Although the results of a study from the Annals of Internal Medicine are out today noting an increase in the rate of sexually transmitted infections (STIs) among those taking drugs for erectile dysfunction, this item “hot off  the wires” practically invites the media to take a stance assuming direct causation.

Jokes aside — and you can assume that lead-ins are probably replete with them — the compelling numbers^[1] suggest a greater problem afoot: the overall numbers of sexually active men over 55 years of age is increasing. Re-evaluating incidence and prevalence rates to include this ever-burgeoning population will only become more commonplace in medical education as this retrospective study underscores one major point: the necessity of other types of trials studying the effects of preventive practices toward STIs in those much younger and applying them to this patient population. | LINK

1. Researchers followed over 1M men (average age of 60) by examining their insurance records. Among non-users of drugs like Viagra, 106 in 100,000 contracted an STD. That number increased to 214 in 100,000 for men who were using Viagra, Cialis or Levitra — the major drugs to treat ED. [↩]

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. [↩]

Is Florida sensing an “advantage” for its subsidized healthcare delivery? If the legislature’s voting is any indication, the state could be on the path to privatization of its Medicaid program in its entirety. Facing an extreme budget crunch, Florida could allow state-based and national for-profits contracts with the government program to help pay for care.

States’ Medicaid funds are usually matched by government subsidy to assist in the delivery of care to all ages who qualify on a means-tested basis. Traditionally, elderly long term care and care of the disabled have been responsible for the lions share of costs to many states’ healthcare coffers. And in a system where private payers in Medicaid managed care plans are increasingly denying payment to hold on to profit, privatization is an option.

So it doesn’t come as a surprise that HMOs and other plans are lobbying hard for this; the Florida GOP couldn’t be happier.

Republicans in the Legislature say Florida can’t afford to wait, or rising Medicaid costs will overwhelm the budget. Almost all states have some portion of Medicaid recipients in so-called “managed care,” but Florida would be one of the first to put the elderly and disabled requiring special care in the hands of commercial HMOs.

Advocates of taxpayer-subsidized care to this patient population say that the state is “abdicating its care” in this case, as fears of a corporatized healthcare infrastructure threaten care access (to physicians who cannot afford to provide care) in the name of profits while incentivization to get the patient better and out of Medicaid will be sacrificed. Senate Republicans want to move — and fast. Dems “want more data”. Should be a lightning-rod issue in a state with fireworks in yet another political arena. | 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, the murder of a nursing home resident in Minnesota made headlines when a peer, a locally famous wrestler in his younger days, became agitated and assaulted the resident, breaking his hip — an injury which led to the victim’s death. The aggressor, a patient with longstanding Alzheimer dementia, was not charged with a crime because of his diagnosis. While this episode highlights the issues patients with dementia may pose to other nursing home residents with respect to the potentially violent behavior that characterizes the condition, it does not address the other etiology of such behavior in long term care settings.

With increasingly tight budgets and even tighter staffing standards, many group homes and traditional boarding facilities for the functionally mentally ill in this country are forced to cease operations, transferring patients to nontraditional settings such as nursing homes. Adult mentally ill patients in society needing skilled nursing in settings other than nursing homes are being forced into those new environments and facing similarly violent fates; as a consequence, criminal charges usually follow. Staff and elderly patients are increasingly the vulnerable ones. | LINK

Nursing homes (NH) and — by extension — long term care, have always been the also-rans in discussions related to the delivery of healthcare in this country. Generally, healthcare and the potential profits of third parties render policy considerations on anything but acute hospital care, ambulatory care, and drug and medical device patents as essentially insignificant. However, as we approach the end of the first decade of the 21st century, the rules of the game are about to change, if they haven’t already.

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Certain Minnesota home care agencies which accept payments from Medicare and Medicaid for services rendered are not taking a recent national survey lightly. Recent CMS quality assurance parameters^[1] place this state just above three others in overall “quality”.^[2] Only Texas, Wyoming — and surprisingly Vermont — scored lower in 30 specific areas. An organization which represents these CMS-certified home health agencies has hired an East Coast consultant to jack up the state’s rankings within the next two years. Gotta love that Minnesota defiance and tenacity. | LINK | OASIS Parameters LINK

1. Dubbed OASIS: Outcome and Assessment Information Set — the set of data which follows a patient during each episode of home care per institution. [↩]
2. Quality parameters may be affected by inaccurate reporting, billing practices, varying administrative policies within each home healthcare institution and may not indicate the absolute quality of patient-focused medical care in Minnesota. [↩]

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

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