An acute change in mental status is com monly observed among frail older adults. There are many possible reasons that a NF resident/patient can have a change in mental status. Commonly seen triggers include medication, infection, and/or pain. Research suggests that the prevalence of memory loss in NF patients varies between 50 % and 80 %, therefore it is critical to get a baseline cognitive assessment completed within the first few days after admission. If a recently admitted patient is diagnosed with delirium and/or depression, their cognition should be reevaluated after successful treatment of their acute change in mental status (see chapter “Dementia, Delirium, and Depression” for further discussion of Depression and Delirium).

Many clinici ans have heard staff report, “the patient seems more confused”. When this occurs, use the opportunity to educate staff that an increase in confusion is more appropriately called delirium and reinforce the importance of recognizing such a change in mental status and notifying the PCP. After recognizing a change in mental status and obtaining vital signs, staff should contact the PCP. The patient’s complaints and any significant physical findings on nurse assessment need to be conveyed to the PCP. The PCP should then inquire about the patient’s medical history, medications and recent laboratory studies. Vital signs should be monitored each shift for at least 3 days. When reviewing the patient’s medications, it is important to look for any problematic medications (see chapter “Medication Management in Long Term Care” on Medication Management for further discussion) and recent medication changes. Recent laboratory studies should be reviewed for any evidence of disease including but not limited to hematologic, liver or renal abnormalities. Some laboratory studies may need to be repeated. Nursing facilities should have established systems of care that facilitate licensed staff assessing any resident’s acute change in condition in a timely manner. Early recognition, diagnosis, and treatment of an acute change of condition plays an important role in preventing avoidable hospitalizations.

In most setti ngs chest pain is viewed as a potential 911 call. However, 911 may not always be appropriate in the nursing facility setting. If the PCP has had a previous conversation with the resident/POA regarding goals of care and the risks and benefits of hospitalization, many residents prefer treatment in the NF whenever possible. This is especially true for patients who have established “comfort” as their goal of care at which time the primary treatment of chest pain is usually focused on pain relief. Then treating chest pain with aspirin, nitroglycerin, and morphine sulfate would be appropriate.

Dehydration is freq uently caused by acute onset of protracted vomiting and/or diarrhea without adequate fluid replacement. Early diagnosis and intervention can potentially prevent an avoidable hospitalization. Early interventions include adding medication to treat the symptoms, holding or reducing any medications that may cause further adverse effects (such as warfarin, digoxin, diuretics, iron, bowel medications) and administering intravenous (IV) fluids or giving careful attention to oral fluid intake. Intravenous fluids may not be appropriate in patients who have multi-morbidities associated with progressive unavoidable weight loss (see chapter “Weight and Nutrition” for further discussion).

If goals of care h ave previously been addressed, the decision to withhold artificial hydration or to not hospitalize is usually less difficult for the patient/POA. Occasionally, if the problem is acute, some patients/POAs request IV therapy. Since more than 60 % of long-term care facilities (LTCF) residents have significant cognitive impairment, it is appropriate to request that a family member be present when administering IV therapy. This family member can calm a delirious patient and prevent the accidental removal of the IV line.

Acute onset of phy sically or verbally aggressive behavior is common among NF residents in memory loss specialty units. The PCP should have a conversation with the POA regarding physical or verbal abusive behaviors that are unresponsive to behavioral interventions. This is especially important when a patient is attempting to physically harm staff or other patients. Residents that are subjected to verbally aggressive speech from another resident may manifest distress by becoming abusive to the offender.

Hospitalizing residents with se rious behavioral problems has little benefit other than temporarily removing them from the NF until the staff can successfully de-escalate the behaviors of the remaining patients. Consequently, successful memory loss units have experienced staff and PCPs who use creative behavioral interventions to de-escalate most physically or verbally aggressive behavior. Maintaining educated and consistent caregivers and staff that are familiar with the nuances of the unit residents is extremely important. Administrators frequently find preventing high staff turnover very challenging as they work to maintain consistency and quality of care in memory loss units.

Because of the lack of ps ychiatrists trained in geriatrics, many NF PCPs use psychiatrists trained in adult psychiatry to assist with residents who have challenging behaviors. Unfortunately these psychiatrists often are not trained in evaluating and treating behavioral problems in residents with memory loss. There are no psychotropic medications approved by the FDA or proven effective in treating behavioral symptoms of dementia as of 2015. Although there are no medications that have been shown to improve the behaviors of residents with dementia, many clinicians and facilities have found the advice of psychologists who are interested in helping staff manage the behaviors of these cognitively impaired residents to be extremely helpful.

As a last resort, medicati ons can be used off-label to attempt improvement of disruptive resident behaviors. Before resorting to using any off-labeled medications, a family member or the resident’s POA may want to assist with de-escalating their family member’s behavior by phone contact or by a visit to the NF. If a PCP is considering using an off-label medication for behavioral problems, it is important that staff or preferably the PCP to share with the POA the risks and benefits of using these medications.

Unexpected we ight gain that occurs either very rapidly or is not due to high calorie intake is usually congestive heart failure until proven otherwise. CHF is the second most common diagnosis for which residents are hospitalized, and the hospitalization is often avoidable. During monthly or bimonthly visits the residents’ weights should be reviewed. Except for very rare situations (e.g., ruptured heart valve), PCPs should be able to treat CHF at the faculty and avoid hospitalization unless refractory pulmonary edema develops. The management of heart failure is thoroughly reviewed in AMDA’s clinical practice guideline on Heart Failure in the Post–Acute and Long–Term Settings.

One of the m ost commonly overlooked vital signs is a slightly elevated temperature among frail older adults. It is not uncommon for fevers in NF residents to be symptomatically treated like they are in younger and healthier people. Standing orders for antipyretics in NFs should be avoided. Giving medication for a fever without identifying the underlying cause can lead to poor outcomes. Castle et al. have reported that repeated oral temperatures greater than 99 °F (37.2 °C) has a sensitivity of 80 % and specificity of 89 % for fever. In addition, Castle advised that either a single oral temperature greater than 100 °F (37.8 °C) or, a single temperature 2 °F (1.1 °C) above a patient’s baseline, or repeated oral temperatures greater than 99 °F (37.2 °C) are significant for infection and need to be addressed by the PCP [7]. CMS has indicated that pneumonia and urosepsis are two common diagnoses among NF/SNF residents that lead to potentially avoidable hospitalizations. It is reasonable to suspect that many of these potentially avoidable hospitalizations resulted from poor monitoring of vital signs, lack of licensed staff adequately assessing the ill resident, and lack of timely notification of the PCP.