From Hospital to Home:  Post Hospital Syndrome

From Hospital to Home: Post Hospital Syndrome

Recently I addressed the Post-Acute Care Continuum in White Plains, New York. An organization whose goal is to educate and share best practices in post-acute care and care transitions. I was asked to speak about how geriatric care managers can help to ensure that patients return home and remain home beyond the initial 30-day period. Of course, we do not want our clients to return to the hospital at any time, but there is a reason for the specific 30 days.  In 2013, the United States Department of Health started to penalize hospitals for re-admission of patients within thirty days. The Department of Health wanted patients to be discharged responsibly with adequate follow-up care, hence this law was enacted.

Because of this act, the rate of 30-day re-admission has dropped from 20% to 17%. But often, while the reason for hospitalization has been addressed, the consequences of a hospitalization are just being felt when our clients return home. Dr. Harlan Krumholtz, MD of Yale-New Haven Hospital refers to this return as the Post Hospital Syndrome. He attributes this re-admission within 30 days to five major factors:

  1. Sleep deprivation: The patient is in a new environment. The illness combined with being in a different bed, in a different place will impact on cognitive and physical performance. A situation of perpetual jet lag has been created.
  2. Malnourishment: Certain tests and procedures require nothing by mouth for the day or evening prior. And if the test is cancelled and then rescheduled, another period goes by without nutrition. This results in protein-energy malnutrition. The consequences of such a scenario is that wound healing is impaired, there is a chance of increased infection and one’s immune system is compromised.
  3. Pain and discomfort: For any of us, especially those dealing with pain in the hospital environment, pain can lead to sleep disruption, mood disturbance, impaired cognitive functioning and may also impact on the immune system.
  4. Altering medications: Stopping one medication and adding another can have its impact on cognition and physical functioning: too much of a medication, too little, the wrong medication, an allergic reaction to a medication. A patient’s body becomes a roller coaster of experimentation in an effort to cure.
  5. Deconditioning: Time in bed for rest can put a patient at greater risk of accidents and falls. While physical therapy may take place in the hospital, Dr. Krumholtz questions if there is still too much inactivity. The result being once the patient returns home he or she is at greater risk for developing blood clots.

As discharge approaches, what must be done is a TOTAL evaluation of the patient. This evaluation should go beyond the reason for hospitalization. Attention must be given to sleep, nutrition, activity, strength and how all symptoms are treated and managed. As a geriatric care manager, it is my responsibility to observe, question and advocate for clients whose care has been entrusted to me.

Slow Medicine and Dr. Dennis McCullough

Slow Medicine and Dr. Dennis McCullough

It is not often I can write a blog in an hour. Usually it’s written, reviewed, accuracy checked and making sure I have made my client, who has provided me with a particular insight, indistinguishable from the message I am sharing.

This blog is different. There is nothing to cover up, on the contrary. In telling you of the recent and untimely death of Dr. Dennis McCullough, I am introducing you to the world of “Slow Medicine,” which he pioneered with the publication of his book, “My Mother, Your Mother” in 2008.  Regrettably, dying at the age of 72 he did not have the opportunity to put into practice what he encouraged. Or maybe it is not regrettable. He died a quick death, the result of a heart attack. Nothing prolonged and no heroic measures. He would have liked his death.

The essence of Slow Medicine is kind medicine. Less is more medicine. Often as spouses and adult children we feel compelled to do as much as we can to help a loved get better. Dr. McCullough has asked us to step back,  just minutely out of the box and ask ourselves this question:  by doing additional testing, surgical procedures, adding more medications are we really helping someone at the end of their life?  He faced this personally when his mother went from a nursing home to a hospice care center. Medications, other than those for pain were stopped.  It was here that her dignity took center light, with family and familiar caregivers close by. She was one of the sources for his book. The other being his own experience as a “vulnerable” patient for over a three year period.

I have touched ever so briefly on Slow Medicine. I think Dr. McCullough said it best in “My Mother, Your Mother.”  “Slow Medicine is not a plan for getting ready to die; it is a plan for understanding, for caring, and for living well in the time that is left.”

An untimely death, but an eternal message.

Brand Name vs. Generic Medication: The Silent Problem

As an Aging Life Care Advisor (our profession has had a name change, but not what we do), one of the major concerns voiced by adult children is whether a parent is taking  his/her medication correctly, or for that matter, whether they are taking their medications at all.

If taking medication as prescribed is not a sufficient problem, the issue of brand name vs. generic medication, may be a silent problem. What am I talking about? A brand name drug (both over the counter and prescription drugs) is a medication that is developed by a specific pharmaceutical company. Once approved, they receive a patent from the FDA that prevents other drug companies from duplicating that drug. When the patent expires, other drug companies may now enter the playing field. Think Lipitor whose generic name is atorvastatin.

According to the FDA, the generic drug must contain the same active ingredient  that makes the drug work. It must have the same dosage strength. It must be in the same dosage form, a pill for a pill. It must have the same route into the body, if by injection, it must continue to be manufactured that way.  It must deliver the same amount of medication and in the same amount of time.

So what is the silent problem?  We all know that generics are kinder to the wallet. But beyond this, because they are now produced by multiple companies, they have different shapes, sizes and colors. This in itself may be problematic to an older adult, who gets the same medication at renewal time, but each time it may look different depending on the supplier the pharmacy is using. But here is the crucial crux of the problem: what doesn’t have to remain the same? The dyes, the fillers and the binders. This is the silent problem. Yes, the drug is substantially the same, but in unmentioned ways, it is not. The result may be allergic reactions to the particular dye, having side effects to the medication never before had, and having the effectiveness of the drug diminished due to different binders and fillers.

