This realization was what drove palliative care doctor and filmmaker Jessica Zitter to create the documentary “Caregiver: A Love Story.” The film follows couple Bambi and Rick as they navigate the joys and challenges of trying to give Bambi a “kinder death” at home.

This raw and emotional film shows Rick’s journey as primary caregiver: his sense of duty to take care of his wife, his frustration at not having help, and the impact on his health. As much as Rick feels “thrust into the role” and unqualified to provide this level of care, he doesn’t see an option to stop because of the love he has for his wife. “Why am I doing this? It’s all about love,” Rick says. Yet this takes a toll on his physical and mental condition, and he feels his health is “deteriorating with hers.”

Dr. Jessica Nutik Zitter practices critical and palliative care medicine at a public hospital in Oakland, California. She is the author of Extreme Measures: Finding a Better Path to the End of Life and her work was featured in the film EXTREMIS, which was nominated for an Oscar and two Emmys. We spoke with Dr. Zitter about the film and why they are trying to get as many clinicians as possible to watch it.

To watch the film, check out the full list of screenings. Clinicians who are members of Docola can watch the film and attend a Q&A with Dr. Zitter on January 26th.

Lown Institute: Where did the idea for this documentary come from?

Dr. Jessica Zitter: We originally were making a film about how getting out of the hospital was a good thing, it was not intended to be about family caregiver burden. But when we reviewed the film, we recognized that Rick’s story really needed to be told, not just Bambi’s. We needed to share the voice of people like Rick taking care of loved ones at home, work that is not usually given attention.

What do you hope that clinicians take from the movie?

I hope that clinicians will lift their heads out of the hospital and understand that the hospital is not the limit of their responsibility. For me it was a shock to watch my own movie and realize I was sending people home without any knowledge of what they were up against. I was setting them up for failure when I could have had an impact. Hospitals are used to focusing on the patients inside the hospital, but not very good at looking at the patient as a person that lives outside the hospital too. Even those in palliative care are missing something.

We need to start to think about creating a structure that provides support to the people we treat, not just kick them out of the hospital. We shouldn’t be the “hospital on a hill,” siloed off from the rest of the world. This will just make things worse for people.

How can hospital clinicians better support family caregivers?

Hospitals have the responsibility to identify caregivers while patients are in the hospital and direct them to resources, so they’re not going out blind. Caregivers should be connected to resources like Meals on Wheels, hospice, respite services, support groups , educational programming, and adult day care centers. We should have a follow-up mechanism, so that clinicians at the hospital aren’t depending on caregivers to reach out if they need help (caregivers are often too overwhelmed to do this).

How is the health of caregivers being impacted by the move from hospital to home?

Caregiver burden is one of the rising silent epidemics in our time. In 2017, more people died at home than the hospital, but we’re not shifting support outside the hospital. As people are leaving we’re not supporting them or their caregivers. All of these caregivers are having to leave the workforce, and many more women than men leave the workforce. That’s tens of billions lost because caregiving itself is a full time job but we don’t pay for it.

There are profound consequences for caregivers of doing this job unsupported and untrained. There are very high rates of depression and loss of financial security. Family caregivers don’t take care of themselves; they forgo their own care. You see this in the film very powerfully.

Do you have advice for patients or caregivers who are feeling overwhelmed?

A lot of people don’t realize that they are family caregivers or that they need help. This film, if nothing else, mobilizes a movement. We are creating a program for the film specifically for family caregivers, as a first step to help them find resources within their community.

The post “I feel like my health is deteriorating with hers”: The struggles of caregiving and what clinicians need to know appeared first on Lown Institute.

While older adults are more susceptible to medication side effects, they are also more likely than younger adults to be taking multiple medications, which can lead to harmful adverse drug events. Some of these medications may not be appropriate for older adults to take, or may be too high of a dose.

Getting medications right is one of the primary concerns for older adults and their caregivers. But are they aware of the potential side effects that certain medications can cause? The John A. Hartford Foundation partnered with WebMD to conduct a survey of older adults and caregivers to find out more about their views on certain aspects of aging, including medication use.

The survey included responses from 2,361 randomly-selected patients age 65 or older, and 405 caregivers. The survey found that multiple medication use is common for older adults; 40% of caregivers reported that the individual in their care takes six or more different prescription drugs each day. Among older adults with more than six chronic conditions, one in three take more than ten drugs each day. 

