Good Medical Care for the Elderly and How to Get It

The "Beers Criteria": Dangerous Drugs for the Elderly

It has been quite a long time since I have posted to this blog. It's difficult to believe that my mother passed away almost thirteen years ago. The cause of her death was, quite simply this: all of the medications she was prescribed accumulated in her body because she was dehydrated. Then her kidneys malfunctioned. As a result, she became toxic. Put another way, she was poisoned and died.

During the course of my research to find out what had caused her death, I became very familiar with the work of Dr. Mark Beers. At the time, Dr. Beers was the editor of the Merck Manual and the Merck Geriatric Manual. We had a good email correspondence relationship and he encouraged me in my work. Essential to my research was an understanding of which drugs were dangerous for the elderly. Dr. Beers was the primary researcher for the "Beers Criteria." This was a list of drugs dangerous to the elderly published in 1991.

The Beers criteria was updated in 2003 and again in 2012. You may read the Journal of American Geriatric Society article containing the 2012 Beers Criteria here: Download 2012BeersCriteria_JAGS

You will find this article and the useful chart containing the Beers Criteria very helpful when providing care to the elderly. For more information about how psychotropic medications are often inappropriately prescribed for the elderly, see this blog article below, written by Stan Berg. Mr. Berg maintains a blog in honor and memory of his wife, June K. Berg, and his mother. Ellen F. Silbaugh,  both victims of Alzheimer's. June died  23 October 2008. Stan's mother Ellen died 21 October 2007.  The Dr. "Beers Criteria": Dangerous Drugs for the Elderly! This blog contains a wealth of helpful information for caregivers.

Social Security & SSI Payments Protected from Creditors

The National Consumer Law Center® (NCLC®) is a non-profit organization specializing in consumer issues on behalf of low-income and other vulnerable people. Since 1969, NCLC has worked with legal services and nonprofit organizations as well as government and private attorneys across the United States, to create sound public policy for low-income and elderly individuals on consumer issues. The NCLC has just sent out a press release explaining how recipients of social security and SSI payments will be protected from seizures from bank accounts by creditors because of a recent change in the law. Effective March 1, 2013, both new applicants and current recipients who do not choose another option (and have not been granted a wavier) will automatically receive their payments on the federal government’s Direct Express card.

Current benefits recipients have until March 1, 2013 to choose an electronic payment option. After that date, no payments will be issued via check, unless the person qualifies and is approved for an exemption.

To continue receiving paper checks, recipients must be approved by the US Treasury for one of the following exemptions:

•       Aged 90 years or older, as of May 1, 2011 (no wavier required)
•       Mentally impaired
•       Live in a remote geographic area lacking the capability to support an electronic financial transaction

Here are more details from the press release:

Advance Medical Directives | April 16th - National Healthcare Decisions Day

April 16th is National Healthcare Decisions Day. Many people are talking about advance medical directives these days. Some folks want to stop doctors and nurses from talking about end of life care with patients, calling this a "death panel." Others are identifying advanced medical directives as a means by which a person may control the care and quality at the end of life.

I've often written about end-of-life care decisions on this blog. You may access the archives of that topic here.

You may also view a video hereabout Advance Care Directives produced to be aired on community access stations in a program titled  Graceful Aging. Michigan elder lawyer Jim Shuster discusses the importance of having an advance care directive (a/k/a "living will"). You may watch the video here.

Consider the Conversation

A new documentary is available to the public on DVD to help patients and their families talk with their physicians about end-of-life care. Following a model I’ve seen on Aging with Dignity website,  "Consider the Conversation" is a documentary available to the public on DVD to help patients and their families talk with their physicians about end-of-life care.  The documentary film will be available on PBS television this Spring and is also available for purchase on Amazon.com. Made in a volunteer effort and funded entirely by donations, the producers explain the film as follows:

“The bottom line is that Consider the Conversation does not seek to hand down answers.  Rather, it provides something far more important - the questions all of us need to contemplate.  That being said, the producers have three goals for this film: 1) to change the current American attitude from one that predominantly views end-of-life as a failed medical event to one that sees it as a normal process rich in opportunity for human development, 2) to inspire dialogue between patient and doctor, husband and wife, parent and child, minister and parishioner on end-of-life issues, and 3) to encourage medical professionals, healthcare organizations and faith leaders to take the lead in counseling others.”

Talking about End-of-Life Care

Thanks to my friend, Wendy Harpham, author of Happiness in a Storm and Only 10 Seconds to Care, for bringing to my attention a new guide for patients and their loved ones helpful to families and patients who are coping with final illness. Written by Paula Span, author of When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions, “Advanced Cancer Care Planning: What Patients and Families Need to Know About Their Choices When Facing Serious Illness” may be downloaded free of charge from the American Society of Clinical Oncology’s website.

I read the guide and believe it may be useful in any kind of situation—not just when a final illness is cancer. Using language that if both compassionate and direct, the booklet is easy to read. It explains, for example, that the word “advanced” is synonymous with 'end-stage' or 'terminal,' and that this doesn’t mean that an advanced illness is untreatable or that death is imminent. It also explains that choices for care relieving pain and discomfort remain when cancer is progressing even though a patient is receiving the best available anti-cancer therapies.

Making Decisions about When to Stop Driving

Jane Gross wrote in the New York Times recently about the angst primary care doctors face when   confronting a patient and family about whether an aging patient should still be driving. Questions raised are:

When is it time for someone with physical or cognitive problems to give up the car keys?

Who makes that decision?

How can it safely and compassionately be enforced?

Gross provided a link to a comprehensive and thoughtful handbook published by the American Medical Association in collaboration with the National Highway Traffic Safety Administration. Recently updated, the “A.M.A. Physician’s Guide to Assessing and Counseling Older Drivers” can be accessed by doctors and also family caregivers.

Knee & Hip replacement | Good tips from New York Times resources

The New York Time published a extremely valuable article about hip and knee implants over the 4th of July weekend. According to statistics, about 806,000 such procedures were performed in the US in 2007. This is twice as many as were performed a decade earlier. Though routine, replacements are not without risk or potential for a future replacement.

Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston told the NY Times that implants must sometimes be replaced. According to a 2007 study, 7 percent of  hip implants in Medicare patients had to be repeated within seven and a half years.

Dr. Malchau states that while this may seem insignificant, the study suggests that thousands of hip patients eventually require a second operation. That translates into additional recoveries, and increased medical expenses. The failure rate should be lower. Dr. Malchau and Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn. had some very good suggestions to improve the success rate for seniors undergoing hip and knee replacements. Photo credit Mayo Clinic.

Internet resources for seniors & others seeking affordable medical insurance

Reported in a newsletter by MoveOn.org, here is some valuable information about Internet resources to assist seniors (and others) trying to assess and access affordable health care.

• Yesterday, www.HealthCare.gov, a new online portal where anyone can go to find insurance options in their state, went live. It's a very handy resource for information that used to be difficult to find. It's available to help millions who need insurance find it, and as a resource for those who want to shop around for new options or find out their new benefits under the new law.

Delirium | Why family caregivers need to assist in diagnosis & prevention

In the New York Times on June 24th, Pam Belluck reported on the risk that elderly patients may become confused and delirious while in the hospital. She offered suggestions for family caregivers on how to assist their loved ones from suffering irreversible or serious complications.

