Articles Posted in Cognitive Issues

A new study published in the Journal of American Medical Directors Association, looks into the care of dementia in nursing homes. The researchers focused the diagnosis and treatment aspects of dementia, finding very low levels of each in nursing homes in the US and across Europe. Knowledge about dementia and how to properly care for those suffering is an important issue in nursing homes, as there is usually a high percentage of dementia patients. This means that nursing home staff must be trained and knowledgeable in how to identify, care for, and properly medicate dementia patients.

In America, patients suffering from diagnosed dementia generally make up from 26 to 48% of nursing home populations. This number is probably even higher as patients with general cognitive impairment are not included. Many residents also go undiagnosed, mainly due to a lack of knowledge about the condition on the part of nursing home staff. This recent study has identified that roughly 1/3 of all dementia go undiagnosed, resulting in them never receiving any treatment or specialized care. Official diagnosis with dementia is important as it shapes how the individual care plan is formed. Dementia patients are more susceptible to falls, so special precautions and observation need to be used to prevent such events. More direct care is needed to care for nursing home residents diagnosed with dementia.

Direct care staff are frequently untrained in the identification and care of common nursing home ailments, including dementia. There are two main medications recommended for dementia: cholinesterase inhibitors (ChEIs) and memantine, an N-methyl-D-aspartate receptor antagonist. These two treatments work especially for dementia due to Alzheimer’s and Parkinson’s. The drug can help lessen behavioral problems and aggressive outbursts, meaning that the patient does not have to be restrained and can maintain a more normal and freer lifestyle. This means that the intensity of direct care necessary is lessened, decreasing the possibility of staff burn-out, which is more common when caring for dementia patients. And yet 26 to 60% of patients remain untreated. And even when they are prescribed, it is not uncommon for their use to be discontinued, commonly due to lack of funding. These medications can be beneficial to the patient, and the nursing home facility, so it is important that staff are well informed about their use and in identifying which patients have dementia and are thus can be helped by their use.

Unfortunately due to understaffing and the lack of training in care facilities, there are not enough qualified nursing staff to adequately monitor and assist these patients and unnecessary physical restraints are used to subdue them. Antipsychotic drugs used excessively can act as chemical restraints and benefit from these medications is usually outweighed by the harmful side effects of the drugs. It is important that medication should be individually tailored to each patient’s health needs and not used recklessly and improperly, as happens when used as a chemical restraint. The use of uncalled for restraints, due to a dearth of trained nursing staff, is against the Patients’ Bill of Rights. Nursing homes are required to employ enough staff to individually care for all of their residents. Understaffing can also result in the preventable spread of common diseases and pressure ulcers.

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Depression is a cognitive disorder that plagues one out of every ten Americans. Osteoporosis a bone disease, is also extremely widespread in the American population. Both are especially common in the elderly, and recently, researchers believe they may have found a link between the two. An article published in the June 2012 issue of the Journal of American Medical Directors explores the question “Do SSRIs Play a Role in Decreasing Bone Mineral Density?” The article reports that a certain type of antidepressant drugs may affect bone density. These drugs are classified as selective serotonin receptor inhibitors (SSRIs) and 62% of all antidepressant drugs fall within this category.

This recently discovered side effect of SSRIs highlights the need for extreme caution when administering antidepressant drugs. These types of drugs are very commonly abused in skilled nursing facilities and sometimes even used as chemical restraints. Before your loved one agrees to begin an antidepressant drug regime, make sure that he or she has exhausted all other alternatives. Leisure and social activities are just two examples of non-pharmacological therapies that improve depressive symptoms. The caregiver’s attitude toward his or her patients also has a profound effect on mental health. It is extremely important that your loved one’s caregiver is emotionally supportive and takes the time to personally interact with him or her on a daily basis. This will help prevent patients from feeling socially isolated and delay depressive symptoms.

The link between SSRIs and decreased bone mineral density, however, does not excuse the skilled nursing facility from any liability. In fact, a staff that is continually trained and educated should be aware of these risks and take them into consideration before administering an antidepressant drug regime to their patients. Each and every nursing home patient is entitled to access to an adequate staff. This legal right encompasses both quality and quantity of the staff available. If your loved one’s skilled nursing facility is lacking in either aspect, he or she may be a victim of nursing home neglect.

