When an Older Adult is Hospitalized

One journal that I always look forward to receiving in the mail is Caring for the Ages from the American Medical Directors Association. The current issue, October 2012, is chuck full of great articles. I write about only one of them here.

When an elder is hospitalized, there is a high risk for the onset of delirium. Delirium was once perceived as a short-term, transient cognitive disorder. Now there is increasing evidence that delirium carries longer-term effects on cognitive function.

Studies which show such results highlight the importance of “proactive interventions” to prevent delirium and to lessen its impact if and when delirium is diagnosed. One highly recognized program that addresses this very issue is the Hospital Elder Life Program (HELP).

The website for that program is this: http://www.hospitalelderlifeprogram.org/public/public-main.php

I encourage readers to access that website for the valuable resource that it is.

On the left side of the HELP homepage, you will find numerous helpful links. For anyone who is responsible as a family member for an elder, click on the “Older Adults/Caregivers” link near the top of that long list of links on the left. There is a wealth of information there for the elder and for the caregiver.

As a corollary to this topic of delirium, I’m reminded of some writings of Jerald Winakur, MD, a geriatrician in San Antonio, Texas. Dr. Winakur-- speaking both as a geriatrician and a son who cared for his elderly father – says again and again that an elder should never be left alone the first night s/he is in the hospital.

Good reading for good advocates! Carry on your noble work!

Information about Psychoactive Drugs

Yesterday I posted an article about antipsychotic drug use on our elders in nursing homes. Today I post this table for your use. It is a list of all the drugs that CMS looks for in reporting on usage of antipsychotic drugs in nursing homes.

 

You can Google the name of any drug here and learn much more about that drug's intended (on label, FDA-approved) use and its side effects.

 