The elderly frequently develop hospital delirium (about 70% in research). When I was writing Taking Charge: Good Medical Care for the Elderly and How to Get It, I read one study that said that delirium was missed as a diagnosis about 95% of the time, even though the nursing notes usually carried enough information that a doctor should have called it right. Unfortunately, the consequences of delirium can be serious: these detrimental consequences are common:

FDA Warns About Unapproved Nitroglycerin Tablets

Patients who take nitroglycerin tablets may ask whether they are receiving an unapproved brand subject to recent FDA action, as reported in the New York Times on Friday. The FDA sent warning letters to two major manufacturers of unapproved nitroglycerin: Konec, Inc. and Glenmark Generics, Inc. The drugs are not being recalled; the manufacturers have 180 days to stop shipments.

According to the article, some manufacturers previously argued that they didn't need approval because nitroglycerin was available before the FDA was formed. The FDA says the drugs need prior approval and that some unapproved versions have "significant quality and efficacy problems." Only Pfizer has FDA approval to market nitroglycerin tablets.

Apply for social security online

CMS sent out a message this afternoon announcing that people can now apply for Medicare on line at www.socialsecurity.gov.  The Social Security web page has a "Retirement/Medicare" link in the middle of the page.If seniors have access to the Internet, this could be a real time-saver.

 

Palliative care | Dignity and peace

Jane Brody writes about palliative care at end of life for her husband of 43 years in the New York Times. Her column is moving and tender.

"This is a very personal story of living gracefully with a fatal diagnosis. When I wrote Jane Brody’s Guide to the Great Beyond, I had no idea that I’d be putting its precepts into practice in my immediate family within a year of publication. But as I said in the book, 'You never know.' You never know when your time will be up, and so it is best to prepare for the end sooner rather than later.

"On Feb. 2, we learned that my husband of 43 years had Stage 4 lung cancer. There was no asking 'Why me?' Richard knew very well why. He’d been a pack-a-day smoker for 50 years. Although he quit for good more than 15 years ago, it was far too late. After a few weeks of encroaching weakness and coughing, a PET scan showed that cancer was ravaging his body, taking up residence in both lungs (along with emphysema), in his spine, his adrenal glands and his brain. It was inoperable and incurable. He was looking at weeks or months of remaining life, maybe a year at most."

Jane Brody's column ">When the Only Hope is a Peaceful Ending" here.

My friend Wendy Harpham's blog about Jane's column is here.

Jane Brody has long written for the New York Times. In the past few years, she has been on leave from her regular columns, contributing occasionally on issues related to health and aging. First, it was her mother's death. Jane took some time off and wrote a wonderful book "Jane Brody's Guide to the Great Beyond," helpful to the legions of family caregivers tending to parents or other loved ones at life's end. I wrote here about her book on April 12, 2009.

What it means to be a health care proxy

I just watched Keith Olbermann's Special Comment -- MSNBC -- February 24, 2010. Olbermann spoke  movingly about what it means to be a patient advocate for a loved one and about the importance of end-of-life planning, both for the patient and for the loved one(s) who may be chosen to make health care decisions when a patient is no longer able to do so. Olbermann also spoke passionately how important it is for our Congress to make health care accessible to all Americans.

I have to say that, having acted as a health care proxy for my parents at the end of their lives, I wept throughout Olbermann's extremely moving plea.

Palindrome - From AARP for all generations

A palindrome is a word that may be spelled the same backwards and forwards. My last name "Hannah" is a good example. AARP has published a video on YouTube that is a little different. It is named "Lost Generation" and begins with with sentences written on a blackboard, read aloud by a teenager. This video reads the exact opposite backwards as forward.  Not only does it read the opposite, the meaning is the exact opposite. It is a brilliant assemblage of thoughts and values.

This video was submitted by a 20-year old in a contest sponsored by AARP, and titled "u @ 50"  I'm told that this video won second place, but what could possible top this? The concepts are simple, and yet they are brilliant.

See Lost Generation here:

Continue reading "Palindrome - From AARP for all generations" »

There's been a lot of focus lately on how to avoid exploitation of the elderly and also domestic violence perpetrated by caregivers and/or family members.

Josh Ard, a noted elder law attorney who practices in Williamston, Michigan called to my attention an interesting case involving aspects of both issues (if one counts financial exploitation as a form of domestic abuse. I believe that financial exploitation is a form of abuse. See the Power and Control Wheel). In this case, the adultery and perjury of the elderly nursing home resident's husband trumped the lack of notice (and a false statement about notice) required by a guardianship petition filed by a granddaughter. The case occurred in Mississippi, but the concepts are equally applicable under Michigan law. These are the facts:

---

Ruby Chism Ellis, married to Bobbie Ellis since July, 2000, entered a nursing home in June, 2006. In 2008, Ruby’s granddaughter, Stephanie Chism Turner, filed a petition to be appointed as Ruby’s conservator. Stephanie represented to the court that she served the petition on Bobbie although she had not.

The court appointed Stephanie as conservator and, according to Bobbie, his first notice of the proceeding was when Stephanie showed up at the home with the conservatorship papers, demanding that he vacate the premises. Bobbie, for his part, had been carrying on an affair over the previous eighteen months, even moving his paramour into Ruby’s home.

After Stephanie moved money from Ruby and Bobbie’s joint account, placing it in a conservatorship account, Bobbie sought to have the conservatorship set aside or, in the alternative, to replace Stephanie as conservator. Bobbie argued that he was Ruby’s appointed agent under a power of attorney. It was at this point when Stephanie’s perjury became apparent.

A guardian ad litem was appointed who prepared a detailed report quoted at length in the appellate opinion. Significantly, the guardian ad litem found that Bobbie’s loyalties had been transferred to someone else and may once again. The trial court declined to dissolve the conservatorship, but ordered Stephanie to submit an accounting. The court noted that Mississippi law does not give a spouse preference in a guardianship proceeding and that any procedural deficiency in Stephanie’s appointment was resolved by later hearings. On appeal, the judgment was affirmed. The presence of a power of attorney does not deprive the court of jurisdiction and, although the court was displeased with the conduct of each party, the determining factor appeared to be Bobbie’s shifted loyalty.

You can read the appellate court's opinion (and the GAL's accounting) here. In re Conservatorship of Ellis, 2009 Miss. App. LEXIS 873, Appeal No. 2008-CA-01993-COA (December 8, 2009)

The opinion gives you the understanding about what types of conduct may fit into the pattern that will be helpful for the court in making an informed decision.

The New York Times reported on December 4, 2009 on concerns of home health care patients about possible cuts that may occur if the legislation passed by the House and also passed in the Senate.

Many elderly patients rely upon home health care - both supplies anxd visits by home health care nurses to keep them out of the hospital. Home health care nurses can review and monitor a patient's condition and medications. The proposed legislation would reduce Medicare spending on home health services, a lifeline for home bound Medicare beneficiaries, which keeps them out of hospitals and nursing homes.

Under the pending legislation, more than 30 million Americans would gain health coverage. The cost would be offset by new taxes and fees and by cutbacks in Medicare payments to health care providers.

See Home Care Patients Worry Over Possible Cuts By ROBERT PEAR - The New York Times here. Contact your representatives in Congress today.

Several articles in the New England Journal of Medicine concerning Pandemic Influenza A (H1N1) Virus (”Swine Flu”) are offered free of charge to all. One of those articles indicates that early results on testing show that one dose of the vaccine may be sufficient for most groups. The NEJM calls the preliminary studies “reassuring.”

