Monthly Archives: October 2015

Medical Director Guidebook Coming Soon

Doctor to Doctor Stock photo lower res
Several copies of Doctor to Doctor, Second Edition, revised this year, will be distributed this week to all Golden LivingCenters. Medical Directors also will receive an electronic copy via email. This guidebook is full of information which can help Golden Living Medical Directors with how to be a success at the position. If you are new to medical directing, have been doing it for a while or are even an “old hand” at it, you’ll want to check this out.

There are there practical tips on everything from what to do during survey time to your role in QAPI to how to document in a way that minimizes your risk. The medical director’s contractual obligation section is revised to focus on what is absolutely required of you, and how to work with your ED and DNS on identifying your objectives for the year. There’s even a copy of the monthly timesheet you need to fill out for your Executive Director conveniently located in the back of the book.

Because doctors are busy, and medical directors are no exception to this, the guidebook is concise enough that you could probably read it in one sitting over a cup of coffee.

For Medical Directors to request an electronic copy, please contact

Diabetes Update:  FDA Warns of Severe Joint Pain Caused by DPP-4 Inhibitors

-Al Barber PharmD, CGP  AlixaRx Clinical Services


On August 28, the U.S. FDA warned that a commonly used class of medications for Type-2 diabetes (DPP-4) inhibitors may cause joint pain that can be severe and disabling.  (1)

Commonly used DPP-4 inhibitors include:

  • Sitagliptin (Januvia®)
  • Saxaglipitin (Onglyza®)
  • Linagliptin (Tradjenta®)
  • Alogliptin (Nesina®)

DPP-4 inhibitors lower blood glucose levels in Type-2 diabetics by slowing incretin metabolism.  Incretins, (including GLP-1) are gut hormones that are secreted from enteroendocrine cells into the blood within minutes after eating.  One of their many physiological roles is to regulate the amount of insulin that is secreted after eating.

Since 2005, two new classes of drugs based on incretin action have been approved for lowering blood glucose levels in T2DM: incretin mimetics (i.e. exenatide, which is a potent long-acting agonist of the GLP-1 receptor) and incretin enhancers (i.e. sitagliptin, which is a DPP4 inhibitor). Exenatide is injected subcutaneously twice daily and its use leads to lower blood glucose and higher insulin levels, especially in the fed state.

There is glucose-dependency to its insulin secretory capacity, making it unlikely to cause low blood sugars (hypoglycemia). DPP4 inhibitors are orally active and increase endogenous blood levels of active incretins leading to prolonged incretin action. The elevated levels of GLP-1 are thought to be the mechanism underlying their blood glucose-lowering effects.  (2)

Information for Health Care Professionals

  • Severe and disabling joint pain has been reported with the use of DPP-4 inhibitors. The time to onset of symptoms following initiation of symptoms varied from one day to years. Patients experienced relief of symptoms upon discontinuation of the medication. Some patients had a recurrence of severe join pain when restarted on either the original or a different DPP-4 inhibitor.
  • Consider DPP-4 inhibitors as a possible cause for any patient who presents with severe and persistent join pain, and consider discontinuation of therapy with this class of drugs.
  • The FDA identified 33 cases of severe arthralgia reported with the use of DPP-4 inhibitors from 2006 to 2013. All patients experienced arthralgia that resulted in a substantial reduction in their prior level of activity, including 10 patients who were hospitalized due to disabling join pain.  In 22 cases, symptoms appeared within one month of therapy initiation.  In 23 of 33 cases, symptoms resolved less than one month after discontinuation of the drug.
  • Ten of the 33 cases reported fever and chills, rash, and swelling, which are suggestive of an immunological reaction. However, the majority of these patients had negative or normal test results and the positive results were not specific for a particular autoimmune condition that can cause severe joint pain.

The bottom line:

While the DPP-4 inhibitors are an important class of medications, if you have a patient on one of these who has developed severe unexplained joint pain, even years after beginning treatment, consider a trial off of the medication.   –mjy


  1. FDA Drug Safety Communication 8-28-15: FDA Warns that DPP-4 inhibitors for type 2 diabetics may cause severe joint pain
  2. Wook K, Egan J The Role of Incretins in Glucose Homeostasis and Diabetes Treatment  Pharmacol Rev. 2008 Dec; 60(4): 470–512.  Published online 2008 Dec 12

Dr. Mary Evans Presents: A “How To” guide for decreasing Inappropriate use of antipsychotic meds


