The use of medical technology is as commonplace today as the doctor’s ubiquitous black bag was sixty years ago. Technological advances have been both blessing and bane, allowing those who benefit to live longer, as with their chronic diseases. Of course, for many patients, this means being sicker longer. In end of life care scenarios, one such advance is creating complications — the automatic internal cardioverter-defibrillator (AICD), a life changing device use to pace and assist heart failure patients whose disorder would have shortened lives just a few years ago. An interesting tidbit of medical news today notes that the willful disconnection of such a device rarely occurs in such end of life discussions with patients and families in the way that cessation of drugs and other aspects of medical care are. An advocacy group of cardiologists and other medical subspecialists is out to change that. It has released guidelines on the withdrawal of support in the hospice and palliative patient and the ethics surrounding such an action. | LINK

Although the prevalence rate of dementia is higher overall in women over 65; this is due to a variety of factors — overall elderly age demographic prevalence, hormonal declines (circulating estrogens), and the presence of certain vascular related disorders, just to name a few. But what about the incidence of dementia in a male spouse as an association for the incidence of dementia in females — both of whom had no signs of the disorder initially?

A trial published in the latest Journal of the American Geriatrics Society shows that over 1000 patients (married couples in a single Utah county) were followed for a period of at least 12 years^[1]. Initially without the diagnosis of Alzheimer dementia, those caregiving wives developed dementia along with their husbands in 30 cases. Although the study did not specifically examine wives as caregivers using explicit criteria, most lived in the same space as the male spouse at the time of diagnosis. An interesting result that should spur more study in the gerontological (social scientific) realm of dementia treatment and incidence in the community. | LINK

1. All married couples were dementia-free at baseline in 1995 and were followed-up for an average of 12.6 years (median follow-up, 3.3 years) to monitor for incident dementia in husbands, wives, or both, according toDiagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, diagnostic criteria. [↩]

Pennsylvania’s Corrections Department is getting creative in the healthcare delivery to its aging prison population. With funding courtesy a grant from the National Institute of Nursing Research, the state will be bringing together the appropriate caregiving provider contingent to study the cheapest and most effective ways to deliver end of life (EOL) care. This pro-active move will likely be a point of reference as state budgets come under increasing pressure to provide this level of service to this patient population in the unique ”perfect storm” of declining state budgets devoted to healthcare delivery; exponential growth of geriatric populations/units in correctional facilities; and competition for federal healthcare dollars as the result of the Obama reform package (whenever that occurs).

The project will develop an intervention toolkit for use by staff at any prison in the country. [..] Prison workers, including health care professionals, chaplains, prison society volunteers and corrections officers, will provide information on current limitations, strengths, existing perceptions of end-of-life care among prison stakeholders and areas of care that bear improvement. Using the data collected, researchers will create a set of educational strategies for use by prison staff that they can tailor to fit individual prison’s needs.

The devotion of grant money to fund this type of research is appealing and compelling on many fronts — not the least of which is a shared national discourse which is sure to follow on such unique EOL care initiatives. | LINK

The relationship between Medicare funding/reimbursement patterns and nursing home operational expenses has always been a factor in long term care delivery — often taking the brunt of state Medicaid systems’ lapses in payments to facilities for healthcare services. That relationship just became a little more tenuous. Faced with looming cuts courtesy of Medicare adjustments that call for at least a $15B drop in long term care funding over the next 10 years, skilled nursing facilities could see more urgent staff layoffs and outright closure. For example, some facilities in Connecticut were forced to shut doors when proposed state Medicaid payment increases promised by lawmakers there fell by the wayside — presumptively because of recession influenced budgetary issues.

Could long term care delivery to the nation’s rapidly increasing elderly population (last year, nursing homes housed almost 1.9M elderly and disabled residents — an increase of around 4% over the previous year) be getting short shrift in the entire healthcare debate? It would certainly appear so — setting up a perfect storm of deep federal and state cuts and sharp increases in geriatric patient care needs. | LINK

Recently, CMS published data on the readmission rates for hospitals as part of an ongoing effort to make transparent quality indicators from which hospitals could improve healthcare delivery. A recent U of MN study which just wrapped shows how focusing on patients at risk of rehospitalization can cut those potential costs by directly screening for and averting those risks in the nursing home following discharge.

