October 2006

In this Edition:

Homecare Falls Short According to a Racent Study
Medication Managementy
Medication Management & Health Advocacy
Tips for Medication Management


Homecare Falls Short According to a Recent Study
by Rona Bartelstone LCSW, BCD, CMC, Chief Executive Officer

The United Hospital Fund of New York recently completed a study that was reported in The Millbank Quarterly in June 2006 demonstrating that caregivers of patients with chronic conditions "receive inadequate support from healthcare providers." This study followed family caregivers - the majority of whom were women with a mean age of 57 - who provided "substantial" amounts of care to their family member with a stroke or brain injury.

The family caregivers reported several concerns to the researchers. Typically, family caregivers did not understand how the level of homecare services was determined, who was paying for what, which agencies supplied different kinds of worker and what they should expect from each. Nearly 40% of the caregivers reported that they found out about termination of services, just one day before the end of care and usually from a therapist. There was little use of social work services to help family caregivers transition from funded services to community agencies and private care. Between one third and one half of the caregivers reported being unprepared for the homecare services to end. This resulted in caregivers reporting significant levels of isolation, anxiety and depression.

What this study tells us is that family caregivers, who provide 80% of all of the chronic custodial and skilled care services in the US, are unprepared for this growing role and that professionals need to provide better transition support.

Family caregivers are an important resource in the delivery of healthcare services. Therefore, it is imperative that health professionals, especially physicians whose practices are primarily made up of older adults must become more sensitized to and aware of other resources to support family caregivers. Although the physician is already under time constraints, it is to their benefit to help connect patients with other services in the community. This simple task can help the elder to remain safe and independent for a longer period of time, and therefore reduce expensive crises. It is also imperative to support family caregivers, especially when the caregiver is an aged spouse, or there is a good chance that the spouse will pre-decease the person in need of care. When this happens it often results in the expensive and less desirable institutionalization of the care recipient.

Although the United Hospital Fund study focused on families who were coping with stroke and brain injury, the same conclusions can be drawn for families providing care for someone with Alzheimer's disease, Parkinson's, diabetes, multiple sclerosis and a host of other chronic illnesses. In fact, Diane Lade reported in the Sun Sentinel in August 2006 about family caregivers who received diagnoses of a dementing illness and were sent into the community with no guidance or support for how to cope with the degenerative nature of the disease process. The caregiver in Ms. Lade's article reported a sense of frustration and fear about how she would cope with the daily challenges of caring for her father. The caregiver who receives a new diagnosis about a loved one is dealing with their own sense of grief, while trying to figure out what to do about this new information.

The American Association of Geriatric Psychiatry has taken the position that health professionals need to take a more active role in helping families to cope with these chronic illnesses. They have recently published a checklist that outlines non-medical, but critical areas that practitioners need to discuss with patients and families. This discussion must also include information about other resources that can provide support for the new roles that the caregiver will be assuming.

Clearly, the physician cannot be the single person to provide education, emotional support and resources to the family. However, physician offices must begin to arm themselves with resource information for community resources, private care managers, respite services, driver evaluation programs, financial and legal advisors and definitions about the different types of care. Caregiver education and emotional support will quickly become a more critical need as the Baby Boom generation begins to address their age related health challenges and the increase of chronic health care needs. It will not longer be acceptable for physicians to work in isolation from the rest of the caregiving team.

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Medication Managementy
by Sandy Dunlap, RN, LCSW, Director of Nursing

Seniors use more medications than any other age group. Multiple medical problems often mean multiple physicians who are all prescribing medications. In addition to prescribed medication, many seniors take over the counter pills to combat their ailments. They may even take their spouse's, neighbor's or friend's pills because "it helped them."