Despite the prevalence of multiple medication use, a significant proportion of both older adults and caregivers were unaware that certain medications are not recommended for older adults. Half of older adults and 45 percent of caregivers who responded to the survey were not aware that older adults should avoid certain medications, such as anti-anxiety drugs, sleep aids, over-the-counter anti-allergy medications, and certain diabetes medications. Only about 60% of older adults and 68% of caregivers knew that certain medications, such as anti-cholinergic drugs, anti-anxiety medications, and antipsychotic medications, can increase cognitive impairment or confusion. Even fewer patients and caregivers were aware that medications like sleep aids and blood pressure medications can increase the risk of falls.

Awareness of medication risks was not the same across patient race and ethnicity. Hispanic and Black respondents were about 15% less likely to know that older adults should avoid certain medications, compared to White respondents. About one-third of Hispanic adults responded that they were not at all familiar with medication risks, compared to about one-quarter of Black respondents, and one-fifth of White respondents. This awareness gap likely has an impact on the potential for deprescribing; according to the survey, Hispanic and Black respondents are less likely to have had discussions about unnecessary medications with their doctors, compared to White respondents. These results point to an important health disparity that may be leading to increased harm for older people of color. 

Overall, only half of survey respondents said that a health care provider has talked to them about stopping medications. This is discouraging but not surprising, given that many clinicians do not have the time to engage in conversations about medications, nor are they reimbursed for doing so. Additionally, clinicians may expect patients and caregivers to resist deprescribing, so they do not attempt to bring up the subject. However, if more patients and caregivers are aware of potential drug harms, they may be more likely to express their concerns about medications and ask for a prescription checkup to discuss deprescribing. 

The JAHF survey is enlightening, but there is still much we don’t know about patient and caregiver views on medications. The survey did not separate responses by age, so it is unclear how medication use and knowledge varies between adults in their 60s and 70s compared to very old adults and their caregivers. Nevertheless, the survey provides useful information about awareness of medication harms in older adults and caregivers, showing a potential avenue for public awareness campaigns, as well as highlighting the need to target older people of color in these campaigns.

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In the latest edition in the “Right Care” series, Dr. Nick Bott and Dr. Ann Lindsay from the Stanford University School of Medicine tackle the question, “Why is it difficult to provide the right care to adults with dementia?”

A large part of the problem is the way we view dementia, write Bott and Lindsay. Currently, most clinicians view dementia as just another medical condition, like high blood pressure or diabetes, rather than a condition that affects all other aspects of the patient’s life and health. This is partly a result of our fragmented health care system, in which patients are often seen as a “collection of diseases” rather than a whole person. 

“In reality, dementia is a life-limiting terminal illness for the patient, and a life-altering diagnosis for the patient’s family or caregivers,” the authors write. “A diagnosis of dementia should be considered the primary problem under which care for all other problems is considered.” There is no cure for dementia, and generally dementia gets worse over time. This means that patients and family/ caregivers may have to reconsider health goals and treatment decisions. For example, cancer screenings are unlikely to benefit older patients with dementia, and often lead to overtreatment and harm.

Clinicians should also let patients and caregivers know about the increased risk of hospitalization and hospital complications in patients with dementia, so they can take steps to avoid preventable hospitalization whenever possible. Patients and caregivers should make use of alternatives to inpatient hospitalization, such as Hospital At Home (HAH), which delivers medical care at home for common conditions.

Another reason dementia often goes ignored is because clinicians may not know that there are steps they can take to help patients with dementia and their family/caregivers. However, primary care clinicians can change the course of a patient’s health care for the better by helping patients and their families with advanced care planning, reviewing medications, and creating a care plan that focuses on preventing harm.

“A thoughtful pause opens the door for intelligent intervention that is goal congruent and invaluable for reducing complications and preventable morbidity,” write Bott and Lindsay.

Read the full piece on American Family Physician!

The post Why is it difficult to provide the right care to adults with dementia? appeared first on Lown Institute.