Jane E. Brody, columnist for the Health section of the New York Times wrote about how to choose a good nursing home on October 5, 2009. She said:

I have often said in no uncertain terms that I never want to be placed in a nursing home unless it is to recover from a treatable illness or injury. I have heard so many horror stories of neglect, mistreatment, under-staffing, poorly trained attendants and even corruption. I shared the common perception of a nursing home as the last place you go before you die, and this was not how I wanted to spend my last days.

Brody was then invited to tour one of the largest nursing homes in Florida. She came away with an entirely different perspective.

In a recent blog post, "Dollars & Health: Living wills, death panels and my dad," Andy Miller advocates for use of "living wills." These documents are also called "advance directives" or "patient advocacy designations." This topic is timely given the growing health care reform debate and concerns about so-called "death panels."

Miller's father was 88 and had multiple health problems when he was hospitalized. He did not, however, have a terminal illness. Miller and his brothers soon discovered that they would need to make decisions about their father's health care.

Earlier this year, Anne Underwood wrote about a program called Guided Care in Caring and Coping, a "New Old Age Blog" featured by the New York Times. The Guided Care program provides services from a registered nurse to help seniors get coordinated care. Research shows that repeat hospital re-admissions caused by often life-threatening complications are significantly reduced when care is carefully transitioned between the hospital and another care setting (home, assisted living, rehab, etc.)

Rosanne M. Leipzig is a physician and professor at Mount Sinai School of Medicine. She wrote in the New York Times today about how lacking in skill and training most doctors are in the practice of geriatrics. This is particularly troubling to her because geriatrics is not a required course in medical schools around the country. If you’re a caregiver or if you are one of those who is “of a certain age” to need competent curative and/or preventative care from a doctor, you’ll want to read what Dr. Leipzig has to say. In a nutshell . . .

“I was part of a group of doctors and medical educators who recently published in the journal Academic Medicine a set of minimum abilities that every medical student should demonstrate before graduating and caring for elderly patients. Nicknamed the “don’t kill Granny” list, it includes being able to prescribe medicines, assess patients’ ability to care for themselves, recognize atypical presentations of common diseases, prevent falls, recognize the hazards of hospitalization and decide on treatments based on elderly patients’ prognosis and their personal preferences.

“The 2008 Institute of Medicine report “Retooling for an Aging America” resolved that all licensed health care professionals should be required to demonstrate such competence in the care of older adults. But this resolution lacks teeth. Medical resident training programs that receive Medicare money should be required to demonstrate that their trainees are competent in geriatric care. Medicare should finance medical training in nursing homes. And state licensing and medical specialty boards should require demonstration of geriatric competence for licensing and certification.

“Basic geriatric knowledge is preventive medicine. Nurses, social workers, pharmacists and other health care professionals should have it, too, in order to improve care for older people. But until doctors get this basic training, we can’t even begin to give 80-year-olds the care they need.”

Dr. Leipzig’s entire op-ed piece can be read here.

For more information see Elsevier Health's publication: "Human Anatomy Books" 

This is amazing. What strength and courage. Are you going to finish strong? We could all learn from this young man.  As famiy caregivers, we all need to find motivation and encouragement. Try this:

I have just finished reading an extraordinary book, a book so remarkable that I am making a list of all of the people with whom I will share it. The book is Jane Brody's Guide to the Great Beyond: A Practical Primer to Help You and Your Loved Ones Prepare Medically, Legally, and Emotionally for the End of Life. Imagine next time you celebrate an occasion, giving your spouse, your child, or children a book about preparation for dying. The idea may seem strange to you. I ask you to suspend your negativity until you’ve seen this book.

Can you imagine spending two weeks in the hospital after suffering a seizure, being cared for by nurses, seen by doctors, having medications prescribed, being transferred for "rehab" to a nursing home, then arriving home to find that most of your care wasn't covered by Medicare?

That's exactly what is happening to some patients. The Chicago Tribune published an article on March 10th explaining a little known category of hospital care called "observation stay."

My niece sent me a link to a web site featuring a very powerful message about how our elderly loved ones wish to live and to die with dignity. Set to the music of Josh Groban ("You Raise Me Up"), this is very thought-provoking. I'll be honest. It moved me to tears.

Parents' Wish - view it here.

Reuters reports that a survey released on November 18, 2008 shows that nearly half of the primary care
doctors in the United States feel overworked and nearly half of them plan either to retire or to cut back
on how many patients they see or to quit the practice of medicine altogether. This poses serious
problems for the elderly, most of whom are cared for by primary care doctors, either family practice
doctors or internists.

In the survey 60 percent of 12,000 general practice physicians surveyed said that they wouldn't recommend medicine as a career.

The survey was conducted by the Physicians' Foundation. One doctor participating in the survey was quoted as saying: "The whole thing has spun out of control. I plan to retire early even though I still love seeing patients. The process has just become too burdensome."

The New York Times reports on September 16, 2008 that most ("a vast majority") of emergency room patients are discharged without understanding the treatment they received or how to care for themselves once they get home. As borne out by earlier studies, and in particular, by the research of Dr. Eric Coleman who is the director of the Care Transitions program at the University of Colorado, the lack of communication when patients are discharged from one care setting to another can lead to medication errors and serious complications that can send them right back to the hospital.

You can read the entire New York Times article here. E.R. Patients Often Left Confused After Visits

For more information see Dr. Coleman's website caretransitions.org. Be sure to look at the intervention section and also to access a Caregiver's Tool kit for caregivers and patients. This toolkit will help you safety negotiate not only safe care in the emergency department, but also to handle successfully transitions between hospital and home or hospital and another care facility such as a rehab center.

Thursday, July 31, 2008: According to the Boston Globe, Massachusett’s Division of Insurance is investigating sales of Evercare private Medicare plans following complaints from Massachusetts seniors about sales representatives using misleading and abusive marketing. These plans are sold in Michigan, according to the company’s website. [Enter a zip code.]  NOTE: I checked this. These plans are being sold in Michigan.

Falls can be deadly. About 10,000 elderly persons die every year in the U.S. as a result of injuries suffered in falls. Over one-third of these deaths occur among persons older than 85 years. The vast majority of these deaths are related to hip fractures; patients with hip fractures are 15 to 20 times more likely to die than those who have not had a fracture. Even when falls do not cause death, they can cause significant disability in the elderly, such as minor soft tissue injuries, hip fractures, other types of fractures, and serious soft tissue injuries. Injuries from falls may mean that your loved one won't be able to grow old in his or her own home.

Even short-term use of typical or atypical antipsychotic medications in the elderly with dementia produces serious events. If you are a regular reader of this Blog, then you know that I frequently write about the dangers of using antipsychotic medications with the elderly. My earlier posts may be accessed here. A new study, released on May 28, 2008, makes clear that even short-term use of these drugs may cause serious complications and even death for the elderly patient. That study was discussed in my May 27 Blog article, and is discussed in a recent article in Journal Watch Psychiatry June 23, 2008

Today, the Archives of Internal Medicine published a "retrospective cohort study" in which is is reported that the short-term use of antipsychotic therapy in older people with dementia is often followed by adverse events leading to hospitalization or death.

Shortly after my mother died in November 2000, I filed a report with the FDA's Med Watch --a reporting system for adverse medication reactions causing death and other serious complications. I told the FDA that risperidone, an atypical antipsychotic, prescribed for my mother when she was delirious was a likely contributing factor in her death. What did MedWatch do with this report?

