paralyzed side?
  • 4 weeks
  • 4 months
  • 1 year
  • 4 years

Bone Loss after Stroke
  • Bone loss most severe in first 3-4 mo.
  • Upper extremities ? by 9.3 (P 0.01)
  • Lower extremities ? 3.7 (P 0.01)
  • Hamdy 1995 Am J Phys Med Reh 74351-6

  • Consider Rx for
  • clinical hip or spine fracture,
  • radiological evidence of a VF,
  • BMD data if available.
  • Since O/P Rx demonstrate Fx reduction in 1
    year, do not use if lt 1 year life expectancy.

Greenspan et al. JAGS 2012 60(4)684-90
  • Cochrane review-reduction of hip and nonvertebral
    fractures when vitamin D and calcium were taken
  • subgroup analysis benefit most significant in
    institutionalized persons
  • Avenell et al. Cochrane Database Syst Rev 20053
  • CD000227.
  • Feb 2013 USPSTF did not endorse but did not
    engender LTC residents
  • Ca side effects
  • Constipation
  • Ca-carbonate
  • Ca-citrate
  • Binding effects
  • ? Vit D levels vs. empirical supplementation
  • Uncouple Ca D

Evidence for Bisphosphonates in LTC admittedly
  • alendronate (10 mg po qd) vs. placebo in elderly
    women in LTC w O/P
  • alendronate increased BMD in both spine and
    femoral neck
  • good tolerance,
  • incidence of Fx lower in alendronate group but
    did not reach statistical significance
  • limited participants
  • short follow-up.
  • Greenspan et al. Ann IM 2002 136(10)742-6.
  • Extrapolate from less frail popns
  • Bisphosphonates post hip fx reduce recurrences

QI ramifications
  • Identify patients with a diagnosis of
  • Consider 2o causes if appropriate
  • Look for risk factors
  • Assess if all patients in facility who have
    osteoporosis are treated or have a documented
    reason for no treatment
  • Recognize impact of immobility
  • Engage the IDT for suggestions re diet,
    weightbearing, sun exposure
  • Pharmacy review
  • Vitamin D and Calcium on MAR
  • Minimize interactions
  • Correct administration of other Osteoporosis meds

  • Vitamin D 800-1000 IU daily, higher in deficiency
  • Calcium 500-600 mg twice daily if inadequate
    dietary intake
  • Discuss high fracture risk, additional medication
    treatment with family

In parting
  • Dont get mad or despair-get creative
  • Keep up with developments best practices
  • Goals are care processes rather than clinical
  • Engage the team
  • Be persistent