Hospice eNews 
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What the Media Said about End-of-Life Care This Week
Week of
August 29, 2005
…a
service of
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ELDERS SUSCEPTIBLE TO “POLYPHARMACY” ISSUES
The
August 1 issue of RN has an article that addresses the higher risks
faced by elderly patients who are taking multiple medications. Elderly patients taking several
medications (polypharmacy) are “at high risk for
drug-related problems,” say authors James Wooten and Julie Galavis. Aging
not only affects how the body processes medications, but the average elderly
patient takes four or five prescriptions and two over-the-counter (OTC)
medications. Additionally, elders “are
also more likely to be taking a medication that has been prescribed
inappropriately – one that’s unnecessary, ineffective, or potentially dangerous
– and to suffer an adverse drug event (ADE).” One study of 150,000 elders found that 29%
had gotten at least one potentially inappropriate drug. Another study, of 27,600 Medicare patients,
found more than 1,500 ADEs in one year.
Most ADEs occur because of drug interactions, and the risk rises
dramatically as the number of medications taken increases. Some estimates put
the risk of drug interactions at 6% in patients taking two medications a day
and 50% in those taking five.
The authors cite
several factors that contribute to the number of medications taken by elderly
patients. One is that there are more
drugs than ever before available for them.
Drugs formerly available only by prescription are now OTC and their use
is increasing. Alternative and
complementary medicines are increasing. Patients over 65 are more likely to have
several chronic conditions and may be treated by several different
physicians. Pharmacies check for drug
interactions only on the medications that they know the patient is taking, so
patients who use different pharmacies are more likely to have an ADE. Physicians may interpret reactions to one
medication as symptoms of another disease and prescribe even more medication to
treat it.
Aging affects both pharmacodynamics, the effects of the drug on the body and
pharmacokinetics, the effects of the body on the drug. Pharmacokinetics involves absorption,
distribution and clearance of medications.
Oral absorption in the elderly is affected the least, but absorption
through the skin may increase. Drugs are
distributed into either fat or water in the body, so fat-soluble medications
may remain in the body longer and water-soluble medications may have higher
than expected levels. Clearance may be
slower in elders because of decreased liver and kidney function.
Pharmacodynamics
are affected by changes in drug receptors and patients
may be more or less sensitive to some medications. In general, the elderly are far more
susceptible than younger patients to drugs that act on the central nervous
system because of changes in the blood-brain barrier.
In addition to ADE’s, elders may have drug-disease interactions when
medications adversely affect a disease. For example, anticholinergic
drugs can affect Alzheimer’s, benign prostatic
hyperplasia and glaucoma.
The authors suggest
ways that healthcare providers can help to protect elderly patients.
* Know which drugs are culprits for
frequent problems for the elderly.
* Take a thorough drug history,
including OTC and herbal medicines. Use
the “brown bag” method, in which the patient brings in all medications, rather
than depending on the patient to remember what he or she takes.
* Check that the patient is taking
prescription medicine as prescribed.
* Monitor lab values carefully,
particularly those that show liver and kidney function. Be aware that serum creatinine
may give inaccurate values, because elders often have less body mass than
younger patients.
* Consider any new signs and symptoms to
be drug-related until proven otherwise.
GI distress and CNS symptoms are likely candidates for ADEs.
* Teach patients to use only one
pharmacy.
* If you prescribe, “start low and go
slow.” Doses for the elderly often are
only one-half to one-third the standard adult dose. Give single drugs to treat conditions rather
than combinations. Review the medical
record and eliminate duplicate or unnecessary drugs. (RN,
2005;68(8):44)
HARVARD WOMEN’S HEALTH WATCH PROMOTES HOSPICE
An article in Harvard Women’s Health Watch explores
the basics of hospice and says, “Hospice care offers end-of-life comfort and
support.” The article encourages readers
to think about hospice before they need it. The author includes a doctor’s perspective on
hospice and also covers the history and philosophy of hospice, Medicare and
insurance information.
The author offers a
section that explains what hospices do, explains the approach hospices take to
help consumers evaluate hospice programs and suggests the following questions
that readers should use to evaluate a hospice program:
* What services are available to
patients? To family
members?
* How much involvement do families have
in providing care?
* What roles do doctors, nurses and
other healthcare personnel play?
* Who is on the hospice team? How is the team trained? Screened?
Managed?
* How are pain and other symptoms
managed?
* Can services be moved to another
setting, such as home or healthcare facility, if the person’s condition
changes?
* Does the hospice offer bereavement
services? For how
long?
* Is the program accredited? How?
How is it reviewed and licensed?
Is it Medicare-certified?
* How are payments and billing
handled? The author also recommends that
patients and families get all financial arrangements in writing.
The article also
identifies and addresses the many reasons that readers should choose hospice
care. Hospice, says the article,
“allows people to end their lives as
comfortably as possible, surrounded by family and friends. Home-based hospice gives patients and their
families a greater sense of control than a hospital allows. And hospice places a much greater emphasis on
the spiritual and emotional aspects of dying.
