Poster Abstracts / JAMDA 14 (2013) B3eB26B6

antibiotics. However, caution is warranted as these agents are consideredas supplements and not regulated drugs. Although controversy exists, weoffer additional evidence supporting the use of enteral vancomycin forMRSA AAD in high-risk patients. Educational take home points: 1.Vulnerable patient populations for methicillin-resistant Staphyloccusaureus (MRSA) colonization and infection include: elderly, males, AfricanAmericans and those in facilities frequented by multiple patients (e.g.,rehabilitation centers and nursing homes). 2. MRSA Antibiotic-AssociatedDiarrhea is typically characterized by diarrhea unrelated to medications,recent antibiotic use (within 8 weeks), negative stool assay for Clos-tridium difficile, no other identified enteric pathogen, heavy growth ofMRSA in stool and little or no normal flora. 3. Recent data suggest thattreatment with oral vancomycin (500 mg by mouth every 6h) does notdemonstrate multidrug resistance and appears to be a safe and effectivetreatment in MRSA AAD when used appropriately.Author Disclosures: All authors have stated there are no financialdisclosures to be made that are pertinent to this abstract.

Is this Dementia or Alcohol Intoxication or Both?

Presenting Author: Wanda Colón Cartagena, MD, MPH, Baystate MedicalCenter GeriatricsAuthor(s): Wanda Colón Cartagena, MD, MPH; and Sandra Bellantonio, MD

Introduction: I am presenting the case of an independent ladywhose activealcohol abuse masked her new onset dementia.Case Description: Ms. G is a 76 year old female who lives alone ina continuum of care retirement community. She has difficult-to-controlhypertension, hypothyroidism, B12 deficiency, anxiety, and adjustmentdisorder which started after her husband, who was an alcoholic, committedsuicide. She struggled with alcohol abuse herself through the years. Shetakes citalopram, amlodipine, B12 injections, and vitamin D supplements.She has lived in this community for 4 years. She has made new friends andcurrently has a new boyfriend, with whom she likes to vacation with ata beach house during the summer. Earlier this year, she had an emergencydepartment visit because she was “funny in her head.” Her daughter wasvery concerned about new onset speech abnormalities. Physical exam wasremarkable for dysarthriawithout any other focal neurological deficit. Initialevaluationwas done to rule out a stroke, including a head CT which showedno acute pathology. At that time, she admitted to using “too much alcohol.”Blood alcohol level was 190 mg/dL at 6:30 AM. Since then, she has been toher PCP multiple times for worsening memory. In three consecutive visitsduring a 1-month period, she was noted to have dysarthria and wordfinding difficulties, as well as impaired memory and orientation. Her clockdrawingwas impaired. She had difficulty placing the hands of the clock at 10past 11, drawing a straight line instead of 2 lines. On all of these occasions,her blood alcohol level was elevated (15 e 162 mg/dL) when checked in themorning before her PCP appointment. Her pill box and home safety wasassessed, all was found in order. Her daughter was also very concernedabout hermother’smemory; therefore, shewas visiting hermore frequentlyand accompanying her to her medical appointments. On her fourth PCPappointment, she still had slurred speech and appeared disheveled. Herblood alcohol level was 0 mg/dL; therefore, an MMSE was performed. Herclock drawingwas normal, including placing the hands at 10 past 11, but shehad trouble with orientation, fluency and following a 3-step command. Hertotal score was 22/30 compared to 30/30 in 2009. An MRI of the brain wasordered which showed old lacunar infarcts and extensive white matterchanges. Currently, she is still living independently with more support andsupervision for her medical regimen.Discussion: Elderly patients move into continuum of care retirementcommunities to preserve their independence and their autonomy. Thesecommunities respect those values and commit to provide a safe environ-ment surrounded by the support and activities needed to enhance seniors’quality of life. This contract is challenged when the residents’ habitscompromise their safety and increase their health risks. As geriatricians it ischallenging to manage patients with history of alcohol abuse that startdementing. Their tolerance for alcohol changes, making them more apt tosuffer falls, depression, high blood pressure and other accidents andillnesses. Alcohol also interacts with multiple medications, increasing thepotential for adverse side effects or events.

Author Disclosures: All authors have stated there are no financial disclo-sures to be made that are pertinent to this abstract.

Multidisciplinary Pharmacy Rounds in the Nursing Home: FindingSolutions to Challenging Nursing Home Pharmacy Problems

Presenting Author: Katherine Leigh Coffey-Vega, MD, VCU GeriatricsAuthor(s): Katherine Leigh Coffey-Vega, MD, Angela Gentili; andMeredith L. Bremer