As I have earlier written on Aging in Place, companies like Microsoft and Google are getting into the medical record storage business.  Last week, however, the New England Journal of Medicine raised important questions about whether medical privacy rules should be extended to these private firms. Steve Lohr wrote in the New York Times that the authors of The New England Journal article say there are still more questions than answers about the new “personalized health information economy.'’

How many people really read those thick pamphlets that credit card companies, banks, and/or insurance companies send out periodically to advise of a change in policies, interest rates, etc.? Many of these mailings surely end up in a stack that you’ll read when you “get around to it.”

Thus many seniors accustomed to paying a $20 co-pay may have been surprised the last time they went to pick up a refill of commonly used medications used to treat diseases such as multiple sclerosis, rheumatoid arthritis, hemophilia, hepatitis C and some cancers. New pricing systems adopted by many insurance companies now require patients to pay hundreds or even thousands of dollars for medications prescribed to help them save their lives or to slow a disease process.

For more about this troubling trend, see the April 14, 2008 New York Times,
Co-payments for Expensive Drugs Soar.

See also earlier posts Saving money on prescription medications and   Getting medications without charge

An FDA advisory panel has recommended further strengthening warnings for the use of erythropoiesis-stimulating agents in cancer treatment, according to news reports.

The panel voted to recommend keeping Aranesp (darbepoetin alfa) and Procrit (epoetin alfa) on the market to treat anemia resulting from chemotherapy. But it said they should be given only to patients with incurable cancer and should not be used for those with breast or head and neck cancer. Evidence that the drugs may increase the risks for death and tumor growth led to the new restrictions.

The panel also advised that patients should sign forms indicating that they consent to receive the drugs after being fully informed of the dangers associated with them, according to the New York Times.

The New York Times story may be read here.

Some seniors struggle financially while trying to age in place. The Financial Industry Regulatory Authority (FINRA) recently advised senior homeowners to proceed with caution before using reverse mortgages to access their home equity. The group warned that a reverse loan--meaning that a bank makes payments to a homeowner instead of the homeowner making payments to a bank--can be a risky financial move.

If you or one of your loved ones takes heparin, a blood-thinner often prescribed for patients with heart conditions, you should be watchful for the following symptoms:

• difficulty breathing
• nausea
• vomiting
• excessive sweating and
• rapidly falling blood pressure

Recently, a caregiver complained that a hospital would not allow her to elect a transfer to a psychiatric unit for her parent suffering from dementia. The hospital’s position was that the health care power of attorney did not allow the patient advocate to make a psychiatric admission. They said that only the patient could make that choice. The patient was described as being “delusional.” What seemed probable was that this patient was delirious, not psychotic. If that were the case, then a psychiatric admission would potentially be very harmful to the patient.

Avoiding an inappropriate psychiatric hospitalization for an elderly person can be life-saving for that patient.

Bedsores can be a serious complication of aging. The clinical name is pressure ulcers. These ulcers occur when skin breaks down because blood circulation is cut off by sustained pressure. Bedsores can be so difficult to heal that prevention is the recommended approach. A recent study shows that a teamwork approach can reduce the incidence of bedsores by 69%.

Patients who are confined to beds and wheelchairs in hospitals and nursing homes are most at risk for bedsores. Other complications, such as dehydration and poor nutrition, can put the elderly at greater risk to develop bedsores. Incontinence also can lead to bedsores.

The New York Times reports today that Baxter Healthcare, the manufacturer of about half of the heparin used in the U.S., has stopped making it after hundreds of patients reported severe allergic reactions to the drug. Heparin is a blood thinner widely used in surgery and dialysis. Reportedly, at least four people have died. It's important to note that the complications reported were related to large dosages being injected in patients. Most of the cases were reported in late December or January. 40 percent of the cases were reportedly serious.

Federal regulators say that a shutdown in manufacturing will surely result in shortages of the drug.
Alternative drugs do exist. However, doctors were warned today of serious consequences if heparin becomes truly scarce.

You may read the New York Times article, Problems in Drug Lead to Halt by Factory here.

In the December 10, 2008 issue of the New Yorker, author Atul Gawande writes: “If something so simple [as a checklist] can transform intensive care, what else can it do?”

Gawande gives some amazing examples of extraordinary ICU care evolving through the use of checklists. ICU care is complicated. A time and motion study of ICU care in Israel was cited. The study showed that the average ICU patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs. Any kind of mistake, in the procedure or in the sequence of actions, could result in fatal error.

A Traverse City elder law practice, Rizzo & Associates, has just begun a new blog -- Michigan Elder Law Updates. I've already emailed friends in Kentucky a link to the article about changes in Michigan's property tax. As summer residents and property owners in my neighborhood, they will be very interested in this update.

You'll find Michigan Elder Law Updates here: http://michiganelderlaw.blogspot.com/

On January 30, 2008 the Wall Street journal reported an important change to the tax code. A cherished tax break is the exclusion of as much as $500,000 of gain from gross income when, as a one-time event, a couple sells their principal residence as long as they file their tax returns jointly. (The exclusion is $250,00 for a single person). Yes, there are some conditions. You aren’t entitled to the exclusion unless you owned the home -- and lived in it as your primary residence -- for at least two of the five years prior to the sale.

Usually I write about issues important to the elderly. Today, I want to introduce you to Wendy S. Harpham, M.D. I am proud to call Wendy my friend, and I am grateful for her mentoring. Without Wendy’s thoughtful suggestions and encouraging words, Taking Charge: Good Medical Care for the Elderly and How to Get It would not exist. Wendy read the manuscript twice. She helped me “find my voice” as an advocate and she encouraged me every step of the way.

Wendy is an amazing woman. She was a young internist with a thriving private practice when she was diagnosed in 1990 with non-Hodgkin's lymphoma. Her children were 1, 3, and 5. While going through chemotherapy, she was amazed by and grateful for all she was learning about life on the other side of the stethoscope. From her useful perspective as physician-patient, she wrote a manuscript to guide patients through diagnosis, evaluation and treatment. WW Norton, a major publisher, offered Wendy a contract two days after she sent them the manuscript. Now in its third edition, it is entitled, Diagnosis Cancer: Your Guide Through the First Few Months of Healthy Survivorship.

Caring at Home has published a valuable article about how seniors can help prevent serious medical errors by paying attention and speaking up when they have questions about their care or the medications prescribed for them.

You can read and reprint this article here.

"To Prevent Health Care Errors, Patients are Urged to SPEAK UP"

Three articles in the current Annals of Internal Medicine provide useful information about palliative and end-of-life care. A helpful table is included with each article to help caregivers manage decision-making. Although written for doctors, many family caregivers will find this information useful.

I'd like to share with you today, a wonderful message from Rosalyn Carter about caregiving. Our former First Lady has been actively involved in caregiving for a long, long time. The Rosalyn Carter Institute provides a wide variety of valuable resources for family caregivers and for professional caregivers.

Mrs. Carter writes:

"My interest in caregiving goes back to my childhood. I was deeply influenced by how chronic illness affected and shaped my family and by the heroic and selfless efforts of health care providers, including Jimmy’s mother, Lillian Carter.

                                                                          * * *
In fact, the backbone of our country’s long-term, home-based, and community-based care systems is the family caregiver. The approximately 15 million caregivers in the United States provide $306 billion worth of unpaid services each year. That amount is almost twice as much as is spent on homecare and nursing home services combined ($158 billion).

                                                                          * * * 

But the strains on our society and on these individuals as a result of providing care are becoming apparent. To read more, click here.