A recent study by Grace K. Mahoney, MS of the Department of Biomedical Informatics, Harvard Medical School; Henry J. Henk, Vice President of Research at OptumLabs in Cambridge, MA; and Dr. Rozalina J. McCoy, endocrinologist at the Mayo Clinic, finds that inappropriately intensive treatment of type 2 diabetes leads to thousands of hospitalizations and emergency department visits for low blood sugar (clinically known as hypoglycemia) each year. While other studies have estimated the rates of overtreatment of diabetes in certain populations, this is the first study to estimate the number of hospitalizations and ED visits attributable to intensive treatment of diabetes in the full US population. 

Type 2 diabetes is a chronic condition that affects nearly one in ten Americans. Type 2 diabetes is usually treated with diet, exercise, and sometimes medications to lower blood sugar levels. Keeping patients’ blood sugar levels under control is important for reducing diabetes symptoms and complications. However, lowering blood sugar too much can cause hypoglycemia, which can lead to fainting, seizures, and even coma. 

Patients who are older and have multiple chronic conditions are at greater risk of adverse drug events like hypoglycemia. In fact, diabetes medications are among the most commonly implicated in ADEs leading to ED visits for Americans age 65 and older. Guidelines recommend that patients who are older or have multiple chronic conditions or advanced conditions (such as dementia or chronic kidney disease) be treated less intensively for type 2 diabetes, and that clinicians use a higher blood sugar target for these patients than for younger, healthier patients.

Nevertheless, Mahoney et al. found that between 2011-2014, about 21% of patients with below-average blood sugar levels were treated with medications to further lower their blood sugar, regardless of their age or other chronic conditions. As a result, there were more than 9,500 hospitalizations and ED visits for hypoglycemia over a two-year period due to intensive diabetes treatment. About 8,200 of these events could have been avoided if clinicians had identified the patient as someone at higher risk for hypoglycemia and treated them less intensively.

“Intensive treatment is a risk factor for hypoglycemic events. This is something that we as clinicians have control over and can prevent,” said study author Dr. Rozalina McCoy. “We need to recognize that there is no one-size-fits-all approach to lowering blood sugar.” 

Patients can also help prevent future adverse events by telling their clinical team if they have an episode of hypoglycemia, and by asking about the harms and benefits of medications to lower blood sugar. 

The post Overtreatment of diabetes leads to thousands of hospitalizations each year appeared first on Lown Institute.

In the same way that medication overload is a neglected public health problem, few clinicians are addressing signs of loneliness in their patients, because it isn’t something clinicians are necessarily trained to do, or have time to do.

“We see loneliness in our older patients every day, but we don’t have time to ask them about it, because we have to check off so many other boxes,” said Dr. Carla Perissinotto, geriatrician and Associate Professor of Medicine at the University of California, San Francisco.

Loneliness is by no means a new problem, but demographic and social changes are setting the stage for an “epidemic of loneliness,” said clinicians and public health experts at Pulse: The Atlantic Summit on Health-Care. Because of a myriad of cultural, technological, and economic changes, Baby Boomers have fewer social ties, spouses, and children, and attend fewer community events compared to their parents’ generation, said Dr. Robert Putnam, Professor of Public Policy at Harvard University and author of Bowling Alone. Now, as the Boomer generation ages, they will have fewer friends and family members to help take care of them. Medicaid will then have to pick up the tab for more long-term care, a cost that the program is not adequately prepared to pay.   

Perissinotto and others are leading a movement to create more visibility for loneliness as a health issue for older Americans. Clinicians who care for older patients should be made aware of the health consequences of social isolation, be given the time and training to ask patients about their loneliness, and be given tools to connect lonely patients to other community members. We also need to demand structural changes such as age-friendly transportation options and creating more opportunities for social interaction in communities. And we need to change our culture, which too often is centered around the individual.

“We need a social movement” to encourage person-to-person connection, said Dr. Sachin Jain, Professor at Stanford Medicine and CEO of CareMore Health.  

Those who are leading the movement are wary of the possibility of pharmaceutical companies co-opting and medicalizing loneliness. “It’s easier to prescribe a pill than to ask ‘Why are you lonely?’ and listen to the answer,” said Perissinotto. “The last thing we need is more polypharmacy.” It is important to understand the health risks of being lonely, but we must tamp down the impulse to medicate loneliness.