Introduction: It is an all too common scenario: carefully crafted medica-tion treatment plans fail because of nursing home patient refusal ofmedications, or because of difficulty obtaining blood draws to monitordrug levels. Because of this challenge, the Richmond McGuire VA nursinghome care team created weekly multi-disciplinary pharmacy rounds witha nurse, nurse practitioner, physician and pharmacist. Through thiscollaborative effort, multiple patient medication problems have beensolved through creative and practical solutions. Examples of these solu-tions include behavioral management approaches, revising medicationadministration times based on patient behavior patterns, off-label use ofmedications when necessary, and simplification of treatment regimens.Some specific examples follow.Case Description: A patient with traumatic brain injury was admitted toour nursing home and proved particularly challenging, refusing to swallowpills or allow blood draws or injections. When she developed a lowerextremity DVT, we were unable to use low molecular weight heparininjections as she refused them. Warfarin was not an option as she wouldnot allow blood draws for monitoring. Through pharmacy rounds, theteam arrived at the solution of the off-label use of Rivaroxaban, an oralfactor Xa inhibitor, which can be administered once daily and can becrushed and mixed with food. The next challenge in treating this patientwas her refusal to eat or swallow anything in the morning, which is thestandard time for “daily” drugs. On pharmacy rounds, nursing noted thatthe patient was much more cooperative with the night staff, so her dailydrugs were all switched to night administration with success. A similarsuccess occurred with a patient with dementia and behavioral issues whowas transferred to the VA nursing home from another nursing home withdifficult to control diabetes. The patient would often require hospitaliza-tion for his diabetes because he would refuse finger sticks and insulininjections. Through pharmacy rounds, the patient’s regimen was simpli-fied to once a day blood glucose checks with once a day Glargine, allowingblood glucose levels in the 200-300 range. After implementation of thisregimen at a time of day when the patient was most cooperative, thepatient accepted the once a day regimen and did not require additionalhospitalizations for his diabetes.Discussion: Implementation of multi-disciplinary pharmacy rounds in ournursing home has proved highly successful in generating practical solu-tions to difficult situations, resulting in better care for our patients.Author Disclosures: All authors have stated there are no financialdisclosures to be made that are pertinent to this abstract. Authors willdiscuss off label use of Rivaroxaban for DVT treatment.

Necrobiosis Lipoidica Diabeticorum

Presenting Author: John H. Bailey, DO, CMD, Wesbury United MethodistCommAuthor(s): John H. Bailey, DO, CMD; and Autumn Ferringer, RN

Introduction: Identifying andManagingNecrobiosis LipoidicaDiabeticorumin the Long Term Care setting.Case Description: 59 year oldmale residentwho resides in a Long TermCarefacility presented with a pretibial rash-like area worse on the right than onthe left. These areas were being treated topically and once the treatment wasdiscontinued within a couple of days the areas would reappear. He hadseveral comordities thatwere first thought to be the causitive factors, such asfluid overload (takes Bumex), venous insufficiency (managed with 6 inchelastic bandages or TED hose), history of a DVT (managed with Coumadin),diabetes (managed with Glucotrol). It was through this process that he wasdiagnosed with Necrobiosis Lipoidica Diabeticorm. We reviewed the

Poster Abstracts / JAMDA 14 (2013) B3eB26 B7

literature and saw the similarities in this resident with others affected byNecrobiosis Lipoidica Diabeticorum.Discussion: Once the accurate diagnosis was made, treatment was focusedon this area and, while not entirely resolved completely, it is being managedconsistently. According to this resident’s family it was something theystruggled with for years prior to admission to our facility and was nevergiven a diagnosis for these recurrent areas.Author Disclosures: All authors have stated there are no financial disclo-sures to be made that are pertinent to this abstract.

Respite Care: A Window into Elder Neglect

Presenting Author: Lidia Vognar, MD, Duke University GeriatricsAuthor(s): Lidia Vognar, MD; and Kathryn Rackson, MD

Introduction: The following case occurred in a VA long term care facilityand concerned a patient who presented for a respite stay. Respite is a typeof short stay often provided by nursing facilities which allows caregiversa period of temporary relief from their routine duties involving loved oneswith dependence and often complex medical issues. Medicare data showsthat about 43% of people 65 years or older will likely spend time ina nursing facility and of these, 24%will stay for less than 1 year. These shortstays can often provide windows of opportunity for medical professionalsto evaluate these patients, provide needed intervention, diagnosesyndromes and assess inappropriate living situations that exceed thefunction of the caregiver.Case Description: Our patient is a 74 year old male with a history ofrefractory PTSD, diabetes complicated with retinopathy and subsequentblindness, gait abnormality with falls, progressive dementia, and BPHwith a supra-pubic catheter who presents frequently to the VA longterm care facility for respite stay. His wife, who is his primary caregiver,demonstrates possessive behavior towards her husband and consistentlyrefuses supportive care for her husband, such as home health aides andassistance in the home. She alludes to patient being bed-bound, thoughthis is not reflective of his true functional status. His warfarin, despitefrequent follow up and repeated education of wife, continues to beinappropriately given. Physical exam reveals a malodorous gentleman,purulent drainage around the supra-pubic catheter, soiled dressings, andsurrounding skin blisters. Further examination reveals several ulcera-tions on bilateral heels with deep tissue injury secondary to prolongedwearing of therapeutic shoes. During evaluation, patient expresseda sense of relief and enjoyment at being in the VA and noted frustrationregarding his wife’s possessiveness and associated lack of socializationand restriction of mobility.Discussion: Elder abuse is defined as harmful acts toward an older adultand includes physical, sexual, emotional and financial abuse, as well asneglect. Neglect is the most common type of abuse, but it is generally notknown that there are different types, including active, passive and self-neglect. Passive neglect is the unintentional harm inflicted secondary toa caregiver’s failure to recognize and meet the needs of their loved one,whereas active neglect is the intentional harm of a loved one, whosecaregiver has the knowledge and abilities, but refuses to meet the needs ofa loved one. Red flags of neglect include inappropriate medicationadministration, frequently missed doctor appointments, ignoringa patient’s wishes, isolation, poor personal hygiene and pressure ulcera-tions. Respite stays often provide an ideal opportunity for long term carestaff and providers to recognize neglect and offer possible interventions inour older adults. Such interventions include the education of caregiversabout medications and health care needs, provision of support throughhome health agencies and other community outreach programs. Evalua-tion of the caregiver’s cognition and function is an imperative part of thisassessment, and deficits are often the cause of passive neglect. Inconclusion, our case serves to demonstrate that elder neglect is prevalentin the community and its recognition holds clinical significance, as it hasa great impact on a patient’s health and quality of life and has a role inmorbidity and mortality. By increasing recognition, we hope to increasediagnosis and decrease the prevalence of this ever-growing problem.Author Disclosures: All authors have stated there are no financialdisclosures to be made that are pertinent to this abstract.

