California Nursing Home Abuse Lawyer Blog

A recent study titled “Emergency Hospitalizations for Adverse Drug Events in Elder Adults” available in the November 2011 issue of The New England Journal of Medicine has discovered four drugs that are directly responsible for two thirds of all hospitalizations and overdoses in elder adults. Interestingly enough, these drugs are not considered by physicians to be risky, but rather are very commonly used, especially in elder adults. These drugs include blood thinners and medications for diabetes.

The study recorded that 33% of hospitalizations were caused by a blood thinner called Coumadin. Insulin was responsible for 14% of hospitalizations, with other blood thinning drugs following closely at 13%. The last type of drug, called a hypoglycemic agent, is an antidiabetic drug that is taken orally. It was found to be responsible for 11% of hospitalizations of elder adults. These four drugs all have one thing in common: a narrow therapeutic index. This means that the line between a recommended dosage and a fatal dosage is very thin. Therefore, close monitoring of every individual is required in order to attain an ideal dosage that is both safe, as well as effective.

While taking blood thinners and antidiabetic drugs, it is highly recommended and often required for patients to undergo periodic blood tests. Their blood must be monitored closely to ensure that the drugs are not having any negative side effects on the patient. Additionally, it is important for the patient to have routine check-ups in the case that he or she is eligible for a dosage decrease. Because the therapeutic index of these drugs is so narrow and the risk of overdose is so high, it is especially important that your loved one’s dosage is closely monitored and maintained at a safe level.

Although it may be a tedious task to monitor someone taking one of these drugs and ensure that they are constantly receiving blood tests and necessary check-ups, it is crucial to their health and safety. Therefore, if your loved one resides at a nursing home, it is important for you to make sure that the home is adequately staffed and that the caregivers are well-trained and closely monitoring your loved one.

Another factor that must be monitored when an individual is taking one of the four aforementioned drugs is nutrition. Food can interact with these drugs and alter their effectiveness. This may lead to a necessary change in dosage as a precaution against overdose or hospitalization. Therefore, it is essential that your loved one is not a victim of malnutrition because in addition to its obvious health-related repercussions, malnutrition may also contribute to an inappropriate dosage amount and possibly hospitalization and overdose.

It is also important that your loved one’s nursing home is organized. Every resident should have detailed and extensive medical records. If your loved one’s records are unsubstantial, he or she may be at higher risk for polypharmacy, which is the excessive use of multiple prescribed drugs simultaneously. Because these drugs already put your loved one at higher risk of overdose, taking more than one can be especially dangerous. Therefore, it is important that the nursing home keep track of all medications that their residents are taking so that their physicians are aware that they are taking these drugs before prescribing other ones. While keeping records of all residents’ health should not be a difficult task, it is indeed an important one because a lack of organization may have serious consequences such as overdose and even death.

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In today’s scientifically advanced world, determining whether or not a nursing home resident displays symptoms of depression can be done quite simply and accurately. A more prevalent issue relating to depression involves the quality of treatment in nursing homes. A recent study titled “Antidepressant Prescribing Patterns in the Nursing Home: Second-Generation Issues Revisited” conducted by the Journal of American Medical Directors Association takes data from ten different nursing homes and analyzes how different factors influence the use of antidepressants among nursing home residents. The results of the study show a significant correlation between quality of treatment and pertinent documentation provided for this treatment.

In order to provide your loved one with the best possible care, it is important first to know exactly what his or her rights are. The Omnibus Reconciliation Act of 1987 requires that nursing home staff provide detailed records and regular assessments regarding the use of psychoactive drugs, including documentation of reasons for use and periodic attempts at dose reduction. This law was enacted for a specific reason. It is a health risk for nursing home residents to be using antidepressants without proper documentation of the patient’s depressive symptoms, the original reason for the prescription, as well as the reason for continued use of antidepressant drugs, and any side effects that these drugs may have.

In their study, the American Medical Directors Association found that 33% of nursing home residents who used antidepressant drugs had no documentation of actually being diagnosed with depression. Although in some of these cases antidepressant drugs were being used to treat other illnesses, many lacked any reason for the prescription of these drugs in the first place.