That’s why it has become the choice of increasing numbers of the dying
and their families.”
Physician
Celeste Robb-Nicholson says, “Our duty as physicians is to help our patients
discover what’s good for them, and one way we can do that is by providing
information about hospice care. If your
doctor doesn’t start the discussion, consider starting it yourself. You may find that it allays fears about the
end of life and goes a long way toward building the sort of trusting
relationship among you, your family, and your physician that becomes very
important at the end.” (Harvard Women’s Health Watch, 9/1)
PAIN NOTES
* The FDA has issued a public
health advisory about the safe use of fentanyl
patches for pain, saying the FDA is “looking into reports of death and other serious side effects from
overdoses of the narcotic fentanyl in patients using
the fentanyl transdermal
skin patches for pain control.” See www.fda.gov/cder/drug/infopage/fentanyl/default.htm
for more information. (
* The brain will release its
own natural painkillers if a person believes that a medicine will relieve pain,
say the authors of a new
RESEARCH AND RESOURCE NOTES
*
* Moderately religious people
fear death more than those either more or less religious, according to a new
study of people born in the
* The National Institute on
Aging is offering a free fact sheet of cancer information in Spanish. You can order by calling 800-222-2225 or
going online to www.niapublications.org. (NIH
News, 8/15)
* A study from
* The new issue of the Journal of the American Geriatrics Society,
with a focus on the genetics of aging, is online at www.blackwell-synergy.com. Abstracts for many articles are available for
viewing. (Blackwell-Synergy Website).
* A study, originally
published in the Journal of Pain and
Symptom Management, reported on the use of The Palliative Care for Advanced
Disease (PCAD) protocol at the
* A study sponsored by
* September has been
designated Pain Awareness Month.
Activities at both the national and state levels will spotlight efforts
to broaden public awareness of pain.
Persons wishing to express concern to members of Congress before the
pain hearing of the Senate Health Subcommittee for Energy and Commerce should
click on “Take Action Now” at the website of the American Pain Foundation, www.painfoundation.org. An online resource guide is also available at
the website of the American Pain Society, www.ampainsoc.org. Click on “September is Pain Awareness
Month.” (American Pain Foundation
Website; American Pain Society Website)
* A half-day conference on
FDA’s efforts to stop the diversion of prescription painkillers will be held on
September 9 in
PUBLIC POLICY NOTES
* Fiscal year 2006 Medicare
payment rates for hospice were announced by CMS this week. The rates reflect a 3.7% increase over those
for FY2005. NHPCO created a resource
page in the Regulatory section of its website.
(NHPCO News Release, 8/25; CMS Website)
* CMS has released a revised
hospice cap amount for the year ending October 31, 2005. The new amount, $19,777.51, is an increase of
$814.04 over the amount published in August of this year. See www.cms.hhs.gov/manuals/pm_trans/R663CP.pdf
for more information. (CMS Website)
* CMS will allow a one-year
transition to the new Core Based Statistical Areas, which will replace the
Metropolitan Statistical Areas in April.
During the transition, a blended rate (50% of the old rate and 50% of
the new rate) will be in effect. Bob
Wardwell, of the Visiting Nurses Association of
America, expects that home health agencies will get the same transition. (Eli’s
Home Care Week, 8/15)
OTHER NOTES
* Two articles focus on the
need for advocacy for elders. “Alone
in Illness, Seeking Steady Arm to Lean On,” an article in The New York
Times, tells the story of Grace McCabe, a 75-year-old without family, who
must depend on a friend to be her emergency contact. In The San Diego Union-Tribune, an
article called “How Do You Know It’s Time?” reflects on author Marsha Kay Seff’s experience with her mother during her last illness.
(The New York Times, 8/26; The San Diego Union-Tribune, 8/20)
* NHPCO announced that The
Robert Wood Johnson Foundation has awarded $4.9 million for continued funding
of Caring Connections, NHPCO’s consumer program. The grant will support Caring Connections
through October 2007. (NHPCO Press Release, 8/11)
* AARP’s Watchdog Project
reports that the average price increase of brand-name drugs in the first three
months of 2005 was more than twice that of the Consumer Price Index and six
times that of the 75 most commonly used generic medications. (AARP
Website)
* In “The Living Will: A Vital Sign,” JoAnne Herina
Jeffreys, a Certified Elder Law Attorney, offers
suggestions to attorneys assisting elders in preparing end-of-life documents. Jeffreys is
co-author of Representing the Elderly
Client, Law and Practice. (
* Klotho,
a hormone made by a gene, suppresses aging in mice and may someday result in a
way to extend human life. “It’s a
long way from here to there,” though, says Dr. Makuto
Kuro-o, author of the article in Science. According to Kuro-o, humans have a near-identical version of the Klotho gene and “some studies show that variations of the Klotho gene are associated with extended life in
humans.” (RedNova Website, 8/25)