DRUG	On Label Use	Trade Name(s)
Clozapine	Schizophrenia	Clozaril, Gen-Clozapine
Haloperidol Deconate	acute psychosis, schizophrenia, and Tourette's syndrome	Haldol
Droperidol	Used as an antiemetic and antipsychotic. Droperidol is also often used for neuroleptanalgesic anesthesia (a state of quiescence) and sedation in intensive-care treatment	Inapsine, Droleptan, Dridol, Xomolix, Innovar
Loxapine	Loxapine is used to treat the symptoms of schizophrenia	Loxitane
Thioridazine	Thioridazine is used to treat the symptoms of schizophrenia	Mellaril
Molindone	Molindone is used to treat the symptoms of schizophrenia	Moban
Theothixene	Thiothixene is used to treat the symptoms of schizophrenia	Navane
Olanzapine	is used to treat the symptoms of schizophrenia	Zyprexa
Pimozide	Pimozide is an atypical antipsychotic drug used to treat serious motor and verbal tics associated with Tourette's syndrome	Orap
Fluphenazine Deconate	An antipsychotic medication used to treat Schizophrenia. It is a highly potent behavior modifier with a markedly extended duration of effect.	(This is an injection medication.)
Fluphenazine	Fluphenazine is an antipsychotic medication used to treat schizophrenia and psychotic symptoms such as hallucinations, delusions, and hostility.	Prolixin, Permitil
Quetiapine	Quetiapine tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia	Seroquel
Risperidone	Risperidone is used to treat the symptoms of schizophrenia	Risperdal
Mesoridazine	Mesoridazine is a neuroleptic drug used in the treatment of schizophrenia.	Serentil
Promazine	An older medication used to treat schizophrenia.	Sparine
Trifluoperazine	Trifluoperazine is used to treat the symptoms of schizophrenia	Stelazine
Chlorprothixene	Chlorprothixene's principal indications are the treatment of psychotic disorders (e.g. schizophrenia) and of acute mania occurring as part of bipolar disorders.	Cloxan, Taractan, Truxal
Chlorpromazine	Chlorpromazine is used to treat the symptoms of schizophrenia	Thorazine
Acetophenazine	Acetophenazine is an antipsychotic drug of moderate-potency. It is used in the treatment of disorganized and psychotic thinking. It is also used to help treat hallucinations or delusions.	Tindal
Perphenazine	Perphenazine is used to treat the symptoms of schizophrenia	Trilafon
Lorazepam	Lorazepam is in a group of drugs called benzodiazepines and is used to treat anxiety disorders. Includes	Ativan
Oxazepam	Oxazepam is used to relieve anxiety, including anxiety caused by alcohol withdrawal	Serax
Prazepam	Prazepam is indicated for the short term treatment of anxiety.	Centrax
Diazepam	Diazepam is used to relieve anxiety, muscle spasms, and seizures and to control agitation caused by alcohol withdrawal.	Valium, Valrelease
Clonazepam	Clonazepam is used alone or in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks).	Klonopin or Klonapin
Hydroxyzine	Hydroxyzine is used to relieve the itching caused by allergies and to control the nausea and vomiting caused by various conditions, including motion sickness.	Vistaril, Atarax
Halazepam	Halazepam is indicated for the treatment of anxiety.	Alapryl, Pacinone
Chlordiazepoxide	Chlordiazepoxide is used to relieve anxiety and to control agitation caused by alcohol withdrawal.	Angirex, Elenium, Klopoxid, Librax, Libritabs, Librium, Mesural, Multum, Novapam, Risolid, Silibrin, Sonimen and Tropium.
Aripiprazole	Aripiprazole is used to treat the symptoms of schizophrenia	Abilify
Alprazolam	Alprazolam is used to treat anxiety disorders and panic disorder	Niravam, Xanax
Amoxapine	Amoxapine is used to treat depression.	Asendin
Nortriptyline	Nortriptyline is used to treat depression	Aventyl, Pamelor
Wellbutrin	Wellbutrin is used to treat depression. Bupropion is also used to treat seasonal affective disorder	Buproprion
Trazodone	Trazodone is used to treat depression	Desyrel, Oleptro
Venlafaxine	Venlafaxine is used to treat depression.	Effexor
Amtriptyline	Amitriptyline is used to treat symptoms of depression	Elavil, Endep, Vanatrip
Lithium	Lithium is used to treat and prevent episodes of mania (frenzied, abnormally excited mood) in people with bipolar disorder (manic-depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods).	Eskolith, Lithobid
Maprotiline	Maprotiline is used to treat depression, bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods), and anxiety.	Ludiomil
Isocarboxazid	Isocarboxazid is used to treat depression in people who have not been helped by other antidepressants	Marplan
Phenelzine	Phenelzine is used to treat depression in people who have not been helped by other medications	Nardil
Serzone	Nefazodone is used to treat depression.	Nefazodone
Desipramine	Desipramine is used to treat depression.	Norpramin, Pertofrane)
Tranylcypromine	Tranylcypromine is used to treat depression in people who have not been helped by other medications.	Parnate
Paroxetine	Paroxetine tablets are used to treat depression, panic disorder and social anxiety disorder	Paxil, Pexeva
Fluoxetine	Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks	Prozac, Sarafem, Fontex
Sertraline	Sertraline is used to treat depression, obsessive-compulsive disorder, panic attacks, posttraumatic stress disorder, and social anxiety disorder	Zoloft
Doxepin	Doxepin is used to treat depression and anxiety.	Sinequan, Adapin, Silenor
Imipramine	Imipramine tablets and capsules are used to treat depression	Tofranil
Protriptyline	Protriptyline is used to treat depression.	Vivactil
Flurazepam	Flurazepam is used to treat insomnia	Dalmane
Quazepam	Quazepam is used to treat insomnia	Doral, Dormalin
Estazolam	Estazolam is used for the short-term treatment of insomnia	ProSom
Temazepam	Temazepam is used on a short-term basis to treat insomnia	Restoril
Triazolam	Triazolam is used on a short-term basis to treat insomnia	Halcion
Zolpidem	Zolpidem is used to treat insomnia	Ambien, Edular, Intermezzo, Zolpimist

 

 

 

 

 

 

 

 

 

 

Are you an advocate for someone living in a nursing home?

Are you an advocate for someone living in a nursing home? Are you a medical power of attorney for someone living in a nursing home? If so, please read this. You cannot advocate well for someone until you are well informed about standards of care. Of course this is true whether the nursing home is licensed or unlicensed, as is the case with many Sisters who receive skilled nursing care at "home."

Did you know that across our country almost one of every four nursing home residents is on an antipsychotic medication? In the majority of cases, these drugs are prescribed for elder residents who are living with dementia. These antipsychotic drugs given to persons living with dementia are being prescribed "off label." This means that the drug, approved for a particular use (psychosis, depression, etc) is being used for another purpose: to eliminate "problem behaviors."

All too often in retirement settings, persons living with dementia are seen as "having behavior problems, difficult, non-compliant, hostile, aggressive" and on and on all because staff is not trained to understand that all behavior is meaningful, and that the "problem" is not with the resident, but with the staff not yet able to understand the message or need the resident is attempting to convey. Such understanding takes time and a genuine knowledge of the resident. Thus the call for consistent assignment of those providing care.