Medications are prescribed in varying dosages and for different times. Some are taken with meals, after meals, or before meals. Others are taken once or more daily, once weekly, or at bedtime. All of this can be very confusing and stressful even for seniors with no memory loss. For those with even mild memory loss, the task of taking medications may become overwhelming. They may forget to take their medications completely, take multiple dosages, or take them incorrectly. There are many reasons why taking medications can be dangerous for the older adult.

Frequently the senior forgets to tell their physician that they have been prescribed a medication by another physician and the doctor may prescribe something that can cause a negative or harmful response. Often the patient does not remember the name of the medication they are taking or what the medication is for, stating "It is something for my heart". They may mistakenly believe that more medication will cure them faster. Physical problems such as loss of eyesight or physical dexterity may hinder their ability to take the correct medication. For example, the pill bottle will be left open because it is easier and then the pills are spilled and perhaps replaced in the wrong bottle.

There are emotional or psychological issues related to taking medication also. Some people are in denial of the need for medication. Others are feeling better so they stop taking their pills saying "I don't need it any more." They do not understand that they feel better because they are taking the pills and stopping medication without the physician's approval can lead to relapse of the original problem or other adverse effects. Some medications must be gradually reduced in dosage prior to discontinuation to avoid a negative problem. A major reason given by seniors for stopping medication is cost. Even when there are adequate financial resources, the older adult may skip dosages because the pill is very expensive.

In doing a random sample of 50 of our patients, the average number of prescribed medication is 10. If half of the pills are once daily and the others are more, there can easily be 15 or 20 pills taken. One senior has 28 prescriptions all taken at varied times and dosages.

Often when family does not live nearby, they question their loved about health but never think to ask about their medications. An awareness of the potential problems can alert you that additional help may be needed to ensure the safety or well being of your loved one. For this reason, Rona Bartelstone Care Management & Home Healthcare provides nurses who are able to review medications and fill medication box dispensers. This enables the elder, the family and the multiple physicians to know that the person is in compliance with the maximum medication routine for the individual's needs.

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Sam seemed to be declining too quickly and none of the doctors could pinpoint why. He did have multiple medical diagnoses, but all of his symptoms were not accounted for by them. One of Sam's problems was his limited speech, although he didn't have dementia.

Sam also had lots of medications with a very complicated schedule for taking them. His medications changed frequently, which often caused him confusion about which medications he was still taking and exactly when he was to take each one. This meant that Sam didn't always get the medication that he needed. Furthermore, there was a problem of communication among the several doctors who were treating Sam. Since they didn't always share information, there were times when Sam was taking medications that were not supposed to be taken with other prescribed medications.

Sandra Goldberg (Sandy), RN and Clinical Director of Rona Bartelstone Care Management & Home Healthcare began to make nursing visits to fill Sam's medication boxes and to monitor his health at home. Sandra also provided the live-in aide with advice about helping Sam to communicate better, despite his speech limitations.

Because of all of the confusion about his medication and her concerns about his speech problems, Sandy did several things. First she contacted all of the doctors to do a review of his medications and clarify the schedule and dosages for each one. She was able to set up his medication boxes and train the aide to provide the proper reminders, so that Sam could be compliant with his medication routine. Sandy also felt that we needed to have a better understanding of the causes of his speech problem, so she arranged for Sam to be seen at a Memory Disorder Center to determine the cause of this problem. As a result of this visit, the neurologist put Sam on a new medication that helped to improve his speech to a limited degree. Although this was a small change for Sam, it made a significant difference in the quality of his life and his ability to relate to his aide and his family.

As a result of the work that Sandy did to better manage his medications, Sam's diabetes and hypertension are better controlled. His appetite is improved and therefore he is eating better, which gives him more energy. This has helped to ease his depression enough that he is able to be a little more social. Although Sam will continue to become more frail over time, his quality of life has been improved by the ability to better handle his daily medication, nutrition and activity. The results of better medication management and health advocacy work provided by Clinical Director, Sandra Goldberg will continue to enhance the quality and wellbeing of his life.

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Tips for Medication Management