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

Empowerment

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

COPE

C Continuity of care / Communication

O Observations

P Prevention

E Early intervention

A Caregiver’s Crucial Role

• Recognize subtle changes

• Communicate with doctors and nurses

• Advocate for early diagnosis and treatment

• Work with medical team to prevent recurrences

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/advocacy/geriatrics/02016_aar_geriatrics_text.pdf

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.)

Critical Issues

Fragile balance

6 Common medical complications

• Easily diagnosed

• Potentially fatal

• Capable of treatment

• Preventable

6 most common medical complications

• Delirium

• Medication errors

• Adverse medication reactions

• Dehydration

• Protein-energy malnutrition

• Falls

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 15;57(6):1358-66. www.aafp.org/afp/980315ap/espino.html

Medication Errors

• Untreated Symptoms/Illness

• Improper Drug Selection

• Sub-Therapeutic Dosage

• Failure to Receive Drugs

• Over-dosage

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

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 (< 22

kg/m2) The Silent Epidemic, American Society of Consultant Pharmacists

http://www.ascp.com/medhelp/silentepic.shtml

Adverse Drug Reactions

• Urinary or bowel incontinence

• Sedation or dizziness

• Falls

• Difficulty in swallowing or talking

• Bleeding

• Tremor or rigidity

Falls

• Potentially fatal

• Preventable

• Causes– Intrinsic factors– Extrinsic factors

Dehydration

• Most common fluid and electrolyte imbalance

• Aging diminishes sense of thirst

• Kidney function impaired by aging process

• Early intervention criticalWick JY. Prevention and management of dehydration. Consult Pharm. 1999 Aug;14(8). http://www.ascp.com/public/pubs/tcp/1999/aug/prevention.shtml

Untreated dehydration

Leads to

• Electrolyte imbalance

• Shock

• Convulsions

• Coma

• Death

DehydrationSerious 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

Aug;14(8). http://www.ascp.com/public/pubs/tcp/1999/aug/prevention.shtml

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 July;6(7):250.

Protein-energy malnutrition

• Risk factors

• Detecting malnutrition

• Early intervention

• When tube-feeding is appropriate

• Prevention strategies

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

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 statusDepartment 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

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

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

End-of-life Decision-making

• Medical, legal, ethical concerns

• Quality of life

• Dignity

• Pain control

• Spiritual needs

TAKING CHARGEGood Medical Care for the Elderly and How to Get It

www.goodmedicalcare.com

Joseph H. Friedman, MDJeanne M. Hannah