Archive for category Nursing Homes

Over prescribing — high risk for the elderly

hugsnotdrugs

Elderly patients are taking too many drugs.  And, in most cases the drugs can be stopped.  This surprising idea was highlighted by Dr. Ezekiel J. Emanuel in his New York Times article 11/22/15.  He backed up his statements with a study from 2010 (JAMA).  The figures that follow are from that study.

The first figure is the logic diagram for stopping medications in elderly patients who have several chronic diseases.  The second figure is the list of medications that were stopped in the study.  Only 2% of the stopped medications eventually had to be restarted.  The cost savings alone is huge and the reduction in the risk of side effects is likewise tremendous.  “Less is more”.

Health care providers often prescribe drugs intended for younger healthier patients to older sicker patients.  Often the drug testing originally done to approve drugs excludes older sicker patients due to the risks of side effects.  A drug might add many years of life to a 50 year old but that’s not likely for an 80 year old with multiple problems.   In fact, over medicating elderly patients may hasten death — this has been proven in many studies.

Dr Ezekiel suggests asking the following questions to the health care providers who prescribe medications, tests or treatments to elderly patients (or perhaps any patients):

  1. What difference will it make?
  2. How much improvement is expected?
  3. How likely and severe are the side effects?

Evaluate the answers carefully, if the answers are: small difference, not much improvement, and fairly likely side effects then perhaps that drug, test or treatment is not needed.

Dr. Emanuel favors the advice of teaching hospital doctors like him, but it’s just not practical or necessary for patients to get a university consultation.  Stopping medications is not rocket science.  As the graphic says, it may be better for many elderly patients to get “hugs not drugs“.

 

Figure 1

drugstop

 

 

Figure 2

medsstopped

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Bleeding to Death at Nursing Homes — warfarin

NHadlsA story in Pro-Publica (7/12/15) and reproduced in the Washington Post highlights the problems with anticoagulants when given in nursing homes.  The graphic at the left shows the magnitude of the problem — lots of patients in nursing homes get these drugs.  The next graphic shows data from North Carolina pinpointing the main culprit: WARFARIN.

NHerrorsInNCWhat is going on?  Well, warfarin is a tricky drug because it changes the body’s system to make the blood clot.  Some people tend to clot too much (and get clots in the brain, a stroke, and some people get clots in the lungs, a pulmonary embolus).  Those people are at risk of death from too much blood clotting.  So, health care providers prescribe an anticoagulant to make the blood clot less easily.  Unfortunately, this creates a state where people bleed easily.  It is indeed a situation “between a rock and a hard place“.

Warfarin is one of the most common of the drugs for this purpose.  It has the advantage of an existing antidote and it is inexpensive.  But, it requires frequent blood testing to keep the anticoagulant effects in a reasonably safe range.  Providers must order the tests and must change the dose according to the results.

Thrombin inhibitors are a new class of anticoagulants which have the same bleeding risks and are expensive.  Their claim to fame is that blood testing is not needed.  They also have the disturbing quality of not having an antidote if bleeding starts.  Taking all this into consideration, most providers choose the older drug warfarin.

The reasons for excessive bleeding in nursing homes are:

  1. Prescribers (not the nursing home staff) fail to order blood testing when they should and fail to adjust the medication as they should.
  2. Prescribers fail to stop anticoagulants when the risk of falling exceeds the risk of blood clotting.
  3. Pharmacists for nursing home patients are not as connected to their patients as they should be — usually the pharmacist is the safety net for bad prescribing — sadly, they are out of the loop.
  4. RNs in nursing homes have the training to catch medication errors but function as administrators and are not on the front line of care.  Thus, like pharmacists they are not performing the safety net function they might in hospitals or doctor’s offices.
  5. Elderly patients are the most prone to adverse drug events — for them, if a side effect is possible they will likely experience it.   It there is a risk of bleeding they probably will.

What should be done:

  1. State certification organizations should develop guidelines that require nursing homes and their prescribers to have a protocol for anticoagulation management — not every prescriber can be allowed to invent their own method — that’s the mess we have already!
  2. Nursing homes should use electronic means to track anticoagulants and the adherence to prescribing protocols.  This is not rocket science, those protocols (evidence based guidelines) and computer programs already exist!  So, USE THEM.
  3. Proactive patients and families should ask about the protocol that will be followed for warfarin in the nursing home — if there is no protocol SPEAK UP — show them a copy of this blog.

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Choosing a Nursing Home — hard on many levels

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If you are choosing a nursing home it means a parent or close relative is not doing well.  It is a time of anxiety and concern.  You think about the fact the average stay in a nursing home is 2 years — bluntly meaning 50% of people who go into a nursing home (ICF) are dead within 2 years.   But, a big question is “which is the right one”?

In years past there were just “nursing homes”.  But, just like a growing tree there are now many branches.   So what are the branches of care in 2014?