At the end of August, Dr. Evans gave a well-received talk on decreasing inappropriate use of antipsychotic medications. Very practical information was shared about how to evaluate your patients and your LivingCenter for off-label use of antipsychotic medications in patients with dementia. Tips on gradual dosage reduction were discussed, and the need for a multidisciplinary approach was stressed. A copy of her presentation slides in PDF format was sent to the doctors on the First Monday distribution list.  If you did not receive this and would like a copy, please click here or contact Reene Dux at

Golden Innovations Newsletter – October 2015

Lynn Freeman, PT, PhD, DPT, GCS, CWS
Special: First Edition
October is National Physical Therapy Month: A Special Thank You to our PTs and PTAs!
Office of Research
Clinical Research and Analytics ORU
The goal of Golden Living’s Organized Research Unit (ORU) is to support clinicians through conduct of health-related research, specifically Health-Services Research (HSR) using pragmatic methods and “real-world” data. An important distinction between HSR and other types of health-related research is its concentration on populations. The population of focus for Golden Living’s ORU is older adults with multiple chronic conditions that receive care across the continuum of post-acute settings. Because HSR is a multidisciplinary field of scientific investigation that requires many resources to conduct, our mission is made possible through collaboration and support from all departments/business lines in the Golden Living family, as well as partnerships with external institutions.
Collaborative Mission: To improve the well-being of the senior population by advancing clinical knowledge and practices in post-acute care through health-services research in the fields of medicine, pharmacy, nursing, rehabilitation, and wellness.
The Instrumented Test of Sensory Integration for Balance: A Validation Study
PI/PD: Freeman (Golden Living ORU); Oregon Health and Sciences University (OR)
Role: PI/PD
Sponsor: None
Increased postural sway associated with aging and degenerative disease is a common indication of postural dysfunction and fall risk which makes objective testing in these areas important. Unfortunately, “gold standard” measures of sway such as SOT are importable and can be costly and complicated to use, thus are often unavailable in post-acute settings. In a study of community-dwelling older adults with known balance deficits, we compared sway measured with SOT to a novel system of portable body-worn movement monitors. We found that instrumenting the mCTSIB improved scale of measure from ordinal to ratio, thus test precision, which allowed clinicians’ to quantify sway with accuracy similar to SOT. We also found that compared to SOT, the instrumented mCTSIB may be better able to differentiate between fallers and non-fallers. READ MORE
Falls, balance, and health related quality of life in older adults
PI/PD: C. Henderson (Aegis DOR); Eastern Washington University (WA)
Role: PI/PD and Study Site
Sponsor: None
Health-Related Quality of Life is an important area for therapists to assess and may be indicative of poor balance and fall risk. Researchers found that all physical aspects of the SF-36 Health-Related Quality of Life survey were highly correlated with fall risk classification and balance performance on several outcome measures commonly used by physical therapists. Assessment of Health-Related Quality of Life is an important element of a comprehensive assessment of the older adult, and low scores may be representative of poor balance and greater fall risk. Study results based on data from Riverview Retirement Community in WA when under contract with Aegis Therapies. READ MORE
Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults
PI/PD: Insight Therapeutics, Brown University (RI) and (Western Reserve University (OH)
Role: Study Site
Sponsor: Sanofi Pasteur
Seasonal influenza has been shown to cause an average of 36,000 deaths and 226,000 hospitalizations per year in the USA. Compared with a standard-dose vaccine, a high-dose flu vaccine (IIV3-HD) improves antibody responses to influenza among older adults. In a study of 15,991 participants from the USA and Canada, research found that IIV3-HD induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza illness than did standard-dose vaccine. Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults
Analysis of pilot data show relationship between gains in rehab and self-performance/burden of care
L. Freeman and M. Yao (Golden Living ORU)
Sponsor: None
Measurement and reporting health outcomes is essential in the evolution of post-acute health care systems. Aggregate data from health assessment systems can be used to inform important decisions regarding service use and best practices. Both the ROM and the MDS are instruments designed to measure functional ability, and both have been used widely with older persons in post-acute care. Comparative information on their properties can help clinicians assess the potential applications of the two instruments. In 2014, we analyzed a data sample of ROM scores from Aegis Therapies’ and MDS data from Golden Living Centers to test relationships and evaluate institutional capacity and readiness to successfully conduct research using our own large datasets. READ MORE
Relationship between MDS 3.0 and rehab outcomes
L. Freeman and M. Yao (Golden Living ORU), University Texas Medical Branch Galveston (TX)
Sponsor: NIH- Center for Rehabilitation Research Using Large Datasets
To further evaluate the clinometric properties of the Rehabilitation Outcome Measure instrument and to explore the extent to which rehab gains are associated with functional performance and burden of care as measured by the Minimal Data Set 3.0.