In the charts of those patients who were documented with a diagnosis of depression, the specific symptoms that led to this diagnosis and the subsequent prescription of antidepressants was missing. There were many patients who were diagnosed with depression and prescribed antidepressants, but later discontinued their treatment and 85.7% of such charts did report the reason. However, these reasons were found by the American Medical Directors Association to be vague, with “little explicit information…provided regarding the reason behind treatment changes.” While documentation is generally a sign of sufficient monitoring of a patient, the quality of this documentation is even more important. Documentation must be substantial and patient-specific in order to really be of any use to the patient and his or her future caretakers.

The accuracy of documentation is another area of concern. Although 65% of patient charts claimed that they were being monitored by psychiatrists, their quarterly reviews did not include documentation of any monitoring for depression symptoms. It is important to extensively investigate your loved one’s nursing home to ensure that his or her caretakers are actually following through on their documented promises.

The lack of monitoring and documentation of nursing homes is often a consequence of understaffing. In their study, the American Medical Directors Association discovered that nursing homes with low licensed nursing staff were less likely than those with higher licensed staff to document the presence or absence of depressive symptoms.

Although clear documentation does signify better organization and closer monitoring of patients, it may seem unimportant in comparison to other priorities of nursing homes. However, lack of documentation can lead to very serious consequences that often result in death. Nursing home residents often take multiple drugs for various reasons, putting them at risk of polypharmacy. In addition to the danger of simultaneously using more drugs than recommended by professionals, polypharmacy also places an emotional burden on elderly adults who have too many pills to take. Additionally, unless a patient is being closely monitored, it is impossible to determine whether or not he or she requires a change in drug dosage.

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If your loved one resides in a nursing home and has dementia, you should work with the medical staff to ensure that your loved one lives in conditions that facilitate a good quality of life.

According to the recent article titled Quality of Life of Nursing Home Residents With Dementia: A Comparison of Perspectives of Residents, Family, and Staff, published in The Gerontologist, since dementia currently has no cure, quality of life (QoL) is recognized as a meaningful indicator of the course of illness and the effectiveness of interventions. It is possible for a resident to receive good care at a long-term care facility, yet not experience good QoL.

Measuring QoL is inherently subjective–it is defined in terms of individuals’ perceptions on their well-being in the context of the culture and values in which they live compared to their goals, expectations, and standards. For residents with dementia, measuring QoL is more complex because the residents’ self-assessment may be affected by cognitive impairment, including issues involving memory and reasoning, and noncognitive ailments, such as depression and psychosis, which are not uncommon in individuals with dementia. Because of these cognitive and noncognitive concerns, measuring QoL for patients with dementia involves a consideration of the views of both the patients and proxies, including the family and nursing home staff.

The authors discuss a study conducted in Spain where the views of nursing home residents with dementia with regard to QoL were directly compared to the views of family and nursing home staff. To measure QoL, residents, family, and staff completed a questionnaire where the individual completing the questionnaire rated various factors comprising QoL in the nursing home environment, including physical health, energy, memory, family, and staff.

Nursing home residents with dementia view their QoL more favorably than their family members and nursing home staff. Residents view many aspects of QoL more favorably than family and staff: energy, mood, friends, ability to keep busy, ability to take care of oneself, ability to do things for fun, ability to make choices in one’s life, ability to live with others, and their life overall. Among all the participants in the study, the people working in the nursing home rated the highest, and memory was rated the worst. For family members and staff, the resident’s abilities for independence and making choices rated among the worst.

Family members and nursing home staff tended to rate the residents’ QoL similarly, but less favorably than the residents, including mood, memory, and physical health. Several reasons for this less favorable assessment include (1) the role that the subjective view of residents play in assessing QoL, (2) the lack of understanding of dementia in family members and staff, (3) the residents’ partial awareness of their declining capabilities, and (4) the external observers’ tendency to weigh negative information more heavily than positive information when forming opinions about other people.

In evaluating the outcome of care, it is challenging to determine whether the proxies’ viewpoint or the residents’ viewpoint into QoL is more valid. However, the study suggests that the residents’ assessment of their QoL should be considered because it provides a different perspective from that of the proxies. Thus, it is increasingly recognized that QoL should be a primary outcome of interest in the care given to residents with dementia.

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