Furthermore, the nursing home staff is responsible for ensuring effective communication with any other team members that provide care for the patient. By operating under a team environment and maintaining accurate medical records, an efficient nursing home staff is able to prevent adverse drug reactions and polypharmacy, which can occur when a patient is taking an excessive amount of medications at once. By carefully documenting all treatments that the patient is receiving, physicians can be mindful of these other medications before prescribing additional drugs.

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Antipsychotic drugs, intended to treat mental illnesses such as schizophrenia, are the most commonly abused class of drugs in Los Angeles nursing homes. Despite warnings from the Food and Drug Administration (FDA) that using antipsychotic drugs to treat dementia patients can be fatal, one in four California nursing home residents receive these drugs before they are given safer and less expensive treatments.

Often, these drugs are used to chemically restrained patients, especially in understaffed facilities that lack the resources to provide proper dementia care to their patients. Rather than sedating dementia patients with antipsychotic drugs, nursing homes should be taking a non-pharmacological approach to the treatment of dementia. Numerous studies have been conducted to test the effectiveness of various dementia treatments and the results have consistently shown that dementia treatments should be behavioral in nature and involve social and leisure activities. In fact, other studies have shown that antipsychotic drugs actually aggravate certain symptoms of dementia, such as agitation, violent behavior, and delirium.

Because the abuse of antipsychotic drugs directly threatens the mental and physical well-being of patients, it has become a major issue of contention in nursing homes today. This week, U.S. Senators Kohl, Grassley, and Blumenthal took an initiative to end the abuse of antipsychotic drugs in skilled nursing facilities. They have proposed an amendment to the FDA’s Safety and Innovation Act S. 3187 that requires nursing homes to inform patients of the risks associated with using antipsychotic drugs and receive consent from the patients or their legal guardians before administering these drugs.

The California Advocates for Nursing Home Reform (CANHR) is working diligently to ensure the passage of this amendment. We encourage you to learn more about CANHR’s Campaign to end the Misuse of Psychotropic Drugs in California Nursing Homes. You can also contact California Senators Barbara Boxer and Dianne Feinstein to urge them to vote for this amendment to the Safety and Innovation Act S. 3187.

Even if you feel that the Safety and Innovation Act does not directly affect you or any of your loved ones, it is still important and beneficial for you to support this initiative because skilled nursing facilities are using Medicare funds to pay for these medications. In 2007, $116 million of taxpayers’ money were used to pay for the off-label use of antipsychotic drugs. This money could have been better spent in other areas desperately lacking in funding, or saved by using cheaper and safer non-pharmacological treatments for dementia.

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Dementia is a degenerative disease that can cause many behavioral and psychological symptoms that make patients difficult to care for. Although medications for these symptoms exist, not many studies have been able to provide conclusive evidence that medications such as acetylcholinesterase inhibitors are actually directly involved in relieving symptoms of dementia. As a result, many studies are now looking at non-pharmacological treatments that involve social interaction, simple physical activities, and other daily activities.

A study published in 2012 tested a treatment known by the acronym “MAKS”: “M” for motor stimulation, “A” for activities of daily living, “K for cognitive stimulation (German word is kognitiv), and “S” for a short introductory phase or a spiritual element (discussing topics such as happiness or singing a song). The results were very positive; the MAKS treatment significantly reduced symptoms of dementia for the 146 residents that participated in the study. Two therapists and one aide conducted the MAKS therapy for 6 months (6 days a week, 2 hours a day). Each 2 hour session started with the introductory phase in which a simple group activity was conducted to make everyone feel included. Then, 30 minutes was allotted to motor exercises, such as bowling, croquet, or balancing a tennis ball on a Frisbee and passing it to one’s neighbor. Another 30 minutes was spent on cognitive tasks, and then the last 40 minutes were spent on an individual activity such as preparing a snack or crafting with wood or paper.

After 6 months, participants in the study were less likely to exhibit challenging behavior such as running away and being aggressive and were generally happier. This improved social behavior, decrease in challenging behavior, and improvement in mood was most evident in residents with mild dementia. This study successfully showed that the MAKS therapy can greatly slow down the progression of dementia at an early stage.