Lofexidine Withdrawal
Worldwide Clinical Trials, NIH – National Institute on Drug Abuse
Sponsor: US Worldwide, LLC
To investigate the efficacy, safety, and dose-response of lofexidine (2.4mg or 3.2 mg per day) in reducing withdrawal signs and symptoms and facilitating completion of detoxification/extending treatment retention in subjects undergoing detoxification from short-acting opiods in a double-blind inpatient setting (Days -17) followed by an open-label inpatient/outpatient setting (Days 8-14). The Investigator hypothesizes that subjects will achieve maximum treatment effect with tolerable side effects at the 3.2 mg total daily dose and that both the 3.2 mg and 2.4 total daily doses will show better efficacy over placebo in treating symptoms of acute opioid withdrawal.
Balancing a Model of Care with Rehabilitation and Prevention Services
L. Freeman and S. Ochoa (Aegis GPS), Galeon Retirement Community (MN)
Sponsor: Minnesota State, Community Service/Service Delivery grant
To expand rehab and wellness services for older adults that allow rural communities to rebalance their long-term service delivery system, support aging in place, and promote independence. With support from Aegis, Galeon proposed to implement and evaluate the impact of evidence-based specialty programs across post-acute care and community settings. Specifically, FTF for high intensity strength training, GEM for condition and recovery phase-specific electrophysical agents, bioDensity™ for high intensity osteogenic loading and Tai Chi for functional mobility. This sponsored project is led by Galeon of Osakis in MN, an Aegis Therapies customer.
Health-Service Related LITERATURE
Medicine and Pharmacy
Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use
Psychiatric Services
Efforts to reduce unnecessary use of antipsychotic drugs in nursing centers have been a regulatory focus for nearly 20 years that has resulted in many evidence-based practice strategies, as recently presented by Dr. Mary Evans Presents. However, there is limited health-services research on the influence of organizational factors such as patient-care models or treatment cultures. In a large multicenter SNF trial, researchers proposed that reductions would be greater in centers with an organizational culture of managing dementia and mental illness which is compatible with regulations, such as resident-centered care models. They found that Organizational greater reductions in use of antipsychotic drugs were found in facilities with a resident-centered culture, a less severe case mix, and a higher nurse-to-resident staffing ratio. READ MORE
Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission
Health Care Management Review
Medication errors contribute to 1.5 million adverse drug events annually, approximately half of which require hospitalization were for individuals 65 years or older. Researchers examined facility-reported medication errors and potential medication errors that occurred during the 7-day transition period for residents entering or reentering a SNF. “Chain affiliation was associated with a reduction in the volume of errors during the transition period” and may be related to processes and mechanisms such as training mandates, nurse staffing levels, standardized medication review systems, risk management reviews resulting in practice changes, and error reporting cultures. READ MORE
Palliative and Hospice
Geriatric rehabilitation for patients with advanced COPD
International Journal of Palliative Nursing
There are several peer-reviewed research studies that show rehabilitation can improve quality of life. Similarly, the importantance of improving quality of life in palliative and hospice care is well established. But is there evidence to support the role of rehab in palliative care? There is a growing need for disease-specific geriatric rehabilitation programs worldwide, including conditions associated with progressive organ failure such as chronic obstructive COPD. The authors developed and implemented a post-acute geriatric rehabilitation and palliative care program in a SNF for patients with advanced COPD that included interventions provided by PT, OT, and SLP. ‘These case studies show that a geriatric rehabilitation COPD programme can offer substantial benefits and can integrate aspects of rehabilitation and palliative care.’ READ MORE
Rehabilitation and Wellness
Intensive treatment of dysarthria secondary to stroke
Clinical Linguistics & Phonetics
Among the more than 5 million people in the USA who have survived a stroke, it is estimated that between 20% and 40% have some type of dysarthria that alters perceptual characteristics of speech and may interfere with speech intelligibility. In this phase I experimental study, authors examined the treatment effects, magnitude of change (if present), and treatment feasibility for people with dysarthria secondary to stroke. Four participants, ranging in age from 50 to 74 years that were 9 months or more post stroke and had dysarthria, completed the study. Using Lee Silverman Voice Treatment (LSVT® LOUD), the authors found statistically significant improvements in vocal decibels of sound pressure level (dB SPL) and phonatory stability as well as larger vowel space area. READ MORE
Abstracts of work submitted/pending/accepted for publication are provided. Full text of manuscripts (research) or white papers (analyses) are provided ONLY when made available from lead author and/or through open access by the journal.

Golden Living

Innovations Report


Connect with Office of Research
Lynn Freeman, VP Clinical Research, c 425-269-1194
Michelle Metzger, Content Editor