TAKING CHARGE

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TAKING CHARGE

• Good Medical Care for the Elderly and How to Get
  It
• Jeanne M. Hannah, Family Caregiver
• Joseph H. Friedman, MD
• www.goodmedicalcare.com

2
Empowerment

• The elderly and their family caregivers are an
  essential part of the care-giving team, despite
  lack of medical training.

3
COPE

• C Continuity of care / Communication
• O Observations
• P Prevention
• E Early intervention

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A Caregivers Crucial Role

• Recognize subtle changes
• Communicate with doctors and nurses
• Advocate for early diagnosis and treatment
• Work with medical team to prevent recurrences

5
Medical crisis

• Only 9,000 of the 650,000 licensed physicians
• fewer than 2 are certified in geriatrics.
• Low reimbursement from Medicare / Medicaid
• Few medical schools with full department of
  geriatrics
• Few medical schools require any course in
  geriatrics
• Few med students take an elective course in
  geriatrics
• Alliance for Aging Research, Medical
  Never-Never Land 10 reasons why America is not
  ready for the coming age boom, 2002. Accessed
  June 10, 2003 http//www.agingresearch.org/advocac
  y/geriatrics/02016_aar_geriatrics_text.pdf

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Medical crisis

• Lack of training in geriatrics
• Only 720 of the nearly 200,000 pharmacists
• Fewer than 1 of registered nurses
• Less than 3 of advance care nurses
• Cuts across the board (speech therapists,
  physical therapists, nurses aides, etc.)

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Critical Issues
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Fragile balance
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6 Common medical complications

• Easily diagnosed
• Potentially fatal
• Capable of treatment
• Preventable

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6 most common medical complications

• Delirium
• Medication errors
• Adverse medication reactions
• Dehydration
• Protein-energy malnutrition
• Falls

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Delirium

• Misdiagnosed/undiagnosed 80 to 95 of the time
• 15 to 26 of patients who become delirious die
  within one year
• Hallmark is sudden onset
• Delirium is a fire alarm
• Espino DV, Jules-Bradley AC, Johnston CL,
  Mouton CP. Diagnostic approach to the confused
  elderly patient. Am Fam Physician. 1998 Mar
  1557(6)1358-66. www.aafp.org/afp/980315ap/espino
  .html

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Medication Errors

• Untreated Symptoms/Illness
• Improper Drug Selection
• Sub-Therapeutic Dosage
• Failure to Receive Drugs
• Over-dosage

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Medication Errors (cont.)

• Adverse Drug Reactions
• Drug Use without Indication
• Drug Interactions
• The Silent Epidemic, American Society of
  Consultant Pharmacists http//www.ascp.com/medhelp
  /silentepic.shtml

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Who is most at risk?

• Elderly (more than 85 years of age)
• Decreased kidney function
• More than six chronic medical diagnoses
• More than 12 doses of several meds per day
• Nine or more different meds per day
• Has had a prior adverse drug reaction
• Low body weight or body mass index (lt 22 kg/m2)
• The Silent Epidemic, American Society of
  Consultant Pharmacists http//www.ascp.com/medhelp
  /silentepic.shtml

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Adverse Drug Reactions

• Urinary or bowel incontinence
• Sedation or dizziness
• Falls
• Difficulty in swallowing or talking
• Bleeding
• Tremor or rigidity

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Falls

• Potentially fatal
• Preventable
• Causes
• Intrinsic factors
• Extrinsic factors

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Dehydration

• Most common fluid and electrolyte imbalance
• Aging diminishes sense of thirst
• Kidney function impaired by aging process
• Early intervention critical
• Wick JY. Prevention and management of
  dehydration. Consult Pharm. 1999 Aug14(8).
  http//www.ascp.com/public/pubs/tcp/1999/aug/preve
  ntion.shtml

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Untreated dehydration

• Leads to
• Electrolyte imbalance
• Shock
• Convulsions
• Coma
• Death

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Dehydration

• Serious consequences
• 50 of those hospitalized with dehydration as the
  primary diagnosis will die within one year.
• Of those, more than 18 will die within a month
  of admission.
• Thus, prevention is critical.
• Wick JY. Prevention and management of
  dehydration. Consult Pharm. 1999 Aug14(8).
  http//www.ascp.com/public/pubs/tcp/1999/aug/preve
  ntion.shtml

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Protein-energy malnutrition

• Affects the elderly no matter where they live
• 40 of nursing home residents
• 44 of home-dwelling elderly
• 50 of hospitalized elderly patients
• Kamel HK, Thomas DR, Morley JE. Nutritional
  deficiencies in long-term care Part II
  Management of protein energy malnutrition and
  dehydration. Annals of Long-Term Care Online.
  1998 July6(7)250.

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Protein-energy malnutrition

• Risk factors
• Detecting malnutrition
• Early intervention
• When tube-feeding is appropriate
• Prevention strategies

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Knowledge is power

• How to detect potential serious complications
• How to recognize the at-risk patient
• How to communicate changes to the doctor or nurse
  
• How to advocate for effective and accurate
  diagnosis and treatment
• How to help devise prevention strategy

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The family caregiver

• 80 of care-giving is done by unpaid family
  caregivers
• Family caregiver is in the best position to
  detect subtle changes in status
• Department of Health and Human Services, Office
  of the Assistant Secretary for Planning and
  Evaluation, Administration on Aging. Informal
  Caregiving Compassion in Action (June 1998).
  http//aspe.hhs.gov/daltcp/reports/carebro2.pdf

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Family caregivers as advocates

• Help minimize the risk of
• Getting the wrong diagnosis
• Failure to get proper and necessary medication
  prescribed
• Harm as a result of misuse of prescription drugs
  and/or over-the-counter drugs
• Potential for drug-drug, drug-food, or
  drug-disease interaction

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Prevention is key

• The effects of dehydration and protein-energy
  malnutrition are so difficult to reverse, that
  prevention is very important
• Some adverse drug reactions and medication errors
  can be fatal, making prevention critical

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End-of-life Decision-making

• Medical, legal, ethical concerns
• Quality of life
• Dignity
• Pain control
• Spiritual needs

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TAKING CHARGEGood Medical Care for the Elderly
and How to Get Itwww.goodmedicalcare.com
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Joseph H. Friedman, MDJeanne M. Hannah