When I began my research to learn what had caused the death of my mother only 65 days after she had been diagnosed with a simple urinary tract infection, one of my first goals was to learn whether an antipsychotic medication that had been prescribed for her could possibly be linked to her death. I learned that this drug was frequently used in nursing homes to control “behavior problems,” that the drug was intended for use with schizophrenics and that use in the elderly was “off-label” – meaning that the FDA had not approved the drug for that use.

I also learned that research linked use of antipsychotics in the elderly with unacceptable risk of harm to the elderly. In fact, the FDA has since issued a public health advisory to alert health care providers, patients, and patient caregivers to new safety information concerning an unapproved (i.e., “off-label”) use of certain drugs called “atypical antipsychotic drugs.” No research has demonstrated that antipsychotics are effective in “treating” behavioral problems in the elderly. The side effects of antipsychotics make them particularly dangerous to the elderly. These side effects include anorexia, drowsiness, dizziness, and dangerous “extrapyramidal side effects” such as dystonia (Involuntary movements and prolonged muscle contraction resulting in twisting body motions, tremor, and abnormal posture), Parkinsonism (motor stiffness, difficulty initiating movements, shuffling, stiff gait, resting tremors, and reduced facial movements), and others. EPSs can be life-threatening.

The Boston Globe today (December 3, 2007) explores the complicated subject to DNR orders -- do not resuscitate orders. When are they appropriate? What if the elderly patient waits too long? What decisions must be made and how can they be made?

The problem is, says the Globe's writer Patricia Wen, many families aren't sure about how to discuss this difficult subject. Often they wait too long, and by the time it's obvious that this decision needs to be made, the elderly loved one is not mentally competent to execute the required documents.

My book Taking Charge: Good Medical Care for the Elderly and How to Get It, discusses end-of-life decisions, the Five Wishes (called by the Miami Herald "the Living Will with a Heart"), and how and when to have this difficult conversation with your elderly loved one.

The Boston Globe article, by Patricia Wen may be read here:

For many, 'Do Not Resuscitate' too painful to discuss
Relatives, doctors often delay in offering patients the option

The Hartford Courant ran the second of a three-part series today (November 20th) on one of those multi-corporation, tiered nursing homes where the goal is to insulate from liability for harm that befalls the residents through neglect. According to the Courant, the minimum staffing requirements haven't changed in 25 years even though currant research shows serious understaffing in nursing home and shows that this can lead to disastrous results.

The topic this time is understaffing and how this leads to neglect of residents and serious harm or death.  Today, the Courant said:

"For four days in April, Bogardus and his close friend, Leona Brenner, tried to convince the staff of the Haven Health Center in South Windsor that he was dying. Bogardus, who had sought nursing-home care after complications from heart surgery, was coughing, struggling to breathe and couldn't walk the six steps from his bed to the bathroom, he and Brenner said.

Only after Brenner threatened to call 911 herself did the nursing staff finally summon an ambulance, the couple recounted. By the time the 69-year-old retired civil engineer arrived at St. Francis Hospital and Medical Center in Hartford, hospital records show, he was dehydrated and his kidneys were failing." More

From the Hartford Courant on November 19, 2007 comes an indepth expose of nursing homes operated by Haven Heathcare, which owns 25 nursing homes -- 15 in Connecticut and 10 in other New England states. The article cites a litany of deaths caused by neglect of the nursing home staff and/or understaffing leading to resident harm.

What good is oversight when nursing homes are fined only a few hundred dollars where a resident dies of dehydration after the home has been cited for violations numerous times, has been made to come up with a plan for correcting the deficiencies leading to harm, but continues to neglect its residents?

The Courant also notes that these nursing homes are owned by limited liability corporations in a maze of three and four-tiered structure, such as the New York Times exposed earlier this year. [See Choosing a good nursing home for your loved one, September 23, 2007] Families can spend a year or more suing a nursing home to recover damages for the needless death of their loved one only to learn that they sued the wrong corporation.

See No Haven for the Elderly: Nursing Home Troubles Show Lack of State Oversight.

Additional boxed warnings and label updates for the erythropoiesis-stimulating agents Aranesp, Epogen, and Procrit have been approved by the FDA. Ths issue causing the new warnings relate to drugs dosages that raise hemoglobin levels over 12 g/dL.

Research shows these high dosages stimulated tumor growth and decreased survival in patients with certain cancers: advanced breast, head and neck, lymphoid, and non-small cell lung cancer. It is important to note that researchers have not ruled out higher mortality and tumor progression when hemoglobin rates are raised to levels under 12 g/dL.

Chronic renal failure patients taking these drugs in order to keep hemoglobin levels over 12 g/dL are at increased risk for death, stroke, heart attack, and heart failure. For these patients, the FDA in recommending that hemoglobin levels be maintained between 10 and 12 g/dL.

FDA press release (Free)

Earlier Blog articles related to initial FDA warning, dosing change for erythropoietin

Technorati Tags: Amgen, Epogen, Aranesp

Exploitation of the elderly

There's been a lot of focus lately on how to avoid exploitation of the elderly and also domestic violence perpetrated by caregivers and/or family members.

Josh Ard, a noted elder law attorney who practices in Williamston, Michigan called to my attention an interesting case involving aspects of both issues (if one counts financial exploitation as a form of domestic abuse. I believe that financial exploitation is a form of abuse. See the Power and Control Wheel). In this case, the adultery and perjury of the elderly nursing home resident's husband trumped the lack of notice (and a false statement about notice) required by a guardianship petition filed by a granddaughter. The case occurred in Mississippi, but the concepts are equally applicable under Michigan law. These are the facts:

---

Ruby Chism Ellis, married to Bobbie Ellis since July, 2000, entered a nursing home in June, 2006. In 2008, Ruby’s granddaughter, Stephanie Chism Turner, filed a petition to be appointed as Ruby’s conservator. Stephanie represented to the court that she served the petition on Bobbie although she had not.

The court appointed Stephanie as conservator and, according to Bobbie, his first notice of the proceeding was when Stephanie showed up at the home with the conservatorship papers, demanding that he vacate the premises. Bobbie, for his part, had been carrying on an affair over the previous eighteen months, even moving his paramour into Ruby’s home.

After Stephanie moved money from Ruby and Bobbie’s joint account, placing it in a conservatorship account, Bobbie sought to have the conservatorship set aside or, in the alternative, to replace Stephanie as conservator. Bobbie argued that he was Ruby’s appointed agent under a power of attorney. It was at this point when Stephanie’s perjury became apparent.

A guardian ad litem was appointed who prepared a detailed report quoted at length in the appellate opinion. Significantly, the guardian ad litem found that Bobbie’s loyalties had been transferred to someone else and may once again. The trial court declined to dissolve the conservatorship, but ordered Stephanie to submit an accounting. The court noted that Mississippi law does not give a spouse preference in a guardianship proceeding and that any procedural deficiency in Stephanie’s appointment was resolved by later hearings. On appeal, the judgment was affirmed. The presence of a power of attorney does not deprive the court of jurisdiction and, although the court was displeased with the conduct of each party, the determining factor appeared to be Bobbie’s shifted loyalty.

You can read the appellate court's opinion (and the GAL's accounting) here. In re Conservatorship of Ellis, 2009 Miss. App. LEXIS 873, Appeal No. 2008-CA-01993-COA (December 8, 2009)

The opinion gives you the understanding about what types of conduct may fit into the pattern that will be helpful for the court in making an informed decision.

Cuts in home health care?