One of the study participants, Theresa McCarthy MD (under whom I once trained), hails the results as they apply to future cost savings in geriatric care. By utilizing a transitional care team made up of the geriatrician, pharmacist, and critical ancillary staff, rates of readmission from patients in this particular care facility fell by 20 per cent. Not only are unnecessary costs averted, potential lives are saved (as many readmitted elderly may become sicker and more susceptible to preventable problems once back in the hospital), but new treatment paradigms are also possible. Smart. | LINK

• Hey, most donors of kidneys lead perfectly healthy lives. So, go ahead and donate!
• FDA approves first topical gel for the treatment of urge urinary incontinence.
• Will Obama’s stimulus be given to some states’ fractured healthcare systems? Not soon enough for some in the Boston metro area.
• A woman recently gives birth to octuplets. Heroism or bad medicine?
• California will ask for the removal of a state prison medical overseer to regain control over its medical care delivery.

Gov. Arnold Schwarzenegger and Attorney General Jerry Brown asked the federal courts Wednesday to block a plan to build new medical facilities at state prisons and give control of the prisons’ health care system back to the state. In a filing in U.S. District Court, Brown said the court-appointed receiver in charge of the system “is spending exorbitant sums to create a medical care system that exceeds industry standards and provides more than medical care.”

What should I do as a physician rounding on one of my many patients on my nursing home service with dementia, complicated by the fact that they are also are suffering from some of its effects on mood? While institutionalized skilled care remains the standard for these patients who are not able to care for themselves, the agitation and delusional thinking suffered by many patients with dementia syndromes puts a new wrinkle on the next level of care — other drugs which carry a certain risk of mortality.

Anti-psychotic drugs commonly used to treat Alzheimer’s disease may double a patient’s chance of dying within a few years, suggests a new study that adds to concerns already known about such medications. [...] Ballard and colleagues followed 165 patients aged 67 to 100 years with moderate to severe Alzheimer’s disease from 2001 to 2004 in Britain. Half continued taking their anti-psychotic drugs, which included Risperdal, Thorazine and Stelazine. The other half got placebos. Of the 83 receiving drugs, 39 were dead after a year. Of the 82 taking fake pills, 27 were dead after a year. Most deaths in both groups were due to pneumonia

In this country, the risk associated with both the newer and older agents essentially requires physicians to frankly discuss risks and benefits with the patient’s family, principal decision makers, and other stakeholders in their care prior to using. For some, the use of these medications (which primarily are used in the mentally ill) represent the only option in dementia with extreme mood and behavioral instability. For others, options are myriad and should be sought. | LINK

Long known to be a risk factor for infarct-related dementia, cerebral ischemia (lowered blood flow to the brain) is now being postulated as a potential cause for primary degenerative (Alzheimer) dementia. The key is in the development of a signal protein harbinger of the abnormal neural types found later in the chronic course of the disorder. Apparently, the risk for the presence of this protein is inversely related to the vascular perfusion of the brain in aging individuals.

“This finding is significant because it suggests that improving blood flow to the brain might be an effective therapeutic approach to prevent or treat Alzheimer’s,” said [Robert] Vassar, a professor of cell and molecular biology at the Feinberg School. A simple preventive strategy people can follow to improve blood flow to the brain is getting exercise, reducing cholesterol and managing hypertension. “If people start early enough, maybe they can dodge the bullet,” Vassar said. For people who already have symptoms, vasodilators, which increase blood flow, may help the delivery of oxygen and glucose to the brain, he added.

You can add this hypothesis to the inflammatory mediation and spinal fluid postulates currently being actively researched in the fight against Alzheimer dementia. | LINK

The reports of sexual abuse in nursing homes which two recent cases catalyzed the issue into the national spotlight is a mixed blessing. For years incidence of these cases was rare, simply because of the stigma involved among all parties. Over the past 10 years, however, it has been brought squarely into the spotlight, undoubtedly the result of massive paradigm shifts in patient advocacy and Boomer generational values — as the latter group represents a potentially affected age demographic. The recent cases of bizarre abuse of nursing home residents in southern Minnesota at the hands of female staff illustrate how atypical this issue is, and how atypical the need to contain such episodes needs to be. | LINK

Happy Holidays from Doctor Pundit!  Posting to resume 12/26/08.

• Plavix is the agent of choice for a multitude of preventive therapies and treatments for stroke and cardiac disease; but , its method of action may be affected by those with a certain genetic variant.
• All I want for Christmas is universal healthcare delivery?
• The American Red Cross is seriously revving up operations for Obama’s inauguration.
• What’s to blame for the sharp increase in drug-drug interactions in elderly patients?

In addition, almost 30 percent of seniors are taking at least five prescription medications and many combine prescription and nonprescription drugs. Among commonly used medications, drug-to-drug interactions extend beyond prescription drugs, with nearly half involving the use of over-the-counter medications or dietary supplements.

• The good news: healthcare is second only to the economy as the most significant concern among consumers. The bad news? The margin of difference is 75 percent to 7 percent.