If you ask any geriatrician or clinician who cares for older patients, they will tell you that too many medications and loneliness are both widespread problems in the older population. And yet, these issues have gone unnoticed — why? Part of the problem is ageism, said Perissinotto. “We’re afraid to grow old, afraid to talk about what it means to grow old. If you don’t ‘age well,’ you’ve failed,” she said. Recognizing and targeting ageism will be a large part of tackling these key public health issues.

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Ricardo Nieves, MD
Tariq Salim, MD
Casey McQuade, MD

University of Pittsburgh Medical Center, Pittsburgh, PA

Clinical Vignette

A 78-year-old female with a history of quiescent lupus and low-gradient severe aortic stenosis presented with chronic longstanding intermittent sharp chest pain. As a part of an evaluation for transcatheter aortic valve replacement (TAVR), she was found to have obstructive coronary artery disease and two drug eluting stents were placed. However, even after stent placement, she continued to endorse chest pain, dysphagia, and odynophagia. A dual-contrast esophagram was completed which was suggestive of esophagitis, as well as esophageal stricturing. Given her ongoing need for dual anti-platelet therapy, esophageal dilation was contraindicated and symptomatic management was chosen. She was administered Magic Swizzle (analgesic mouthwash often used for oral mucositis) as needed for management of her odynophagia, which resulted in significant improvement in her swallowing.

Several days later, the patient briefly became unresponsive overnight and a stroke code was called. As a result, the patient underwent a CT head without contrast, an MRI of the brain with and without contrast, an MRA of the head and neck, and repeat bloodwork. Stroke was ruled out and patient’s sensorium improved with NPO status. On review of the patient’s chart, it was noted she was receiving Magic Swizzle multiple times over the course of a given day. To rectify this, her inpatient medical regimen was altered to include sucralfate rather than Magic Swizzle, and her mental status improved back to baseline and remained stable.

Teachable Moment

Magic Swizzle (known in some pharmacies as Magic Mouthwash) is a generic term often given to a mouthwash with analgesic properties frequently used in the setting of oral mucositis, odynophagia, or dysphagia in patients undergoing chemotherapy or radiation therapy. While not standardized, the formulation often includes equal parts viscous lidocaine, aluminum hydroxide/magnesium hydroxide, and diphenhydramine, with some specific formulations also including steroids or antibiotics.

The case above illustrates the potential for unintentional overdose of a medication commonly added for the alleviation of oropharyngeal and esophageal complaints. The use of diphenhydramine in this case is notable as it is believed that its unintentional side effect largely contributed to the patient’s altered sensorium and resulted in extensive neurological testing and leading to unnecessary use of healthcare resources. This case highlights the importance of examining the Beers Criteria when administrating medications to the elderly. A retrospective cohort and nested case–control study of 374 U.S. hospitals by Rothberg et al., found that four commonly used inpatient medications, diphenhydramine, promethazine, and short-acting and long-acting benzodiazepines, are associated with a surrogate marker for delirium in patient greater than 65 years old.1

Avoidable adverse drug events (ADE) are serious consequences of inappropriate drug prescribing and are disproportionately experienced by elderly patients. The etiology of this result is believed to be multifactorial and closely linked to age-related changes in body composition, renal function, pharmacodynamics, and metabolism along with higher rates of comorbidity and polypharmacy.2 While the Beers Criteria includes many commonly prescribed sedating medications that should be avoided in elderly patients, studies have found that close to half of nursing home patients are prescribed such medications with the total number of prescriptions being the driving force for inappropriate medication use.3

The implications of ADEs are not only medical in nature but extend into the financial realm as well4, a factor that is especially important in light of high healthcare expenditures in the United States. The prescription of any new medications should prompt, either automatically or through a pharmacist, a review of its potential for detrimental effects versus benefit in the elderly. While the prescription of new medications should always be a critical process led by physicians, the review of patient cases and care is best served in a team-based approach with input from providers of different levels. Integrated input from physicians, pharmacists, nurses, physical therapists and social workers is essential in the appropriate care of elderly patients, whose needs are often more extensive than medical problems alone. Lastly, whenever possible, care should be taken to reduce the number of medications prescribed to elderly patients, taking into the account risks and benefits.