  • Family care in the home
  • Family care supplemented with visiting aids and nurses
  • Full time home care (very expensive)
  • Independent living with services (senior apartments)
  • Assisted living — apartment  but with lots of services and meals
  • Residential care facility (RCF) (like assisted living but care includes medical oversight, like with a few nurses)
  • Intermediate care facility (ICF) for people who can not care for themselves.  People who are demented or severely disabled who need 24 hour per day supervision and medical oversight.  There are some reasons for short term stays like severe injuries that take a long time to heal.  But, generally, patients stay there until they die.  The next level is skilled nursing which leads to the concern that ICF is “unskilled” nursing which is not correct.
  • Skilled nursing facility (SNF).  High level of care, nearly like a hospital.  A strong component of therapy with the expectation of improvement and a switch to a lower level of care within a few weeks or few months.  If a patient is a hospital inpatient for at least 3 days they may qualify for 100 days of Medicare payment.
  • In recent years many ICF facilities have chosen to upgraded services to qualify as SNF facilities (at least for some beds) — they still provide long term care but have the option of billing Medicare for those patients who come out of the hospital.  It’s now hard to tell the difference between ICF and SNF in many locations.
  • Rehabilitation Facilities.  Not for long term care and usually paid for by insurance or Medicare.  Qualified patients might need rehab (intensive physical  and occupational therapy) following  joint surgery or following a stroke.  Some long term care facilities are connected to rehab facilities and only offer the long term care if the patient fails to go home after rehab.

Hospice is not a level of care or even home care.  It is medical supervision oriented solely toward comfort and death with dignity.  It is  mainly staffed by nurses plus a supervising physician.  The services are for dying patients.  The average time a person spends under hospice supervision is 2 weeks.  A doctor must certify a life expectancy of less than 6 months to qualify.  Hospice can supervise care in many locations (but not SNF).  Service at home and in the ICF are very common.

In many respects ICF is the last step and often the hardest.  Patients have usually been through several other levels of care and are failing.  Cost is always an issue.  ICF is expensive ($200 -$300 per day) and it is not uncommon to exhaust personal funds and end up requiring State financial assistance (Medicaid).  Because of the expense, patients and families usually see ICF as a last resort.  It is such a difficult step  patients are sometimes hospitalized before the decision to go to ICF is finally made (not good).

OK you need to select an ICF facility.  There are often several choices.  How do you pick one?  What are the main deciding factors:

  • Medicare rating — the higher the better (top is 5 stars)
  • Cost and whether the care center will keep the patient if they do not have money or will run out of money
  • Recommendations from families with relatives in the facility
  • The general appearance of the facility and the smell (smell of urine is a bad sign).
  • The care the facility delivers is vastly more important than the age of the facility or the size of the rooms.   One very highly rated care facility is 40 years old and has rooms holding 3 people each!

The facility needs to answer questions before choosing that facility.  Some questions are intended to set expectations.  Some questions are intended to find issues that might make the facility unacceptable.

  • What is the Medicare quality rating? (avoid less than 3 stars)
  • What is the price per day and what are the options?
  • What expenses are not covered by the room rate?
  • How is pharmacy involved with medications?
  • Can mail-order medications be used in the facility?
  • What are the findings from State inspections for the past 3 years?
  • What is the process to be admitted?  What is required?
  • What is the ratio of care givers (RN, LPN and CNA) per patient — during the day, at night and on weekends.  1 RN + 1LPN + 1 CNA per every 10 patients is good.
  • What is the waiting time for a bed?
  • Is there a house doctor, nurse practitioner or physician assistant that rounds regularly?  (under contract with the facility to make rounds — very nice service)
  • Can an outside primary care doctor also write orders?
  • How does the facility deal with a “do not resuscitate” order?
  • How often can a family call and obtain up to date information?
  • If a doctor or assistant rounds will the care center nurse inform the family of the recommendations?
  • What is the general daily schedule?
  • Is exercise & mental stimulation included every day?
  • What is the menu and how is it rotated
  • Are the rooms treated as just bedrooms or as the place where patients spend the day (the former is better)
  • What is the expectation for frequency of nursing checks at night (in order to prevent falls a check every 15 to 30 minutes is good)
  • How does the facility prevent loss of glasses or hearing aids?
  • Can special meals be served.  Is there a way to limit salt in the diet?
  • What is the average length of employment for staff (5 years is good)
  • Are SNF beds available in case of a short-term problem (like recovery from hospitalization)
  • What is the ratio of private pay to Medicaid pay patients.  (a ratio of 3 to 1 is OK but a care facility with all Medicaid operates with less money and less staff.
  • Does the staff have special training for dementia care?
  • What is the expense for oxygen therapy?
  • Can family bring food for the patient?
  • What are the statistics for falls in the facility for the past few years?  (falls are often a reflection of infrequent patient checks — checks that lead to helping the patient go to the bathroom)
  • Is there a psychiatrist that can assist the other doctors with adjustment of medications for agitation and depression?
  • What sort of alarm systems are present should a patient walk out a door?  (important for demented patients).

It is interesting to note that older care facilities often have better quality ratings than new facilities.   Older facilities can’t suddenly be new so they may opt to  meet strict quality measures.  It differentiates the facilities that otherwise might be squeezed out of the market.  But, any facility that has failed to make renovations over time suggests poor management or excessive profit taking.

Many people have selected nursing homes for loved ones.  Your comments would be appreciated.   Any other questions you think are important?

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