As an Aging Life Care Advisor, when I make a visit to a client, I am always on the “look out.” But knowing what I can’t see, brings a new dimension to these visits.  It’s not enough that it be the same medication. Pink or blue is a pleasant mystery for expectant parents, but not for seniors who need medication consistency for their wellbeing.

Bring on The Liquid Candy Bars and a Scoop of Haagen Dazs

Recently, an article appeared in The New Old Age column of The New York Times entitled: “Geriatricians: Beware Liquid Candy.” The author, Paula Span, reported on the findings of the Choosing Wisely work group of The American Geriatrics Society. They had their annual meeting in Orlando, Florida in May.

At the conference, Dr. Paul Mulhausen raised concern about products such as Boost and Ensure. Yes, they contain proteins and vitamins, but too much sugar, oil and water. And yes, they have value for the very sick and malnourished. But that is where the buck stops for Dr. Mulhausen…..not for this geriatric care manager.

 Now I am sure Dr. Mulhausen is a fine physician, and geriatricians are known to spend more than the allotted fifteen minutes with their patients. Doctors hear about the home situation, but the full physical and mental stress of caregiving is experienced only by the family. In the case of nutrition, older adults appetites’ start to wane. They just don’t burn a lot of calories if their routine is now sedentary. Taste buds change and favorite foods no longer bring pleasure. Forgetting to eat, refusing nourishment, chocking and spitting out what has been patiently fed to the adult senior are some of the challenges caregivers face.

I have never sampled Ensure or Boost. But they must be magical because I have seen clients who refused every other food readily accept a chilled glass of one of these elixirs. And in doing so, I have seen the stress of a spouse or the worry of an adult child drop a notch. Now don’t get me wrong, a bowl of vegetable soup with an added protein is preferable. But preferable, like perfect, are sometimes hard orders to fill in the world of older adults. So, sorry Dr. Mulhausen, bring on the “Liquid Candy Bars,” aka Ensure and Boost, add a scoop of Haagen Dazs and let’s be naughty. If not now, when?

Medications: When a Little is Just Enough

A few months ago this geriatric care manager accompanied a client  to see his cardiologist.  ‘Don’t know why, maybe the next patient canceled, but Pete got more than his twenty minutes with the doc.  He took a good look at Pete’s medications.  And then, like a teacher grading a test paper, he started to make red slashes through some medications and circles around others.  One of the first slashes was through the very medication he prescribed years ago…Lipitor. At age 88 he felt this medication was no longer necessary for Pete. He circled other medications on the list and suggested I consult with Pete’s internist about either lessening the dosage or discontinuing them totally.

There is a name for this medication overload: “polypharmacy.” Too many drugs. Each time a drug is added, it has the potential to work against another drug and cause unwelcome interactions. Add to this trying to keep accurate records of what to take and when to take it and the process can become very confusing.

But getting back to Pete, we were cutting down. At our next visit to his internist she took over where the cardiologist left off.   Pete’s diet had changed considerably over the years, so the Nexium was no longer necessary. The memory medication, well that was not the miracle drug pharmaceutical companies would have liked us to believe. He was weaned off that. “Regularity,” well it hadn’t been a problem, but she did not want to create a problem. So Senna was a stay. That, along with his blood pressure medication and a diuretic are the ones that remain.

This geriatric care manager recognizes the potential that medications have to prevent, control and cure.  But I also learned a valuable lesson from Pete’s doctors. At certain intervals it is necessary to question and re-evaluate. In this case, a reduced medication list was just what the doctors ordered and nobody was the worst for it,  except for the cash register at Walgreens.

Just How Effective are Drugs to Treat Alzheimer’s Disease?

As a geriatric care manager, the topic of whether to try medications  to stop the progression of Alzheimer’s Disease often comes up for discussion. From an evidence based perspective, I have not been impressed with the effectiveness of Aricept, Namenda and other medications in this group.  A recent article appeared in the online newsletter, Consumer Report Best Buy Drugs that specifically addresses this question.  I share the article  with you.  Their bottom line is after three months, if there is no improvement, the medication should be stopped.

Alzheimer’s disease gradually destroys the brain, robbing people of their ability to remember, complete everyday tasks, and function on their own. Sadly, drugs to treat the disease, including Aricept and Namenda, don’t work well. And even when they do, it’s only in a few people. Since there are no other options, some will want to try these drugs anyway, but it’s a gamble most people won’t win. That’s why our new CR Best Buy Drugs report on Alzheimer’s medications doesn’t recommend any of them as Best Buy picks.

Our decision, in part, is based on a recent large-scale analysis by the federal Agency for Healthcare Research and Quality (AHRQ), which found these drugs don’t delay the onset of Alzheimer’s or improve or maintain the mental function of people who already have it. The American College of Physicians and the American Academy of Family Physicians, and another review of Alzheimer’s studies in 2007, reached similar conclusions.

Besides not being very effective, Alzheimer’s medications can have side effects too. While most caused by the drugs are relatively minor, such as nausea, vomiting, dizziness, loss of appetite, muscle cramps, tremors, and weight loss, they could be potentially debilitating to older people. In rare cases, the drugs can also cause a slowed heart beat, gastrointestinal bleeding and ulcers, and possibly convulsions or seizures.

In addition, the drugs are expensive. An average monthly prescription ranges from $177 to more than $400. Last year alone, Americans and their insurance companies spent nearly $3 billion on these medications, according to figures from IMS Health, a company that tracks pharmaceutical data.

Bottom line:
No currently available Alzheimer’s drug provides much, if any, improvement, and all can cause side effects. Still, if you feel compelled to try a drug to help someone you care for, you could consider donezepil (Aricept) or galantine (Razadyne). Neither works better than other Alzheimer’s drugs, but they might be somewhat better tolerated and are available as low-cost generics. Regardless of which drug you use, stop after three months if you don’t see any improvement.