The quick answer to "problems" in too many nursing homes is use of antipsychotic medications which, among other things, can so sedate a resident that the "problem" seems to be taken care of. Of course there are so many negative outcomes from such abusive use of powerful drugs. There are negative outcomes to every system in the body in addition to the side effects of these powerful drugs. I encourage you to Google the name of any drug below, for example, and learn its side effects.

Several years ago the Federal Drug Administration (FDA) issued a Black Box Warning in the case of several antipsychotic drugs when they are used off label for older adults with dementia. Those drugs include the following: Tinclude Compazine (prochlorperazine), Haldol (haloperidol), Loxitane (loxapine), Mellaril (thioridazine), Moban (molindrone), Navane (thithixene), Orap (pimozide), Prolixin (fluphenazine), Stelazine (trifluoperazine), Thorazine (chlorpromazine), and Trilafon (perphenazine).

Newer drugs that continue to carry the black-box warning include Abilify, Clozaril, FazaClo, Geodon, Invega, Risperdal, Seroquel, Zyprexa, and Symbyax. Source of information (accessed Oct. 9, 2012): http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/AntipsychoticMedicationQM.pdf
The Center for Medicare and Medicaid Services (CMS) reports that information covering March through December of 2011 reveal that the national average among nursing home residents who received at least one antipsychotic was 23.9%. CMS has begun an initiative to reduce this usage rate by December 31, 2012.

To emphasize the importance of correcting the abuse of overprescribing antipsychotics for nursing residents living with dementia, CMS has added this topic as one of its Quality Measures (QM). These Quality Measures are found on the CMS Nursing Home Compare website for consumers to do precisely that --- compare nursing homes based on certain quality measures. This measure will be show for nursing home inspection reports made beginning in July, 2012.
(Go to http://www.medicare.gov/NursingHomeCompare/)
As an advocate, ask questions if a doctor or nurse suggests that an antipsychotic drug is advised. What questions should you ask:

1. For what medical issue is this drug being prescribed?
   If the 'medical issue' is really what they call a 'behavior' such as agitation, restlessness, anxiety, etc. be very, very wary. This is the very abuse CMS is addressing in their new initiative to reduce the use of antipsychotics.

2.    Are there alternative ways to treat this medical issue?
3.    What are the benefits of this medicine?
4.    What are the risks of taking this medicine? (What are the side effects?)
5.    How long will the treatment last? (How long will the person be on this medicine?)
Only when you have all this information are you qualified to weight all the facts and then to give informed consent for the treatment to proceed, or informed refusal for that treatment too proceed. The resident, and you, on behalf of that resident if s/he cannot speak for him/herself, has the right to choose or to refuse treatment.

 

 

 

 

More than just cosmetic: the link between lack of dentures and dementia

When I first started working in the field of long-term care, I was hired as an ombudsman in Charleston, WV, not because of any special expertise in the field of long-term care, but because of my mother. I experienced such frustrations and helplessness in the institutional, task-oriented environment of the first nursing home she was in. Luckily, I found a much better nursing home, a not-for-profit home sponsored by the Episcopal Church. My brother and sisters were happy with the change too. My mother lived there for a year before her death, three years before I became an ombudsman. I hadn't needed to bring issues to the attention of the administrator of the director of nurses at Bishop Davies, but I did wonder where one went when there were problems, and solutions were not to be found within the nursing home itself. As a previous community organizer, I thought there must be something that could be done with and for families when they were companioning one of their own in a nursing home. And so I landed in Charleston, West Virginia!

My first task was to become familiar with the federal and state regulations so that I could advocate for nursing home residents, or for their family members should they ask me to look into a particular concern. One of the regulations that always remained sort of in the forefront of them all was the responsibility of the nursing home to replace – at their expense -- a resident's dentures should they become lost. I learned that staff should be trained to shake out dinner napkins before throwing them into the laundry receptacle, as well as to check a resident's dinner tray before discarding everything, unexamined, as trash.

Not having one's dentures does change one's appearance, and it is a matter of the acknowledgement of the resident's dignity – also covered in the regs – to see that the resident is wearing his or her dentures (unless he or she chooses not to). I've always wondered how someone really eats well without dentures. This morning my wondering was grounded in a report that shows a strong link between a lack of dentures (or lack of chewing) and a higher risk for dementia. Several studies demonstrate "an association between not having teeth and loss of cognitive function and a higher risk of dementia."

The report of this research goes onto say that one reason for this correlation between lack of chewing and risk for dementia may be that when chewing is difficult because of lack of teeth or dentures, there is less blood flow to the brain.

Source for this information: Medical News Today. http://www.medicalnewstoday.com/releases/251176.php