Additionally, the study found that not only did the MAKS treatment work, but it also resulted in more long-term results than drug treatments. The MAKS treatment also had no side effects, as opposed to the side effects of drug treatments. The study implies that due to the overall advantage of the MAKS treatment, it is important that nursing homes treat their patients using similar non-pharmacological treatments whenever possible. The MAKS treatment and non-pharmacological treatments similar to it are much cheaper in price compared to the price of drugs, but call for an adequate amount of staff at hand to conduct group activities and to properly supervise each and every resident. Unfortunately, many nursing homes are understaffed, which is why drug treatments are used in place of other more effective and safe treatments.

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Nursing home residents who suffer from dementia often also suffer from coexisting depression. Depression can cause a greater cognitive decline in dementia patients. However, because the overlapping symptoms of depression and dementia such as atypical presentation, lack of insight, and expression difficulties are often overlooked, nursing home residents who suffer from both depression and dementia do not get adequate treatment for both conditions. In lieu of overmedication, alternative methods can be used to alleviate the symptoms of depression. A study published in the American Association for Geriatric Pediatry offers alternative ways to treat depression. These depressive symptoms can be easily remedied by simple leisure activities done two or three times a week.

The study placed thirty-six residents from nine different nursing homes in Hong Kong in three different activities that they would engage in three times a week: mahjong, tai chi, and handicrafts. Results showed that tai chi alleviated symptoms very slightly, and most likely didn’t provide the expected results because the physical movement was too difficult for most residents due to the lack of normal physical activity prior to the study. Results also showed that mahjong had a short-lived effect; symptoms of depression were alleviated immediately after the activity, but returned to baseline level at the follow-up 3 months later after stopping the activity. This means that if done regularly, mahjong will keep nursing home residents at a healthier state of mind, slowing down the cognitive decline of dementia that is caused by depression.

Unfortunately, activity levels in nursing homes are relatively low. The psychological well-being of residents is rarely a priority, and as a result, residents can suffer from both dementia and depression at the same time, causing great emotional distress and cognitive decline. The mahjong activity conducted in the study can be very easily implemented in nursing homes if nursing homes choose to make the effort to hire staff that is motivated to conduct these activities and rouse interest in the residents to engage in these activities. Most nursing homes are usually understaffed and therefore do not have the adequate resources to conduct such activities to improve the quality of care.

Additionally, the activity of choice does not need to be mahjong. The activity can be anything that rouses interest in the residents and whether the activity is doable given the residents’ health limitations (tai chi was deemed too difficult for the residents in the study). The main point to keep in mind is that whatever activity is chosen, it needs to be done regularly. Even the effects of mahjong were limited after the activity was stopped for three months. All nine of the nursing homes that participated in the study discontinued mahjong as an activity despite the results of the study. The cognitive decline of dementia already progresses rapidly, and it is unfair to not implement such a simple activity into the daily lives of residents to prevent their condition from getting progressively worse. There is simply no excuse for nursing homes to have no meaningful activities whatsoever for their residents to participate in.

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An article in the March 2012 issue of the Journal of American Medical Directors Association titled “Is Your Nursing Home a Battlefield?” address the issue of dementia-related agitation in skilled nursing facilities. The article makes the analogy that nursing homes are often comparable to battlefields when dementia patients experience episodes of agitation and refuse care from nurses. Because this issue creates a negative dynamic between nursing home residents, their families, and the staff, it is extremely important to address the issue and understand the solutions that this article suggests.

The first solution is as simple as the elimination of words with negative, violent connotations. Words like “aggressive” and “assaultive” reinforce the idea that the resident intends to harm the caregiver. In actuality, patients who have episodes of agitation are not being violent; rather, they feel the need to defend themselves due to a lack of understanding as to what the intentions of the caregiver are and what purpose his or her actions serve. As a nurse, especially those who handle dementia patients, it is crucial to provide clearly articulated explanations to residents undergoing any form of care or treatment in the facility.

Secondly, the article emphasizes the importance of educating the facility’s staff. This includes nursing aides, directors of nursing, charge nurses, and even the nursing home’s administrators. In addition to having a staff that provides quality care, the skilled nursing facility needs to be adequately staffed. There is a strong correlation between quality and quantity with regard to staffing in nursing homes. Without an adequate amount of staff, it is nearly impossible to meet the high standard of care that each patient needs and deserves.

Nursing homes have strict guidelines and policies to which all patients and nurses must abide. However, the article recommends that the facility maintain a certain degree of flexibility in implementing their policies and guidelines. This openness to modifying certain policies allows for care plans that are more individualized and receptive to the patient’s specific needs. For example, if a patient tends to resist care early in the morning, perhaps the facility staff should consider a later wake up time.