Silent Killer

Presenting Author: Purva Gumaste, University of Pennsylvania GeriatricsAuthor(s): Purva Gumaste, Amarinder Garcha; and Edna Schwab

Introduction: Managing patients with aphasia in long term care settings ischallenging. Cerebrovascular accident and dementia constitute mostcommon causes of aphasia. We present a rare case of focal dementia calledlogopenic progressive aphasia (LPA), a variant of primary progressiveaphasia (PPA), which involves left temporoparietal area.Case Description: A 57-year-old male with diabetes mellitus and atten-tion deficit hyperactive disorder was evaluated in neurology clinic withprogressive word finding difficulty for the past few weeks. Speech wascircumlocutory with significant word finding pauses and paraphasicerrors. There was some difficulty with lexical comprehension butcomprehension of objects appeared to be relatively preserved. He did nothave any memory deficits. Remainder of neurological examination wasunremarkable. Pertinent laboratory studies were within normal limits. Hescored 13/30 on Montreal Cognitive Assessment (MoCA) test. MRI andMRA of the brain showed patency of intracranial circulation and diffusecortical atrophy with age related small vessel ischemic disease. Given hispresentation of profound naming and word finding difficulty with rela-tively preserved object comprehension and only modest difficulty ingrammatical realm he was diagnosed with logopenic progressive aphasia,a type of primary progressive aphasia. He continued to have progressivecommunication decline resulting in frequent hospital admissions foraltered mentation and episodes of passive suicidal ideation. He eventuallyrequired admission to a nursing home at his young age. Over the course oftime, he became completely mute requiring complete assistance for hisactivities of daily living. He continued to have episodes of altered menta-tion warranting 1:1 sitter, frequent blood tests and brain imaging with noconclusive diagnosis. His family eventually opted for hospice and he diedat the age of 61 years.Discussion: PPA is a form of focal dementia characterized by an isolatedand gradual dissolution of language function. The fluency of speech outputin PPA may or may not be preserved. Memory, visual processing andpersonality remain relatively well preserved until the advanced stages andhelp to distinguish PPA from frontal lobe dementia and typical forms ofAlzheimer’s disease. The logopenic variant of PPA has recently beendescribed as possible atypical variant of early onset Alzheimer’s diseasethat occurs at less than 65 years of age. There is no definitive cure ortreatment and acetylcholinesterase inhibitors have been tried withoutmuch success. Early recognition and diagnosis of this focal dementia entitycan prepare the patient and the family for further options such as startingearly speech therapy, caregiver education or finding a long term carefacility. Caring for the patient requires good nursing education in long-term care facilities to recognize signs of pain or discomfort to preventagitation, infections and frequent hospitalizations.Author Disclosures: All authors have stated there are no financialdisclosures to be made that are pertinent to this abstract.

Systemic Amyloidosis

Presenting Author: Kim K. Petrone, MD, CMD, St. Ann’s CommunityAuthor(s): Kim K. Petrone, MD, CMD; and Cheryl Eddinger Nolan, GNP

Introduction: This case highlights the challenges of rendering a diagnosisof systemic amyloidosis due to its pleomorphic presentation. Amyloidosisoccurs due to the abnormal deposition of proteins in various organ systemscausing a host of unusual symptoms ranging from enlarged muscles,neuropathy, hepatosplenomegaly, and periorbital eccymoses. But while itspresentation may be vexing, systemic amyloidosis is a conditionwhich cancomplicate many illnesses that are prevalent in a geriatric populationincluding inflammatory arthritides, end stage renal disease requiringhemodialysis, multiple myeloma, and inflammatory bowel disease. Thus,this diagnosis remains one that a skilled geriatrician must readily recog-nize and effectively manage.Case Description: A 73 year old Caucasian female was admitted toa skilled nursing rehabilitation center following a protracted period ofillness dating back approximately eighteen months prior to her