© Imelda Maurer, cdp January 28, 2009
Jerald Winakur and Dennis McCullough are physicians practicing in different parts of the country but with much in common. They are both geriatricians, each is married to a poet (!) and they are each authors of recently published books emanating from their life experiences in geriatric medicine.
Both men point to the same serious flaws in our healthcare system. One is the reimbursement system which is heavily skewed to procedures rather than what Dr. Winakur calls “cognitive” services. The latter includes taking adequate time to examine a patient,to listen and to watch his/her body language as s/he answers routine questions. We are all familiar with the first visit to a physician which includes the two-to-three page check list we are given to complete in the waiting room: questions about our personal and family medical history and of our daily habits (healthy or unhealthy!). Dr. Winakur chooses to take the time to ask these questions directly of the patient in the examining room, precisely, he says, because of what he learns through the patient's body language, the tone of voice, the hesitation, etc. What a man!
Cognitive services also include a careful review of medications, close monitoring and appropriate adjustments if called for. McCullough refers to this as “taking time for listening and understanding” As a result of how Medicare and private insurance companies reimburse medical services, too many patients are peremptorily “shunted off for various kind of expensive but ‘covered’ technical testing or quickly put on medication based on ever quickening decisions and standardized protocol. Pressures for efficiency and reimbursement plans skewed toward technological interventions routinely overrule more deeply caring and thoughtful responses to individual need.”
Winakur explains in more depth how reimbursement schedules are established. The American Medical Association has much to say about it, but the entire operation is very secretive with physicians such as Winakur and McCullough having little or no voice in arguing the the rightrful place of cognitive skills in the reimbursement schema.
One of the reasons I have heard given over the years as to why there is such a dearth of geriatricians in our country has been that they are not well paid. Now I understand why. Good medical practice for elders may not call for every single test or procedure in the book. (This is not to condone the ageism that is sometime seen when physicians neglect appropriate procedures solely on the basis of a patient’s age.)
Dr. Winakur began his practice as a board-certified internist. He became a geriatrician, he writes, “. . .because my patients and I have grown old together.” (Don’t you love it!) And ‘to keep up with them,’ he writes, I “continued to study the latest developments in clinical geriatrics,” and passed board examinations to become certified with “added qualifications in geriatrics.” Clearly, he’s not in it just for the money. What a man!
There are many good geriatricians out there. Geriatricians are specially trained to care for persons sixty years and older. I encourage everyone so blessed with years to seek one out as their primary care provider. Why a geriatrician at our age over a family practitioner or an internist? The next blog entry!
Perhaps our new President who has already heralded such hopeful signs of change, can help improve our healthcare system with help from an active, engaged public
The books referred to here are these:
Memory Lessons by Jerald Winakur
My Mother, Your Mother by Dennis McCullough
Wednesday, January 28, 2009
Tuesday, January 6, 2009
If You Know Someone In A Nursing Home, You Should Know About Off-Label Prescriptions
© Imelda Maurer, cdp January 6, 2008
I keep seeing it.. Whether it is a newsletter, a professional journal, a TV news story, or just this afternoon a well-written, documented article on the Internet: (http://www.therubins.com/homes/vocal.htm) The article refers to a study I also mentioned in a blog post almost a year ago (January 14, 2008). The study involved 86 individuals being treated for "behavioral problems". One third were given Risperdal; one third another anti-psychotic and another third, a placebo. After a month "behaviors" had "improved". The group with the most significant positive changes was the group receiving the placebo.
There is a stream of information about the use of antipsychotic drugs used on the elderly as a way to address what caregivers mistakenly call "behavioral problems." Behaviors among persons with dementia are not problems. Dr. G. Allen Power, Medical Director at St. John's Home in Rochester, NY believes that the use of terms like "behavioral problems" or "managing difficult behaviors" reinforces the medical view that the 'problem' rests with the person with dementia. Rather, he says, these events should be seen as "symptoms" that occur, not because of a failure of the individual, but rather because of a failure of the care environment to adequately identify and meet the person's needs. This statement is so core to the effective care of persons with dementia, I want to state it again: . . . these events should be seen as "symptoms" that occur, not because of a failure of the individual, but rather because of a failure of the care environment to adequately identify and meet the person's needs.
