It was a time not unlike the present, although more than half a century has passed. The year was 1969, my first year of medical school in Philadelphia. Many of us had long hair back then and wore black armbands over our white coat sleeves to protest the war raging in Vietnam. Richard Nixon had been president since January, his election over Hubert Humphrey enabled by the chaos and violence in the streets of Chicago at the Democratic National Convention. Many American cities remained in turmoil after the civil unrest that followed the assassination of Dr.

Oh, 2020. You aren’t over yet, and I cannot imagine what final miseries you hold in store in your waning days. I’ve always been a glass-half-full person who looks to see the good in others — a consensus-builder, a holder of space, a proponent of the “there is always a lesson to be learned from adversity” philosophy, a believer that things will turn out the way they are meant to, and one with faith in the general kindness of humanity. I have to concede sadly that you, 2020, have taken a serious swipe at my core beliefs.

When thinking about the future of long-term care, we can start by drawing on the thoughts of Amazon’s CEO Jeff Bezos on the subject of strategy. “I very frequently get the question, ‘What’s going to change in the next 10 years?’ ... I almost never get the question, ‘What’s not going to change in the next 10 years?’ And I submit to you that that second question is actually the more important of the two” (Amazon Web Services, “2012 re:Invent Day 2: Fireside Chat with Jeff Bezos & Werner Vogels,” Nov.

Mr. G is an 87-year-old White male who was recently transferred to a nursing home within a continuing care retirement community where he lives with his wife. He was treated in an acute care setting for an exacerbation of congestive heart failure, and he now requires skilled care for deconditioning and medical management. Per state regulations, upon admission he was quarantined in the COVID-19 unit.

Dear Dr. Jeff: I recently completed a geriatrics fellowship and joined a multispecialty group practice in a small city. A few months ago, I agreed to serve as the Medical Director for a nearby 4-star nursing home. We have survived the pandemic rather successfully but as I reviewed patient charts, I was pleased by the nursing documentation but appalled at the medical care our residents receive. Our physicians have all been on staff for years and generally have practices in the community. One is even from my group.

AMDA – The Society for Post-Acute and Long-Term Care Medicine announced recently that it is generally pleased with the final report from the administration’s Coronavirus Commission for Safety and Quality in Nursing Homes. However, the Society observed that some important recommendations were not included and that the Centers for Medicare & Medicaid Services and other government agencies still have much work to do.

Every system is perfectly designed to get the results it gets.—W. Edwards Deming

Times of change — transitions — are always a time for reflection for me, and perhaps for many of you. It allows an ideal opportunity to compare where we are, where we were, and where we aspire to be. My time as chair of the Foundation for Post-Acute and Long-Term Care Medicine is coming to an end. After my two years in this position, this role will soon transition into the very capable hands of Dr. Susan Levy. Upon reflection, I am leaving at a time when the Foundation has much of which to be proud.

Nancy Lerner, DNP, RN, associate professor at the University of Maryland School of Nursing, talks about how you can play role in planning your loved one’s care in a nursing home during the pandemic and beyond.

In the United States, dementia affects an estimated 5.8 million Americans, and this number is expected to rise to nearly 14 million by 2050 (Alzheimers Dement 2020;16:391–460). Most of these future 14 million Americans will receive care from a family member. As practitioners in post-acute and long-term care, we are already aware of the devastating impact of Alzheimer’s disease on caregivers and their emotional, physical, psychological, and financial difficulties. Family caregivers may be responsible for total dementia care support, which limits their social activities, increases their social isolation, decreases their leisure activities, and adds to family distress (Am Fam Physician 2000;62:2613–2622).

In her book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life (Bloomsbury, 2019), which became a Pulitzer Prize finalist, Louise Aronson, MD, MFA, explores the challenges associated with aging in the United States and offers a positive and optimistic approach to overcoming those challenges. “At the very least, we are losing an opportunity to look at the final third of life with the same concern, curiosity, creativity, and rigor as we view the first two-thirds,” writes Dr. Aronson in her book.

The COVID-19 pandemic has given “home” a whole new meaning for older adults. It was always a sanctuary, a place to feel safe and comfortable, but now we know that there also must be ways to keep people connected, engaged, and active when getting out and moving about aren’t options. “Regardless of what is happening in the world around them, older adults — like all of us — want a purpose in life. It is important that community design supports that while keeping them safe and comfortable,” said David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, TX.

For five years, Carey Cowles served as Caring’s managing editor with wisdom, wit, and warmth, not to mention experience. When she lost her battle to cancer two years ago, an award to recognize the author of the most read/downloaded article of the year was established in her name. The 2020 Carey Cowles Award goes to Daniel Haimowitz, MD, FACP, CMD, and Jeanne Manzi, PharmD, BCGP, FASCP, for “Off-Label Use of Gabapentinoids: A New Paradigm” (Caring for the Ages 2020;21[1]:P12–13).

Despite research showing the benefits of nonpharmacologic treatment for behavioral expressions of dementia, clinicians often opt for using psychotropic medications such as antipsychotics, even though these agents are associated with adverse events and new behavioral expressions. For that reason, the Alzheimer’s Association devoted its in-person inaugural April 2019 meeting of the Dementia Care Provider Roundtable, an ongoing consortium of thought leaders in long-term and community-based care, to the challenges underlying the wider implementation of behavioral support and person-centered approaches.

Experts list outdoor and social features as must-haves in the facility of the future. 3

I don’t think that there will be very many of us working in post-acute and long-term care settings who will be sorry to see 2020 come to a close. The COVID-19 pandemic, natural disasters, economic instability, and racial injustice have challenged us in our professional and personal lives. A little over a year ago, the editorial team of Caring for the Ages was excited as we planned for a themed issue to focus on PALTC of the future. Most of us didn’t anticipate a deadly global pandemic that would infiltrate PALTC, wreak havoc on the lives of so many, and change our professional priorities for the foreseeable future.

When asked to describe the ideal medical director, nursing home administrator Mike Moranz’s face beamed with a broad smile. “Well, to understand today’s ideal, you must understand how far we have come over the past 20 years.” Mike Moranz, MPH, started his health care career as a respiratory therapist 50 years ago and ventured into nursing home administration in Maryland 20 years ago. “My first nursing home medical director was an internist with a busy office and hospital practice. He did not have the time or knowledge to really help the nursing home staff in any sort of leadership role.

The American nursing facility has been in continuous evolution since its inception in the early 19th century. The early “old age homes” were places to save “formerly respectable people from the indignities of the almshouse” (Elon et al., “Post-Acute and Institutional LTC for the elderly,” in Reichel’s Care of the Elderly, 7th ed., Cambridge University Press, 2016:659–670). In the late 19th century through the 20th century, nursing facilities were also places to convalesce from acute hospitalization.

Older adults often take numerous medications each day, contributing to polypharmacy and the continuous prescribing cascade. This may lead to adverse effects, poor outcomes, and decreased quality of life. Deprescribing may be one solution to this common scenario.

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