Health Care or Mis-Care

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[Although I know that most people prefer to watch inspirational videos rather than harsh ones like the one I am showing in the next frame, how our society treats the elderly needs to be looked at in all of its harsh realities.  So for the next few weeks to parallel the blogs I have been writing about the elderly, the video will remain.  Please do view it, because in order to change things, one has to confront square in the face what is or can be unpleasant.  Bear with me.  I promise the next video will be inspirational. ]

In my last two blogs,  I have been exploring anti-psychotic drugs and the elderly.  According to a research done by the University of Florida in 2010,  70% of those entering nursing homes end up on psycho-active drugs within three months of entering the home in spite of having no prior history of psychotic problems. Although dementia may occur in old age, more often than not, the delirious or dementia like behaviors are most likely caused by medication or the interactions of several medications the elderly person may be taking.  Benzodiazepines, opiates and tricycic anti-depressants are the main culprits.  These pills come in very many variations and are extremely prevalent in our society.  Today’s blog is exploring the effects that these drugs can have on older users.

AFFECTS ON OLDER PEOPLE

As one ages, The body’s ability to clear drugs decreases often because of a normal age-related decrease in kidney and liver function. This results in a greater accumulation of drugs in the body.

Secondly, Older patients are often prescribed multiple drugs at the same time. Due to complicated interactions between different drugs, side effects can become more prominent.

Last, Some research have demonstrated that neurotransmitters become naturally imbalanced as people age, increasing the brain’s sensitivity to drugs that have activity in the central nervous system.

With the regular use of anti-psychotic drugs in nursing homes, it is no wonder that the Rovner, et al study concluded that nursing homes were “de facto psychiatric institutions.”

Let’s look at the above facts in more detail:

Number 1.  When doctor’s prescribe medication, they often prescribe the full dose without recognizing that in an older patient, “the body’s ability to clear drugs decreases with age.” For example the equivalent dose of diazepam (a short-acting Benzodiazepine) in an elderly individual on lorazepam (a long-acting Benzodiazepine) should be up to half of what would be expected in a younger individual.  Giving full doses of these medications are sure to cause the side effects to increase in severity the more the drug accumulates in the system.

Paradoxically, an overdose of Benzodiazepines can cause the effects it has been prescribed to diminish, ie, anxiety, delirium, combativeness, hallucinations, and aggression.[ (Wikipedia)

Number 2: “Older patients are often prescribed multiple drugs” many patients do not realize that they are taking too many drugs or taking drugs that might interact with the other drugs in an adverse way. Sometimes they may have two prescriptions for the same drug under two different names, thus inadvertently increasing the dosage.

With the fact that “Some research suggest that neurotransmitters” change as we age affecting the brain’s sensitivity to drugs continues the argument that prescribing drugs to older patients has to be done with extreme care.

With all these factors at play, it becomes of utmost importance, then, that in-depth evaluations are done if and/or when an elderly person begins to manifest dementia-like symptoms.

Public Citizens points out:

“Because cognitive impairment caused by drugs is so frequently overlooked, it is important that when symptoms of confusion, altered concentration or difficulty thinking occur that you and your physician review any medications you are taking to determine if any of them might be the cause.

Fortunately, if the cause is a medication, your symptoms should go away or become less severe after stopping the drug, even if it takes weeks or months. (http://www.worstpills.org/includes/page.cfm?op_id=459)”

And Dr. Gary Oberlender, a Specialist in Geriatric medicines,  points out that

“Dementia as the cause of a senior’s cognitive decline should only be considered after a thoughtful and thorough medical evaluation has excluded a potentially reversible cause. The list of common causes of dementia in seniors is short. It includes Alzheimer’s disease, vascular dementia (stroke), Parkinson’s disease, Lewy body dementia, and alcoholic dementia.”

In recent months, the overuse of anti-psychotic drugs is beginning to be noticed.  In an article that appeared in The Telegraph, doctors can get up to five years jail time in the British Isles for prescribing these drugs to the elderly.  Here in the U.S., nursing homes are being forced to reduce their use of anti-psychotic drugs 

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Nursing Homes as De Facto Psychiatric Institutions

Assorted Medicine Pills in Caps

[Continuation of blog on anti-psychotic drugs for the elderly 2011]

“….within three months of admission, 70 percent or more of nursing home residents are on at least one medication with psychoactive properties and 15 to 20 percent are on four or more,” according to a study that was done by the University of Florida in 2010 and reported by Aging Today.  The study also noted that most residents who are admitted to nursing homes come without a history of either psychiatric diagnoses or treatment.

Although dementia does strike some older individuals as a “side effect” of aging, there is more and more acknowledgement that a lot of dementia-like symptoms are caused by the interactions of drugs.