The Center for Medicare and Medicaid Services indicate that nearly 21% of nursing-home residents who don't have a psychosis diagnosis are on these anti-psychotic drugs. It is a way to sedate a person – in the short run --- but without addressing the issues at hand and at the same time setting the stage for complex negative side effects from the drug.
Three of the most frequently prescribed (I should say mis-prescribed) are Risperdal, Zyprexa and Seroquel. All three of these drugs carry "black box warnings", mandated by the FDA, which indicate that 'elderly dementia patients taking these drugs are at higher risk of death.'
Side effects of these drugs include weight gain and stroke, sometimes resulting in death. There is sometimes an increase in blood sugar levels, intolerance to changes in ambient temperature. A most obvious side effect is that of sedation.
Definition of off-label use of a drug.( From my post on January 14, 2008): When a drug has been developed and approved by the FDA for a certain disease or disorder, but a health care provider prescribes it for a condition other than that covered by the drug’s FDA approval, the practice is called off-label use. Physicians attending nursing home residents in far too many cases prescribe any of these antipsychotic drugs as all-purpose tranquilizers
As I write this, I wonder if the broad, expensive, ineffective, harmful and widespread use of off-label antipsychotic drugs among the most vulnerable in our society is a subtle or not-so-subtle manifestation of ageism. Or is it because in our long-term-care system we don't take the time to really know each individual, know him or her as an individual, not just an old person --- who is going to die anyhow ---. Do we as a society, as Dr. Bill Thomas suggests, view nursing home residents as racing toward the exit ramp of life? Of course none of us subscribes to these views consciously, but are they at work in our society and institutions at a subconscious level?
I keep seeing it.. Whether it is a newsletter, a professional journal, a TV news story, or just this afternoon a well-written, documented article on the Internet: (http://www.therubins.com/homes/vocal.htm) The article refers to a study I also mentioned in a blog post almost a year ago (January 14, 2008). The study involved 86 individuals being treated for "behavioral problems". One third were given Risperdal; one third another anti-psychotic and another third, a placebo. After a month "behaviors" had "improved". The group with the most significant positive changes was the group receiving the placebo.
There is a stream of information about the use of antipsychotic drugs used on the elderly as a way to address what caregivers mistakenly call "behavioral problems." Behaviors among persons with dementia are not problems. Dr. G. Allen Power, Medical Director at St. John's Home in Rochester, NY believes that the use of terms like "behavioral problems" or "managing difficult behaviors" reinforces the medical view that the 'problem' rests with the person with dementia. Rather, he says, these events should be seen as "symptoms" that occur, not because of a failure of the individual, but rather because of a failure of the care environment to adequately identify and meet the person's needs. This statement is so core to the effective care of persons with dementia, I want to state it again: . . . these events should be seen as "symptoms" that occur, not because of a failure of the individual, but rather because of a failure of the care environment to adequately identify and meet the person's needs.
The Center for Medicare and Medicaid Services indicate that nearly 21% of nursing-home residents who don't have a psychosis diagnosis are on these anti-psychotic drugs. It is a way to sedate a person – in the short run --- but without addressing the issues at hand and at the same time setting the stage for complex negative side effects from the drug.
Three of the most frequently prescribed (I should say mis-prescribed) are Risperdal, Zyprexa and Seroquel. All three of these drugs carry "black box warnings", mandated by the FDA, which indicate that 'elderly dementia patients taking these drugs are at higher risk of death.'
Side effects of these drugs include weight gain and stroke, sometimes resulting in death. There is sometimes an increase in blood sugar levels, intolerance to changes in ambient temperature. A most obvious side effect is that of sedation.
Definition of off-label use of a drug.( From my post on January 14, 2008): When a drug has been developed and approved by the FDA for a certain disease or disorder, but a health care provider prescribes it for a condition other than that covered by the drug’s FDA approval, the practice is called off-label use. Physicians attending nursing home residents in far too many cases prescribe any of these antipsychotic drugs as all-purpose tranquilizers
As I write this, I wonder if the broad, expensive, ineffective, harmful and widespread use of off-label antipsychotic drugs among the most vulnerable in our society is a subtle or not-so-subtle manifestation of ageism. Or is it because in our long-term-care system we don't take the time to really know each individual, know him or her as an individual, not just an old person --- who is going to die anyhow ---. Do we as a society, as Dr. Bill Thomas suggests, view nursing home residents as racing toward the exit ramp of life? Of course none of us subscribes to these views consciously, but are they at work in our society and institutions at a subconscious level?
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