While the patient presented in this case fortunately did not suffer any permanent sequalae from the events presented, the outlined course of events could have been avoided. A critical review of new medications prescribed during her inpatient stay, review of said medications with a pharmacist, and application of focus on the reduction of medications wherever possible could have prevented the unnecessary testing and examination presented in this case.

References:

1. Rothbert M., et al., Association Between Sedating Medications and Delirium in Older Inpatients. J Am Geriatr Soc. 2013 Jun;61(6):923-30.

2. Trifirò G., Spina E. Age-related changes in pharmacodynamics: Focus on drugs acting on central nervous and cardiovascular systems. Curr Drug Metab 2011;12:611–620.

3. Morin L, et al., Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review. Journal of the American Medical Directors Association. Volume 17, Issue 9, 1 September 2016, Pages 862.e1-862.e9.

4. Stockl KM, Le L, Zhang S, Harada AS. Clinical and economic outcomes associated with potentially inappropriate prescribing in the elderly. Am J Manag Care. 2010 Jan 1;16(1):e1-10.

The post Lown Vignette Winner: The Devil is in the Details: Combination Medications, Oversedation, and Unnecessary Testing in the Geriatric Population appeared first on Lown Institute.

This year, we received vignette submissions from students and trainees all over the country (and internationally!) on topics from avoiding polypharmacy to inappropriate stenting to navigating clinical guidelines.

We spoke with vignette competition winner, Dr. Ricardo Nieves, second-year resident at the University of Pittsburgh Medical Center. His co-authors, Dr. Tariq Salim and Dr. Casey McQuade, are also residents at UPMC. Their vignette, The Devil is in the Details: Combination Medications, Oversedation, and Unnecessary Testing in the Geriatric Population explores what can happen when a commonly used combination drug is not adjusted to an elderly patient’s existing medication regime. 

Lown Institute: Tell me about how this case played out.

Dr. Ricardo Nieves: Tariq [Salim] and I were the night team called to respond to a patient’s altered mental status. She was a 78-year-old with chronic chest pain and esophagitis (enflamed esophagus) and became unresponsive during the night. A stroke code was called and from there, one thing rolled into another. The condition team evaluated her, we got blood work, a CT, and MRI. 

From the tests we could tell she hadn’t had a stroke, so we were wondering why a patient like her would be altered all of a sudden. Then after looking at her chart we realized she was receiving a combination medication called “Magic Swizzle” multiple times over the course of a given day.

Lown: What is “Magic Swizzle”? It doesn’t sound like a serious medication…

Dr. Nieves: Magic Swizzle is a combination medication that helps relieve pain and helps patients swallow. The name sounds harmless but there are some pretty serious drugs in it, including the active ingredient in Benadryl. I had a course of influenza in medical school and I got prescribed magic swizzle, it works great but I never know what it had in it.

Usually we schedule Magic Swizzle a couple of times during the day. For this patient we had evidence of esophagitis, she asked for the medication, and we saw she improved so we just gave her more. We don’t associate a lot of risks with this medication, so we didn’t think it would hurt. But we lost track of the medications given. When we looked in her throat for an exam, we saw that the liquid was still in her throat, she was absorbing it very slowly and getting more and more of the Benadryl. This can cause delirium and confusion.

Lown: How do you think this situation could have been avoided? 

Dr. Nieves: After the fact we were thinking, where did we go wrong? It might have been prevented if we had a pharmacist on our team, which is the case with many teams at UPMC. We have to be much more alert to the fact of medications that are started should be scrutinized, especially with elderly patients. We can’t automatically consider medications safe, but think, what are we treating with it, what are potential side effects, what could we be using that’s better? 

This goes hand in hand with being vigilant about medication we start people on. For the rest of that month we were very cognizant of the different medications we were starting. 

Lown: Is this type of case common in hospitals?

Dr. Nieves: This is not an isolated incident. After looking at some of the research on contraindicted medications (medications that aren’t supposed to be taken together), we saw that it’s exceedingly common among older adults.

Part of the problem is fragmentation of care, which happens everywhere. It’s not like one particular person made a mistake, but no one is taking responsibility. That’s why at UPMC we try to have multidisciplinary teams – have a nurse, pharmacist, social workers, physical therapist – to try and see different aspects of the same case. It all boils down to communication and clear lines of communication, between the clinicians and patients, and between members of the care team.

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