What laboratory tests and medications require routine monitoring in Long-Term Care (LTC) settings?

From the Guidelines

In long-term care (LTC) facilities, routine laboratory monitoring should include complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid function tests, lipid panels, hemoglobin A1c, vitamin B12, vitamin D, and urinalysis, as recommended by the most recent guidelines 1. These tests help assess overall health status and detect common conditions in elderly patients. Medications requiring regular monitoring include:

• warfarin (INR every 1-4 weeks)
• digoxin (levels every 6-12 months, plus renal function and electrolytes)
• anticonvulsants like phenytoin and carbamazepine (levels every 6-12 months)
• lithium (levels every 3-6 months)
• diuretics (electrolytes and renal function every 3-6 months)
• antipsychotics (metabolic parameters quarterly to annually)
• ACE inhibitors and ARBs (renal function and potassium monitoring every 3-6 months)
• Metformin (renal function tests every 3-6 months)
• insulin (regular blood glucose monitoring)
• Opioids (effectiveness and side effects monitoring) This monitoring is crucial because elderly patients often have altered pharmacokinetics, multiple comorbidities, and polypharmacy, increasing their risk of adverse drug events, as noted in a study on the evaluation of fever and infection in older adult residents of long-term care facilities 1. Additionally, renal and hepatic function typically decline with age, affecting medication metabolism and excretion, which is a consideration in the management of older adults with diabetes in LTC facilities 1. Regular monitoring helps prevent complications, optimize therapeutic effects, and improve quality of care in the LTC setting, and is in line with the standards of care in diabetes-2023 and 2024 1. It is also important to consider the individualized glycemic goals and the use of continuous glucose monitoring to assess risk for hypoglycemia in older adults treated with sulfonylureas or insulin, as recommended in the standards of care in diabetes-2023 and 2024 1. The frequency of monitoring should be based on the individual patient's needs and clinical status, and should be guided by the most recent and highest quality evidence available, such as the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1. In general, the monitoring of laboratory tests and medications in LTC facilities should be tailored to the individual patient's needs and should be based on the most recent and highest quality evidence available, as recommended by the clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities 1.

From the FDA Drug Label

Periodic determination of PT/INR is essential Numerous factors, alone or in combination, including changes in diet, medications, botanicals and genetic variations in the CYP2C9 and VKORC1 enzymes may influence the response of the patient to warfarin It is generally good practice to monitor the patient’s response with additional PT/INR determinations in the period immediately after discharge from the hospital, and whenever other medications, including botanicals, are initiated, discontinued or taken irregularly The following factors, alone or in combination, may be responsible for INCREASED PT/INR response: The following factors, alone or in combination, may be responsible for DECREASED PT/INR response:

The laboratory tests that require routine monitoring in Long-Term Care (LTC) settings for patients taking warfarin include:

• PT/INR tests to monitor the anticoagulant response Medications that require routine monitoring include:
• Warfarin itself, as well as any other medications that may interact with warfarin, such as:
  • Salicylates (e.g., aspirin and topical analgesics)
  • Other over-the-counter medications
  • Botanical (herbal) products It is essential to monitor the patient's response with additional PT/INR determinations when initiating or discontinuing any of these medications 2, 2.

From the Research

Laboratory Tests in Long-Term Care (LTC) Settings

• Routine laboratory assessments in severely impaired nursing home residents may have limited value 3
• Laboratory tests such as blood sugars, blood pressure, and lipids should be monitored regularly in residents with diabetes 4
• Rapid access to diagnostic tests such as radiographs, blood tests, and urine cultures can reduce emergency department visits in LTC homes 5

Medications in Long-Term Care (LTC) Settings

• Medications such as lipid-lowering medications and anticoagulation therapy should be used appropriately in residents with diabetes 4
• Sliding scale insulin should be used judiciously in residents with diabetes 4
• The use of evidence-based practice (EBP) in LTC settings can improve resident outcomes, including the appropriate use of medications 6

Routine Monitoring in Long-Term Care (LTC) Settings

• Routine monitoring of residents in LTC settings should include regular assessment of laboratory tests and medications 4, 3, 5
• The use of a quality measurement tool can help identify areas for improvement in LTC settings, including the monitoring of laboratory tests and medications 7
• Strategies to promote the adoption of evidence-based practice in LTC settings include the commitment of management, leadership, and staff knowledge and time 6