According to a study done by the citizen advocacy group, Public Citizens, Worstpills.org (http://www.worstpills.org/includes/page.cfm?op_id=459):

“As people age, they become more susceptible to delirium and dementia** caused by drugs. This is known as drug-induced cognitive impairment, and it is an important syndrome to recognize….

Both in the hospital and office settings, drug-induced cognitive impairment is often overlooked [emphasis added] and attributed to an underlying medical illness or merely to “old age,” when it is actually a side-effect of a drug. In many cases, the reason for prescribing the culprit drug is questionable, or the cognitive impairment is related to taking multiple drugs at once.”

A study done in 1990 by Barry Rovner, et al which appeared in an issue of International Psychogeriatrics found that there was a high prevalence of mental health problems in nursing homes, so much so, that they concluded that nursing homes “can be viewed as de facto psychiatric institutions.”

Dr. Gary Oberlender, a Specialist in Geriatric Medicine, has done many evaluations of older individuals who have been diagnosed with dementia.  He concludes that:

“…..cognitive decline in a senior does not necessarily mean that the person has Alzheimer’s disease, or even that the person has dementia. There are many potential causes for why a senior might have memory loss, disorientation, trouble concentrating, loss of interest, or any of the other common manifestations of cognitive decline.

It is important to recognize that for many seniors, the ability to think clearly and maintain normal cognitive function is a very fragile thing. For some seniors, cognitive performance is the weakest link in their chain. It is the first thing to become impaired when faced with a stressful situation. Any physical, emotional, or even environmental stress can tip the balance and push them over the cognitive cliff.”

One can easily imagine the stress that an elderly person might feel when being moved from their home into a strange situation with strange people manipulating them physically (helping them change and bathe, cleaning them, etc.), surrounded by strangers and eating unfamiliar foods, having to follow a whole schedule that might be different from the one that they had been living.

Dr. Oberlender continues:

“Drug side effects or the onset of depression manifesting as cognitive decline are very common in seniors — more common than the general public or even many health care providers appreciate.

Other potential causes for cognitive decline in seniors include impaired hearing or not listening (these are two different things!); anxiety; vitamin B-12 deficiency; stroke or poor blood flow to the brain; thyroid disease; anemia; poorly controlled diabetes, hypertension, or heart disease; and inadequate nutrition.

None of these are causes of dementia but any one of them can cause a senior to experience significant cognitive decline and look for all the world as if they have dementia! Furthermore, almost all of these potential causes has the potential to be reversed,(emphasis added) which in turn would improve or totally reverse the cognitive decline.”

PSYCHIATRIC PROFILE OF NURSING HOME RESIDENTS

The Rovner, et al study found that there were  “three main categories of residents with psychiatric problems in nursing homes: Those with serious mental illness, those with dementia and behavioral problems, and those who are anxious or depressed.”  The last category, according to the study, is caused by “reduced functioning caused by medical problems and difficulties adjusting to nursing home life.”  Interestingly, there does not seem to have been further exploration done to see whether the second category, ie dementia and behavioral problems, might not be caused by the same reasons.

CULPRITS

There are three drugs regularly prescribed that have side effects that can cause dementia like symptoms:

Benzodiazepines:  These are tranquilizers and sleeping pills which are often prescribed for anxiety, to sedate chronically ill patients, or patients that are planning to undergo surgery.  They are highly addictive and there is a withdrawal that does occur if stopped.

“People who take benzodiazepines chronically for anxiety, which is not recommended, can also develop more chronic cognitive impairment. Furthermore, because addiction to benzodiazepines is common, stopping them abruptly can result in a withdrawal syndrome similar to what is seen with alcohol withdrawal, including sweating, agitation, confusion, hallucinations and even seizures.”

One can see that these combinations are in and of themselves not great but if a patient does not recognize that certain symptoms they are experiencing are being caused by the medication or from withdrawals by stopping the medication, they end up being caught in a cycle of pills and counter-pills to try and alleviate the symptoms.

Opiates: We know that opiates can cause delirium and fogginess of thinking.  They are used quite regularly to alleviate pain of any kind — from a sports injury to cancer.  As with Benzodiazepines, their effectiveness diminishes with use.  The response is to increase the dosage, which increases the symptoms.   Opiates can cause delirium and the more chronic cognitive changes seen in dementia.

Tricyclic antidepressants:  Although an older version of anti-depressant, they continue to be used for severe depression and also for pain symptoms, particularly neuropathy.

Since cognitive impairment symptoms are generally attributable to these three drugs, we need to ask how these drugs might affect an older person.

[Continue on Health Care or Mis-Care to come out next week]

© Yvonne Behrens, M.Ed  2011

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