The New York Times reported on December 4, 2009 on concerns of home health care patients about possible cuts that may occur if the legislation passed by the House and also passed in the Senate.

Many elderly patients rely upon home health care - both supplies anxd visits by home health care nurses to keep them out of the hospital. Home health care nurses can review and monitor a patient's condition and medications. The proposed legislation would reduce Medicare spending on home health services, a lifeline for home bound Medicare beneficiaries, which keeps them out of hospitals and nursing homes.

Under the pending legislation, more than 30 million Americans would gain health coverage. The cost would be offset by new taxes and fees and by cutbacks in Medicare payments to health care providers.

See Home Care Patients Worry Over Possible Cuts By ROBERT PEAR - The New York Times here. Contact your representatives in Congress today.

Pandemic swine flu news

Several articles in the New England Journal of Medicine concerning Pandemic Influenza A (H1N1) Virus (”Swine Flu”) are offered free of charge to all. One of those articles indicates that early results on testing show that one dose of the vaccine may be sufficient for most groups. The NEJM calls the preliminary studies “reassuring.”

Choosing a nursing home - A checklist

Jane E. Brody, columnist for the Health section of the New York Times wrote about how to choose a good nursing home on October 5, 2009. She said:

I have often said in no uncertain terms that I never want to be placed in a nursing home unless it is to recover from a treatable illness or injury. I have heard so many horror stories of neglect, mistreatment, under-staffing, poorly trained attendants and even corruption. I shared the common perception of a nursing home as the last place you go before you die, and this was not how I wanted to spend my last days.

Brody was then invited to tour one of the largest nursing homes in Florida. She came away with an entirely different perspective.

Living wills & "death panels"

In a recent blog post, "Dollars & Health: Living wills, death panels and my dad," Andy Miller advocates for use of "living wills." These documents are also called "advance directives" or "patient advocacy designations." This topic is timely given the growing health care reform debate and concerns about so-called "death panels."

Miller's father was 88 and had multiple health problems when he was hospitalized. He did not, however, have a terminal illness. Miller and his brothers soon discovered that they would need to make decisions about their father's health care.

Care coordination | A life-extender for seniors

Earlier this year, Anne Underwood wrote about a program called Guided Care in Caring and Coping, a "New Old Age Blog" featured by the New York Times. The Guided Care program provides services from a registered nurse to help seniors get coordinated care. Research shows that repeat hospital re-admissions caused by often life-threatening complications are significantly reduced when care is carefully transitioned between the hospital and another care setting (home, assisted living, rehab, etc.)

The "Don't kill Granny" list

Rosanne M. Leipzig is a physician and professor at Mount Sinai School of Medicine. She wrote in the New York Times today about how lacking in skill and training most doctors are in the practice of geriatrics. This is particularly troubling to her because geriatrics is not a required course in medical schools around the country. If you’re a caregiver or if you are one of those who is “of a certain age” to need competent curative and/or preventative care from a doctor, you’ll want to read what Dr. Leipzig has to say. In a nutshell . . .

“I was part of a group of doctors and medical educators who recently published in the journal Academic Medicine a set of minimum abilities that every medical student should demonstrate before graduating and caring for elderly patients. Nicknamed the “don’t kill Granny” list, it includes being able to prescribe medicines, assess patients’ ability to care for themselves, recognize atypical presentations of common diseases, prevent falls, recognize the hazards of hospitalization and decide on treatments based on elderly patients’ prognosis and their personal preferences.

“The 2008 Institute of Medicine report “Retooling for an Aging America” resolved that all licensed health care professionals should be required to demonstrate such competence in the care of older adults. But this resolution lacks teeth. Medical resident training programs that receive Medicare money should be required to demonstrate that their trainees are competent in geriatric care. Medicare should finance medical training in nursing homes. And state licensing and medical specialty boards should require demonstration of geriatric competence for licensing and certification.

“Basic geriatric knowledge is preventive medicine. Nurses, social workers, pharmacists and other health care professionals should have it, too, in order to improve care for older people. But until doctors get this basic training, we can’t even begin to give 80-year-olds the care they need.”

Dr. Leipzig’s entire op-ed piece can be read here.

For more information see Elsevier Health's publication: "Human Anatomy Books" 

Are you going to finish strong?

This is amazing. What strength and courage. Are you going to finish strong? We could all learn from this young man.  As famiy caregivers, we all need to find motivation and encouragement. Try this:

A good death | Jane Brody's Guide to the Great Beyond

I have just finished reading an extraordinary book, a book so remarkable that I am making a list of all of the people with whom I will share it. The book is Jane Brody's Guide to the Great Beyond: A Practical Primer to Help You and Your Loved Ones Prepare Medically, Legally, and Emotionally for the End of Life. Imagine next time you celebrate an occasion, giving your spouse, your child, or children a book about preparation for dying. The idea may seem strange to you. I ask you to suspend your negativity until you’ve seen this book.

Can you imagine spending two weeks in the hospital after suffering a seizure, being cared for by nurses, seen by doctors, having medications prescribed, being transferred for "rehab" to a nursing home, then arriving home to find that most of your care wasn't covered by Medicare?

That's exactly what is happening to some patients. The Chicago Tribune published an article on March 10th explaining a little known category of hospital care called "observation stay."

Parents' Wish | Preserving dignity for your loved one

My niece sent me a link to a web site featuring a very powerful message about how our elderly loved ones wish to live and to die with dignity. Set to the music of Josh Groban ("You Raise Me Up"), this is very thought-provoking. I'll be honest. It moved me to tears.

Parents' Wish - view it here.

Survey shows many primary care doctors plan to quit or cut back

Reuters reports that a survey released on November 18, 2008 shows that nearly half of the primary care
doctors in the United States feel overworked and nearly half of them plan either to retire or to cut back
on how many patients they see or to quit the practice of medicine altogether. This poses serious
problems for the elderly, most of whom are cared for by primary care doctors, either family practice
doctors or internists.

In the survey 60 percent of 12,000 general practice physicians surveyed said that they wouldn't recommend medicine as a career.

The survey was conducted by the Physicians' Foundation. One doctor participating in the survey was quoted as saying: "The whole thing has spun out of control. I plan to retire early even though I still love seeing patients. The process has just become too burdensome."

Lack of communication in ER results in post-discharge complications

The New York Times reports on September 16, 2008 that most ("a vast majority") of emergency room patients are discharged without understanding the treatment they received or how to care for themselves once they get home. As borne out by earlier studies, and in particular, by the research of Dr. Eric Coleman who is the director of the Care Transitions program at the University of Colorado, the lack of communication when patients are discharged from one care setting to another can lead to medication errors and serious complications that can send them right back to the hospital.

You can read the entire New York Times article here. E.R. Patients Often Left Confused After Visits

For more information see Dr. Coleman's website caretransitions.org. Be sure to look at the intervention section and also to access a Caregiver's Tool kit for caregivers and patients. This toolkit will help you safety negotiate not only safe care in the emergency department, but also to handle successfully transitions between hospital and home or hospital and another care facility such as a rehab center.

Evercare private Medicare plans under scrutiny

Thursday, July 31, 2008: According to the Boston Globe, Massachusett’s Division of Insurance is investigating sales of Evercare private Medicare plans following complaints from Massachusetts seniors about sales representatives using misleading and abusive marketing. These plans are sold in Michigan, according to the company’s website. [Enter a zip code.]  NOTE: I checked this. These plans are being sold in Michigan.

