Download TAKING CHARGE - Good Medical Care

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
O
P
E
Continuity of care / Communication
Observations
Prevention
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.p
df
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):135866. 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 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
Untreated dehydration
•
•
•
•
•
Leads to
Electrolyte imbalance
Shock
Convulsions
Coma
Death
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
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 longterm 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 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
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 drugdisease interaction
Prevention is key
• The effects of dehydration and proteinenergy 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 CHARGE
Good Medical Care for the
Elderly and How to Get It
www.goodmedicalcare.com
Joseph H. Friedman, MD
Jeanne M. Hannah