The article also suggests that nursing home facility’s give nursing aides more significant roles in decision-making. The abilities of nursing aides are often undermined, as it is often assumed that they are merely expected to carry out tasks assigned to them by directors of nursing. However, those who make these assumptions overlook the fact that nursing aides provide the most direct care to patients and interact with them on a daily basis. Therefore, the article recommends that nursing aides be included in care plan meetings. As they are most familiar with patients’ needs and preferences, allowing nursing aides a role in decision-making will result in more effective care plans.

Lastly, the article asserts the importance of treatment for patients who reject care. Often, rejection of care is a sign of pain, delirium, delusions, or depressions. Therefore, patients must be carefully evaluated so that they can receive the proper care, before symptoms become more serious. As with every recommendation that the article has made, training of the facility’s staff is instrumental in this step. Previous studies have shown that nurses often fail to recognize symptoms until it is too late and complications have progressed too far. Recognizing and diagnosing delirium poses and especially difficult challenge for nurses. For this reason, nurses must be trained to be observant and recognize the signs of various health complications that arise in skilled nursing facilities.

In addition to ensuring that the nursing home is adequately staffed, you should also be wary of the use of antipsychotic drugs to chemically restrain residents who suffer from dementia. Other than this being a direct violation of the Patients’ Bill of Rights, it is also extremely dangerous and has been proven to actually aggravate episodes of agitation.

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The March 2012 issue of the Journal of American Medical Directors Association features an article titled “Detection of Delirium and Its Symptoms by Nurses Working in a Long Term Care Facility.” Because delirium is often difficult to recognize, the article studied the accuracy of nurses in diagnosing delirium in their patients. Although often associated with dementia, delirium distinguishes itself from dementia because it is a disorder that is usually reversible, while dementia is a chronic illness that develops over a span of time. Delirium affects a patient’s attention span, consciousness levels, and overall cognitive abilities. Patients typically experience disorientation, memory loss, difficulty with perception, agitation, and a disrupted sleep cycle.

While delirium can be caused by infections, such as sepsis, some other causes of delirium, according to the article, include dehydration, medications, and the use of a physical restraint. Previous studies have also cited chemical restraints as a significant factor that contributes to the development of delirium. Some commonly used chemical restraints are antipsychotic drugs, which effectively sedate and restrain patients, but have many extremely serious side effects, including delirium.

The key to finding a suitable nursing home for your loved one requires close observation of both the quality and quantity of the facility’s staff. With proper staffing levels, dehydration, among many other health issues, is avoidable. Therefore, if a nursing home has blamed your loved one’s delirium on dehydration, the facility is ultimately at fault for failing to prevent dehydration in the first place. The use of restraints, both chemical and physical, is often another consequence of understaffing. When nurses are preoccupied with so many other patients, they may find it difficult to provide each patient with the individualized care that he or she needs and resort to the use of restraints.

With respect the issue of quality of staffing, the study results showed that nurses recorded more cases of delirium than there actually were. Although treatments for delirium may not actually be harmful to patients who do not actually suffer from it, the results still reveal the poor training programs that facilities often provide to their nurses.

Beyond this specific case that studied accuracy in identifying cases of delirium, the study has further implications that nurses may be inaccurately diagnosing other medical problems, while some may be failing to do so at all. Sometimes in skilled nursing facilities, employees are actually directed to improperly document and diagnose illnesses, in a practice known as “downcoding,” to avoid liability and injury claims against them. Other facilities “upcode” in order to maximize reimbursement claims from government health agencies. We would like to increase your awareness of the manipulation of medical records that occurs in skilled nursing facilities. If you are ever in doubt of the accuracy of your loved one’s medical records, it is best for you to monitor his or her records and physical health yourself, or get a second opinion.

Although the staff at nursing home in which the study was conducted mistakenly overestimated the cases of delirium at their facility, other facilities may be underestimating the number of their patients who suffer from delirium. If the nursing home is failing to recognize that your loved is suffering from delirium, he or she is not receiving proper treatment for it. The study emphasizes the importance of recognizing the onset of delirium early so that the cause can be identified and the problem can be treated immediately, before progressing and worsening. If your loved one’s nursing home is failing to provide your loved one with proper care, he or she is a victim of elder abuse and nursing home neglect.

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