On Tuesday I discussed a recent upbeat article in the New Old Age blog about a nursing home’s improved approach to the all too widespread problem of medicating the elderly. I also raised questions about why it has taken this long for nursing homes to start addressing this issue when overmedicating the elderly has theoretically been illegal since the Omnibus Budget Reconciliation Act of 1987.
Today I’d like to talk about a report in the American Journal of Geriatric Pharmacotherapy that undermines my hope that things are getting better. (I’ve never seen this journal before, but it has a good editorial board and has recently formed a relationship with the American Geriatrics Society. That is probably why I’m seeing it now.)
Mark Beers, MD, creator of the Beers criteria
Sometimes I worry that we are not making progress in our goal of improving the health of older Americans. Sometimes, the process of incremental change with its two steps forward, one step back seems more like going nowhere.
As I wrote in a recent post, the Foundation has been working on problems in medication prescribing and use among older people for 30 years. Occasionally we have rejoiced at what might have seemed impressive changes, such as the passage of the Omnibus Budget Reconciliation Act of 1987 (known affectionately as OBRA ’87), which addressed medication problems in nursing homes. It specifically targeted dangerous uses of medications aimed at controlling “behavioral problems” of long-term care residents through drugs. But recently I saw two things that made me question even this progress. I’ll talk about the first one today.
First, in the New York Times‘s “New Old Age” column there was a fine piece describing a nursing home that had radically reduced its use of anti-psychotic and anti-anxiety medications by using behavioral interventions (like redirection and distraction). Staff found that when they reduced or eliminated medication “the mental fog” cleared among residents. After they instituted proper pain control, residents’ quality of life seemed to improve.
At the Foundation, we often feel that information we have about improving the care of older adults is simply not getting the attention it deserves. People see a neighbor hospitalized repeatedly for the same chronic condition (say heart failure, the number one cause of hospital admission for Medicare beneficiaries), and they say, “Well, what do you expect, he’s old and sick.”
The notion that health care for older people could be enormously better than it currently is–compassionate, coordinated, expert, illness-preventing, and less expensive–flies in the face of what people think they know about “America having the best health care in the world.” And since much of the improvement in health care for older people would come from high-touch rather than high-tech interventions, and in many cases, doing less of what does not help, it flies in the face of the US consumer culture idea that “more is better.” Indeed, these days if a sick older person doesn’t end up in a hospital, there would probably be some public suspicion that that they were getting substandard care. Only if you have been to the hospital recently you would know that this isn’t a place you want to be unless you absolutely have to.
So this is why I was astonished to see in my own local free “shopper” newspaper, the Park Slope Courier, on March 6, 2009, a special “Focus on Health” feature about geriatric medicine. It even had a “blurb” on the front page–a little advertisement to look for the story farther on in the newspaper. The story, “The More to Take, the Greater Risk You Make,” was a very nice review of the problem of overmedication among older adults, if a so-so take off on the Beatles song lyric (I’m pretty sure that the paper is part of Rupert Murdoch’s chain, but clearly the real headline writers are all working at the New York Post.) In addition, two other stories, entitled “Missed Independence” and “Signs of Adverse Drug Reactions,” offered ideas on how to help older people stay at home and live independently for as long as possible and a very specific discussion of drugs and symptoms of adverse reactions.
It’s a doggone shame to single out man’s best friend when we need to address medication management. A recent posting on the WSJ HealthBlog titled “CDC to Americans: Don’t Trip Over Your Dog” noted that 1 percent of emergency room visits for falls are pet-related. That’s “ruff”-ly 86,000 Americans injured with dogs as the major culprit.
While those 86,000 falls are important, even more important is the need to look at the major causes of the majority of falls affecting one of every three older Americans–about 12 million seniors–such as medications. Dr. Judy Stevens, PhD, an epidemiologist at CDC’s Injury Center, says that “medication reviews are an important method of reducing an older person’s risk of falling. Because of their higher rates of chronic health problems, older adults often take multiple medications whose potential side effects–such as drowsiness and dizziness–can lead to a fall, particularly when the drugs are combined.” With health care costs for falls totaling $20 billion per year, we need to resolve this major contributing factor.
I recently visited with June Simmons, MSW, at the Partners in Care Foundation (PICF), a leader in the use of health information technology that helps identify medication issues and prevent problems such as falls. Her efforts, both in California and nationally, confirm that 60 percent of older adults are on medications that may cause them harm. Partners in Care Foundation is using Hartford Foundation support to demonstrate a technology-assisted medication management program for frail older adults who, despite being eligible for placement in a nursing home, live in their own homes. Targeting high-risk problems such as drug duplication or incompatibilities, the project has home health care personnel enter a client’s medications into a computer, along with recent physical symptoms (such as low blood pressure, reports of dizziness, confusion, or falls), to determine if a pharmacist or doctor should review the patient’s prescriptions. The intervention takes advantage of a key opportunity–social workers and nurses already collect most of the medication data needed to identify potential errors but previously did not have any means to analyze the clinical information.
It doesn’t take very much for things to go very wrong in the health of an older person. While we all must be grateful for the better health and longer lifespan than ever before for older Americans, these are often precarious states and dependent upon health care providers who may lack the skills needed to preserve that health and independence. An example from my own life makes this fact and the limitations of the current health care workforce and system very clear to me.
Last Fall, right before Thanksgiving, while at the Gerontological Society of America meeting in San Francisco, I crossed the Bay to visit my parents in the Oakland hills. After dinner, I noticed that my 73-year-old father’s ankles were quite swollen. He said that they didn’t hurt and that he hadn’t really noticed, but he thought that they might have been swollen for a while.
(My dad is a fairly typical “well” older adult, maintaining an active and independent life–albeit quite overweight, with hypertension managed by three medicines, and increasingly severe arthritis and pain in his hips and knees. While perhaps generally healthier, my mother’s macular degeneration made it difficult for her to notice such things as dad’s swollen ankles.)