The importance of eliminating risks for falling

Falls can be deadly. About 10,000 elderly persons die every year in the U.S. as a result of injuries suffered in falls. Over one-third of these deaths occur among persons older than 85 years. The vast majority of these deaths are related to hip fractures; patients with hip fractures are 15 to 20 times more likely to die than those who have not had a fracture. Even when falls do not cause death, they can cause significant disability in the elderly, such as minor soft tissue injuries, hip fractures, other types of fractures, and serious soft tissue injuries. Injuries from falls may mean that your loved one won't be able to grow old in his or her own home.

Antipsychotics inappropriately prescribed for dementia

Even short-term use of typical or atypical antipsychotic medications in the elderly with dementia produces serious events. If you are a regular reader of this Blog, then you know that I frequently write about the dangers of using antipsychotic medications with the elderly. My earlier posts may be accessed here. A new study, released on May 28, 2008, makes clear that even short-term use of these drugs may cause serious complications and even death for the elderly patient. That study was discussed in my May 27 Blog article, and is discussed in a recent article in Journal Watch Psychiatry June 23, 2008

Antipsychotics prescribed to elderly | Adverse event

Today, the Archives of Internal Medicine published a "retrospective cohort study" in which is is reported that the short-term use of antipsychotic therapy in older people with dementia is often followed by adverse events leading to hospitalization or death.

Shortly after my mother died in November 2000, I filed a report with the FDA's Med Watch --a reporting system for adverse medication reactions causing death and other serious complications. I told the FDA that risperidone, an atypical antipsychotic, prescribed for my mother when she was delirious was a likely contributing factor in her death. What did MedWatch do with this report?

Is online medical record storage safe?

As I have earlier written on Aging in Place, companies like Microsoft and Google are getting into the medical record storage business.  Last week, however, the New England Journal of Medicine raised important questions about whether medical privacy rules should be extended to these private firms. Steve Lohr wrote in the New York Times that the authors of The New England Journal article say there are still more questions than answers about the new “personalized health information economy.'’

Soaring co-pays for prescription medications

How many people really read those thick pamphlets that credit card companies, banks, and/or insurance companies send out periodically to advise of a change in policies, interest rates, etc.? Many of these mailings surely end up in a stack that you’ll read when you “get around to it.”

Thus many seniors accustomed to paying a $20 co-pay may have been surprised the last time they went to pick up a refill of commonly used medications used to treat diseases such as multiple sclerosis, rheumatoid arthritis, hemophilia, hepatitis C and some cancers. New pricing systems adopted by many insurance companies now require patients to pay hundreds or even thousands of dollars for medications prescribed to help them save their lives or to slow a disease process.

For more about this troubling trend, see the April 14, 2008 New York Times,
Co-payments for Expensive Drugs Soar.

See also earlier posts Saving money on prescription medications and   Getting medications without charge

New restrictions on anti-anemia drugs

An FDA advisory panel has recommended further strengthening warnings for the use of erythropoiesis-stimulating agents in cancer treatment, according to news reports.

The panel voted to recommend keeping Aranesp (darbepoetin alfa) and Procrit (epoetin alfa) on the market to treat anemia resulting from chemotherapy. But it said they should be given only to patients with incurable cancer and should not be used for those with breast or head and neck cancer. Evidence that the drugs may increase the risks for death and tumor growth led to the new restrictions.

The panel also advised that patients should sign forms indicating that they consent to receive the drugs after being fully informed of the dangers associated with them, according to the New York Times.

The New York Times story may be read here.

Seniors cautioned about reverse mortgages

Some seniors struggle financially while trying to age in place. The Financial Industry Regulatory Authority (FINRA) recently advised senior homeowners to proceed with caution before using reverse mortgages to access their home equity. The group warned that a reverse loan--meaning that a bank makes payments to a homeowner instead of the homeowner making payments to a bank--can be a risky financial move.

Heparin contamination

If you or one of your loved ones takes heparin, a blood-thinner often prescribed for patients with heart conditions, you should be watchful for the following symptoms:

• difficulty breathing
• nausea
• vomiting
• excessive sweating and
• rapidly falling blood pressure

Avoiding an inappropriate psychiatric hospitalization

Recently, a caregiver complained that a hospital would not allow her to elect a transfer to a psychiatric unit for her parent suffering from dementia. The hospital’s position was that the health care power of attorney did not allow the patient advocate to make a psychiatric admission. They said that only the patient could make that choice. The patient was described as being “delusional.” What seemed probable was that this patient was delirious, not psychotic. If that were the case, then a psychiatric admission would potentially be very harmful to the patient.

Avoiding an inappropriate psychiatric hospitalization for an elderly person can be life-saving for that patient.

Reducing incidence of bedsores using teamwork

Bedsores can be a serious complication of aging. The clinical name is pressure ulcers. These ulcers occur when skin breaks down because blood circulation is cut off by sustained pressure. Bedsores can be so difficult to heal that prevention is the recommended approach. A recent study shows that a teamwork approach can reduce the incidence of bedsores by 69%.

Patients who are confined to beds and wheelchairs in hospitals and nursing homes are most at risk for bedsores. Other complications, such as dehydration and poor nutrition, can put the elderly at greater risk to develop bedsores. Incontinence also can lead to bedsores.

Heparin warnings

The New York Times reports today that Baxter Healthcare, the manufacturer of about half of the heparin used in the U.S., has stopped making it after hundreds of patients reported severe allergic reactions to the drug. Heparin is a blood thinner widely used in surgery and dialysis. Reportedly, at least four people have died. It's important to note that the complications reported were related to large dosages being injected in patients. Most of the cases were reported in late December or January. 40 percent of the cases were reportedly serious.

Federal regulators say that a shutdown in manufacturing will surely result in shortages of the drug.
Alternative drugs do exist. However, doctors were warned today of serious consequences if heparin becomes truly scarce.

You may read the New York Times article, Problems in Drug Lead to Halt by Factory here.

The checklist | A simple way to reduce medical error

In the December 10, 2008 issue of the New Yorker, author Atul Gawande writes: “If something so simple [as a checklist] can transform intensive care, what else can it do?”

Gawande gives some amazing examples of extraordinary ICU care evolving through the use of checklists. ICU care is complicated. A time and motion study of ICU care in Israel was cited. The study showed that the average ICU patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs. Any kind of mistake, in the procedure or in the sequence of actions, could result in fatal error.

Rizzo & Associates new blog

A Traverse City elder law practice, Rizzo & Associates, has just begun a new blog -- Michigan Elder Law Updates. I've already emailed friends in Kentucky a link to the article about changes in Michigan's property tax. As summer residents and property owners in my neighborhood, they will be very interested in this update.

You'll find Michigan Elder Law Updates here: http://michiganelderlaw.blogspot.com/

Aging in Place | A change in the tax law may help

On January 30, 2008 the Wall Street journal reported an important change to the tax code. A cherished tax break is the exclusion of as much as $500,000 of gain from gross income when, as a one-time event, a couple sells their principal residence as long as they file their tax returns jointly. (The exclusion is $250,00 for a single person). Yes, there are some conditions. You aren’t entitled to the exclusion unless you owned the home -- and lived in it as your primary residence -- for at least two of the five years prior to the sale.

Healthy Survivorship | Wendy Harpham coined the phrase!

