Browsing by Author "Kaehr, Ellen"

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    COVID‐19 disease trajectories among nursing home residents
    (Wiley, 2021-09) Carnahan, Jennifer L.; Lieb, Kristi M.; Albert, Lauren; Wagle, Kamal; Kaehr, Ellen; Unroe, Kathleen T.; Medicine, School of Medicine
    Introduction Older adults are at greater risk of both infection with and mortality from COVID‐19. Many U.S. nursing homes have been devastated by the COVID‐19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID‐19. Setting and Methods This is a case series of 74 residents with COVID‐19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents. Results The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID‐19 infection. A subset of residents with COVID‐19 infection experienced a rapidly progressive, fatal course. Discussion/Conclusions Nursing home residents infected with COVID‐19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post‐disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.
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    Deprescribing anticholinergics in primary care older adults: Experience from two models and impact on a continuous measure of exposure
    (Wiley, 2022) Campbell, Noll L.; Pitts, Christopher; Corvari, Claire; Kaehr, Ellen; Alamer, Khalid; Chand, Parveen; Nanagas, Kristine; Callahan, Christopher M.; Boustani, Malaz A.; Medicine, School of Medicine
    Background: Deprescribing interventions delivered through the electronic medical record have not significantly reduced the use of high-risk anticholinergics in prior trials. Pharmacists have been identified as ideal practitioners to conduct deprescribing; however, little experience beyond collaborative consult models has been published. Objective: To evaluate the impact of two pilot pharmacist-based advanced practice models nested within primary care. Methods: Pilot studies of a collaborative clinic-based pharmacist deprescribing intervention and a telephone-based pharmacist deprescribing intervention were conducted. Patients receiving the clinic-based pharmacy model were aged 55 years and older and referred for deprescribing at a specialty clinic. Patients receiving the telephone-based pharmacy model were aged 65 years and older and called by a clinical pharmacist for deprescribing without referral. Deprescribing was defined as a discontinuation or dose reduction reported either in clinical records or through self-reporting. Results: The 18 patients receiving clinic-based deprescribing had a mean age of 68 years and 78% were female. Among 24 medications deemed eligible for deprescribing, 23 (96%) were deprescribed. The clinic-based deprescribing model resulted in a 93% reduction in median annualized total standardized dose (TSD), 56% lowered their annualized exposure below a cognitive risk threshold, and 4 (17%) of medications were represcribed within 6 months. The 24 patients receiving telephone-based deprescribing had a mean age of 73 years and 92% were female. Among 24 medications deemed eligible for deprescribing, 12 (50%) were deprescribed. There was no change in the median annualized TSD, the annualized TSD was lowered below a cognitive risk threshold in 46%, and no medications were represcribed within 6 months. Few withdrawal symptoms or adverse events were reported in both groups. Conclusions: Pharmacist-based deprescribing successfully reduced exposure to high-risk anticholinergics in primary care older adults, yet further work is needed to understand the impact on clinical outcomes.
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    Front-line Nursing Home Staff Provide Insight on Advance Care Planning in a Crisis
    (Elsevier, 2022) Kaehr, Ellen; Gowan, Tayler; Unroe, Kathleen; Rattray, Nicholas; Hathaway, Elizabeth; Medicine, School of Medicine
    Introduction/Objective: The dynamic changes stemming from the COVID-19 pandemic brought instability in advance care planning (ACP). ACP includes eliciting and documenting goals, values, and preferences for medical treatments, and requires considerable skill and resources. The goal of this study is to describe the nursing home staff experience with ACP including barriers and facilitators to goals of care discussions, which were revisited for all residents during nursing home COVID-19 outbreaks in 2020. Design/Methodology: This cross-sectional interview-based study interviewed 17 nursing home staff who facilitated ACP with residents and families during an initial COVID-19 outbreak, representing 7 Midwest nursing homes. Semi-structured telephone interviews were conducted (November 2020-April 2021), and included the Patient Health Questionaire-4 (PHQ4) and Impact of Event Scale-6 (IES-6) to explore the emotional impact of the pandemic. Qualitative thematic analysis was carried out to investigate the nursing home staff experience with goals of care discussions including the psychological impact on staff. Results: Nursing home staff described barriers to successful advance care planning in a crisis such as personal protective equipment (PPE), visitor restrictions, and lack of disease specific clinical knowledge. Self-reported stress was high, with 53% of participants screening positive for potential severe depression and anxiety (PHQ-4 total score ≥ 9) and 29% screening positive for possible post-traumatic stress disorder (PTSD) based on the IES-6 (mean score ≥ 1.75). Interview data offered evidence of the sources and nature of psychological impact of a COVID-19 outbreak. Participants experienced decreased stress when they reported increased knowledge, increased experience, decreased mortality, resolution of outbreak, and access to vaccination. Conclusion/Discussion: Nursing home staff described pandemic advance care planning as impersonal and uncomfortable compared to prior experiences. In future crises, maintaining in person conversations or equivalent interactions and supporting staff with adequate clinical knowledge and personal mental health resources is important in ACP.
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    Utility of the Easy-Care Standard 2010 in the Comprehensive Geriatric Assessment of Adults Aging with Developmental Disabilities
    (Elsevier, 2016-12) Kaehr, Ellen; Abele, Patricia; Little, Milta; Department of Medicine, IU School of Medicine