Good Medical Care for the Elderly and How to Get It

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.

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.

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"

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.

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

Medication errors occur frequently with surgery

The Washington Post reported on March 6, 2007 that patients having surgery face a significant risk of medical error involving medication, citing a report prepared by U.S. Pharmacopeia, a private group that sets standards for the drug industry.

The report was based on data from more than 400 hospitals. Statistics were collected about medication errors occurring between 1998 and 2005 during outpatient surgery, in preparation for surgery, in the operating room and in recovery.

According to the Post, a total of 11,239 errors were reported, including giving the wrong drug or the wrong dose, or giving it at the wrong time. Five percent of the mistakes caused harm, making surgery one of the most dangerous times for medication mistakes.

The entire article may be read here.

Amgen discloses risks in 'off-label' use

The New York Times reported on January 25, 2007 that Amgen, the manufacturer of the anti-anemia drug Aranesp, has acknowledged an increased risk of death when this drug is used to treat certain cancer patients. Aranesp, Epogen (also from Amgen), and Procrit (from Johnson & Johnson) are three anti-anemia drugs that have been used for what are called “off label” purposes. “Off-label” purpose means a use not approved by the FDA.

Recently an Amgen executive vice president estimated that about 10 percent to 12 percent of Aranesp sales are used for “anemia of cancer.”

Amgen’s disclosure related to recent clinical trials involving Aranesp. Amgen’s stated goal in these trials was to see whether Aranesp could reduce the need for blood transfusions to treat anemia caused by certain cancers.

Amgen now says that the company found that the drug did not reduce the need for transfusions compared with a placebo, but did increase the number of deaths by the end of 16 weeks by a statistically significant amount. While Amgen did not provide any numerical results from the trial, the company said in a news release that in this particular population the “risk/benefit ratio for Aranesp use is at best neutral and perhaps negative.”

According to today’s New York Times article, the sale of anti-anemia drugs is a $10 billion business for the drug companies. The drugs are marketed globally; about one million American patients receive prescriptions for this class of drug every year.

Earlier this fall, I wrote about the risks posed to dialysis patients when Epogen, Amgen’s other anti-anemia drug, was overused by dialysis patients. Responding to current research reports, I wrote that most dialysis clinics administer the anti-anemia drugs intravenously rather than by injection. As a result, each patient gets about one-third more drug than the patient would need if he/she received the drug by injection.

After the Epogen/dialysis story broke, on November 30, 2006, the New York Times reported that an expert panel of doctors for the National Kidney Foundation plans to study whether the intravenous administration of the anti-anemia drugs to hundreds of thousands of patients with kidney disease is subjecting the patients to unnecessary threat of harm. The purpose of the study is to determine whether to change guidelines for how patients should be treated.

You can read the entire New York Times article, here.

Medication Errors Common Among the Elderly

In a recent news article, Associated Press writer Jeffrey Gold described a recent study finding that people over 65 are nearly 7 times more likely to suffer as a result of a medication error than younger patients. This is because the elderly often have multiple chronic conditions and take several different kinds of drugs – both prescription and over-the-counter – every day. Also, seniors often have more than one doctor and when drugs are prescribed by several doctors, it’s not uncommon that drug-drug interactions occur.

Taking Charge: Good Medical Care for the Elderly and How to Get It contains two chapters on medications – Chapter Three concerns medication errors and Chapter Four describes adverse drug reactions in greater detail. An appendices shows common drug-drug interactions seniors need to avoid.

To read Mr. Gold’s entire article click here.