Usually I write about issues important to the elderly. Today, I want to introduce you to Wendy S. Harpham, M.D. I am proud to call Wendy my friend, and I am grateful for her mentoring. Without Wendy’s thoughtful suggestions and encouraging words, Taking Charge: Good Medical Care for the Elderly and How to Get It would not exist. Wendy read the manuscript twice. She helped me “find my voice” as an advocate and she encouraged me every step of the way.

Wendy is an amazing woman. She was a young internist with a thriving private practice when she was diagnosed in 1990 with non-Hodgkin's lymphoma. Her children were 1, 3, and 5. While going through chemotherapy, she was amazed by and grateful for all she was learning about life on the other side of the stethoscope. From her useful perspective as physician-patient, she wrote a manuscript to guide patients through diagnosis, evaluation and treatment. WW Norton, a major publisher, offered Wendy a contract two days after she sent them the manuscript. Now in its third edition, it is entitled, Diagnosis Cancer: Your Guide Through the First Few Months of Healthy Survivorship.

Speak up and prevent health care errors

Caring at Home has published a valuable article about how seniors can help prevent serious medical errors by paying attention and speaking up when they have questions about their care or the medications prescribed for them.

You can read and reprint this article here.

"To Prevent Health Care Errors, Patients are Urged to SPEAK UP"

Palliative Care & End-of-Life Care articles available

Three articles in the current Annals of Internal Medicine provide useful information about palliative and end-of-life care. A helpful table is included with each article to help caregivers manage decision-making. Although written for doctors, many family caregivers will find this information useful.

Rosalyn Carter's message about caregiving

I'd like to share with you today, a wonderful message from Rosalyn Carter about caregiving. Our former First Lady has been actively involved in caregiving for a long, long time. The Rosalyn Carter Institute provides a wide variety of valuable resources for family caregivers and for professional caregivers.

Mrs. Carter writes:

"My interest in caregiving goes back to my childhood. I was deeply influenced by how chronic illness affected and shaped my family and by the heroic and selfless efforts of health care providers, including Jimmy’s mother, Lillian Carter.

                                                                          * * *
In fact, the backbone of our country’s long-term, home-based, and community-based care systems is the family caregiver. The approximately 15 million caregivers in the United States provide $306 billion worth of unpaid services each year. That amount is almost twice as much as is spent on homecare and nursing home services combined ($158 billion).

                                                                          * * * 

But the strains on our society and on these individuals as a result of providing care are becoming apparent. To read more, click here.

Commonly prescribed drugs cause most adverse drug events in elders

When I began my research to learn what had caused the death of my mother only 65 days after she had been diagnosed with a simple urinary tract infection, one of my first goals was to learn whether an antipsychotic medication that had been prescribed for her could possibly be linked to her death. I learned that this drug was frequently used in nursing homes to control “behavior problems,” that the drug was intended for use with schizophrenics and that use in the elderly was “off-label” – meaning that the FDA had not approved the drug for that use.

I also learned that research linked use of antipsychotics in the elderly with unacceptable risk of harm to the elderly. In fact, the FDA has since issued a public health advisory to alert health care providers, patients, and patient caregivers to new safety information concerning an unapproved (i.e., “off-label”) use of certain drugs called “atypical antipsychotic drugs.” No research has demonstrated that antipsychotics are effective in “treating” behavioral problems in the elderly. The side effects of antipsychotics make them particularly dangerous to the elderly. These side effects include anorexia, drowsiness, dizziness, and dangerous “extrapyramidal side effects” such as dystonia (Involuntary movements and prolonged muscle contraction resulting in twisting body motions, tremor, and abnormal posture), Parkinsonism (motor stiffness, difficulty initiating movements, shuffling, stiff gait, resting tremors, and reduced facial movements), and others. EPSs can be life-threatening.

Do not resuscitate orders | A family's dilemma

The Boston Globe today (December 3, 2007) explores the complicated subject to DNR orders -- do not resuscitate orders. When are they appropriate? What if the elderly patient waits too long? What decisions must be made and how can they be made?

The problem is, says the Globe's writer Patricia Wen, many families aren't sure about how to discuss this difficult subject. Often they wait too long, and by the time it's obvious that this decision needs to be made, the elderly loved one is not mentally competent to execute the required documents.

My book Taking Charge: Good Medical Care for the Elderly and How to Get It, discusses end-of-life decisions, the Five Wishes (called by the Miami Herald "the Living Will with a Heart"), and how and when to have this difficult conversation with your elderly loved one.

The Boston Globe article, by Patricia Wen may be read here:

For many, 'Do Not Resuscitate' too painful to discuss
Relatives, doctors often delay in offering patients the option

More from the Hartford Courant - Understaffing

The Hartford Courant ran the second of a three-part series today (November 20th) on one of those multi-corporation, tiered nursing homes where the goal is to insulate from liability for harm that befalls the residents through neglect. According to the Courant, the minimum staffing requirements haven't changed in 25 years even though currant research shows serious understaffing in nursing home and shows that this can lead to disastrous results.

The topic this time is understaffing and how this leads to neglect of residents and serious harm or death.  Today, the Courant said:

"For four days in April, Bogardus and his close friend, Leona Brenner, tried to convince the staff of the Haven Health Center in South Windsor that he was dying. Bogardus, who had sought nursing-home care after complications from heart surgery, was coughing, struggling to breathe and couldn't walk the six steps from his bed to the bathroom, he and Brenner said.

Only after Brenner threatened to call 911 herself did the nursing staff finally summon an ambulance, the couple recounted. By the time the 69-year-old retired civil engineer arrived at St. Francis Hospital and Medical Center in Hartford, hospital records show, he was dehydrated and his kidneys were failing." More

Dehydration, malnutrition, and falls in nursing homes

From the Hartford Courant on November 19, 2007 comes an indepth expose of nursing homes operated by Haven Heathcare, which owns 25 nursing homes -- 15 in Connecticut and 10 in other New England states. The article cites a litany of deaths caused by neglect of the nursing home staff and/or understaffing leading to resident harm.

What good is oversight when nursing homes are fined only a few hundred dollars where a resident dies of dehydration after the home has been cited for violations numerous times, has been made to come up with a plan for correcting the deficiencies leading to harm, but continues to neglect its residents?

The Courant also notes that these nursing homes are owned by limited liability corporations in a maze of three and four-tiered structure, such as the New York Times exposed earlier this year. [See Choosing a good nursing home for your loved one, September 23, 2007] Families can spend a year or more suing a nursing home to recover damages for the needless death of their loved one only to learn that they sued the wrong corporation.

See No Haven for the Elderly: Nursing Home Troubles Show Lack of State Oversight.

Stronger FDA warnings for Procrit, Epogen, & Aranesp

Additional boxed warnings and label updates for the erythropoiesis-stimulating agents Aranesp, Epogen, and Procrit have been approved by the FDA. Ths issue causing the new warnings relate to drugs dosages that raise hemoglobin levels over 12 g/dL.

Research shows these high dosages stimulated tumor growth and decreased survival in patients with certain cancers: advanced breast, head and neck, lymphoid, and non-small cell lung cancer. It is important to note that researchers have not ruled out higher mortality and tumor progression when hemoglobin rates are raised to levels under 12 g/dL.

Chronic renal failure patients taking these drugs in order to keep hemoglobin levels over 12 g/dL are at increased risk for death, stroke, heart attack, and heart failure. For these patients, the FDA in recommending that hemoglobin levels be maintained between 10 and 12 g/dL.

FDA press release (Free)

Earlier Blog articles related to initial FDA warning, dosing change for erythropoietin

Technorati Tags: Amgen, Epogen, Aranesp