Good Medical Care for the Elderly and How to Get It

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.

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" 

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.

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?

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.

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.