Saturday, April 15, 2017

How Many Pills Are Too Many?

By Austin Frakt
THE NEW HEALTH CARE APRIL 10, 2017


The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.

The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.

Deprescribing will work only if patients also get involved in the process. Only they can report adverse effects that they sense but that are not apparent to clinicians. And they need to be comfortable weaning from or dropping drugs that they are accustomed to and believe to be helpful.

Yet an increasing number of Americans — typically older ones with multiple chronic conditions — are taking drugs and supplements they don’t need, or so many of them that those substances are interacting with one another in harmful ways. Studies show that some patients can improve their health with fewer drugs.

Though many prescription drugs are highly valuable, taking them can also be dangerous, particularly taking a lot of them at once. The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.

About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.

Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.

Some are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.

Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.
Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it can reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”

Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.

Reprinted from: https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0

Monday, April 3, 2017

5 Ways Caregivers Can Build a Support System

Posted On 19 Jul 2016
By : Sally Abrahms


When you’re caring for your parents or in-laws, you’re often in fly-by-the-seat-of-your-pants mode. There’s a crisis. You react. There’s infinite scrambling to find resources (i.e. adult day care, a senior center, transportation), and meanwhile, your own life is teeming with additional responsibilities.
It’s hard to catch your breath, let alone consider your own future. You probably have an “I’ll worry about me later” mindset… Not smart!

Ways Caregivers Can Build a Support System

Thinking ahead about who will be there for you when you need care, what you want for yourself, and where you want to live, among other things, is something to begin considering now. It means positioning yourself so that when you are older, you will have as much control of your life as possible.
“The reality is that adult children do not plan for their future, long-term needs the same way their parents haven’t planned for theirs.” — Rhonda Caudell
You don’t have to take action today, but you do need a game plan. “The reality is that adult children do not plan for their future, long-term needs the same way their parents haven’t planned for theirs,” says Rhonda Caudell, a former nurse and geriatric care manager from Atlanta, who teaches an online course: “Crucial Conversations with Aging Parents Before It’s Too Late.”
Caudell believes that adult kids — you! — must break that cycle and be prepared. “You’re giving your kids a gift,” she says. Power of attorney? Check. Living will? Check. End-of-life and housing preferences? Check. But is building a strong support system on that list?
Today, one out of three baby boomers is single. They may have kids who live hours away. Or, even if they’re nearby, they are likely busy with their own lives. You need to count on you.
Want to boost or build a support system? Here’s what the experts suggest:

         1. Figure out what you don’t want.

You may feel you live too far away from your daughter and grandkids, that you will become too dependent on a nearby son, or that you love you can’t live without your community or neighborhood. If you stay in your big old house, it may need ongoing repairs or, with too many stairs, be too hard to navigate later on.

2. Create the life you want for your next phase.

Think about where you want to be, not only geographically but personally in the next 10 years. If you’re considering a move, figure out if you can afford it and what you will need to do to sell your home or condo in the future. Perhaps you can begin to do the work. Also, decide if you’ll have what you need when you need it (alternative transportation, doctors, movie theatres, restaurants  nearby). You might be the type who prefers to surround herself with people or not. Perhaps you want to live quietly.

3. Look around.

If there are enough people in your building or neighborhood who are at a similar age and stage, you might want to get to know one another and/or share services (caregiving, food bought in bulk, housekeeping).

4. Assess your friend situation.

If you want more caring, interesting, sports-minded (fill in the blank) people in your life, you will have to make an effort. Get involved in community activities and join committees or a walking group. Become a mentor or volunteer. Find a book club. Learn bridge. Meetups are a good way to connect with people who have common interests.
There are organizations like The Transition Network (TTN) with chapters around the country for professional women age 50+ “whose changing life situations lead them to seek new connections, resources and opportunities.” Some of its chapters offer the Caring Collaborative, an initiative made up of TTN members who are “there for each other” when help or company is needed.
Barbara Stahura is active in the Collaborative’s New York City chapter. “When you meet women in a social setting, it’s easier to pick up the phone and ask for help. “If you know people in advance you have those personal connections.” A health care consultant who left her full-time job, Stahura, 62 [63 in August] has no children, no siblings who are alive and a husband with a chronic illness. While she’s healthy now, she knows an accident or something else could trip her up anytime. “I now have friends I’ve met through Caring Collaborative I can count on who’ve said, ‘don’t worry, let me know if you need help.’ It’s very reassuring,” says Stahura.

5. Know your housing options.

There are several ways to ensure you will not be isolated, lonely and alone. One friend in her sixties plans to sell her condo and buy a house with her sister. It’ll be company, she’s decided, and by splitting expenses, they can live someplace they wouldn’t have been able to afford alone. It goes without saying that they will take care of each other as they grow older.
Some older adults are opting for cohousing. You have your own place but share some meals and communal space. There’s daily interaction with neighbors who become like extended family.
Continuing Care Retirement Communities (CCRCs or Life Plan Communities) — many with assisted living and skilled nursing — can be appealing, too. Not only are your medical needs taken care of, should you have them, but there are activities, stimulation and caring residents and staff. University-based retirement communities (UBRC) that are on or near college campuses and focus on lifelong learning are one type. There are more than 100 around the country.
The Village movement is also popular. You stay in your home and, for an annual fee, join a neighborhood “Village.” Members get discounted vetted service referrals (i.e. think home repairs, dog walking, a babysitter for your grandchild, transportation), and social opportunities, from museum trips, yoga classes or a group meal out.


Reprinted from: http://www.aplaceformom.com/blog/7-19-16-ways-caregivers-can-build-a-support-system/