Category Archives: Seniors (65+)
Amal Trivedi, MD, MPH, is an alumnus of the Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Physician Faculty Scholars program. He is an assistant professor of health services, policy and practice at Brown University and a hospitalist at the Providence VA Medical Center. His co-author, Danya Qato, PharmD, MPH, is a pharmacist and doctoral candidate in health services research at Brown University. They recently published a study that finds older patients are routinely prescribed potentially harmful drugs, particularly in the South.
Human Capital Blog: Why did you decide to look at this particular topic? And why are some drugs considered high-risk for elderly patients?
Danya Qato and Amal Trivedi: Adverse drug events are an important public health problem. For the elderly, such events are often precipitated by use of potentially inappropriate or high-risk medications. Over the past several decades, clinicians and researchers have sought to identify medications that should be used with caution in the elderly. These high-risk medications should be avoided among people 65 years of age or older because the associated adverse effects outweigh potential benefits or because safer alternatives are available. Elderly patients are susceptible to these medications because they have more chronic illness, greater frailty, and an altered ability to metabolize drugs. The Centers for Medicare and Medicaid Services now require all Medicare Advantage plans to report on the use of high-risk medications among their enrollees.
We undertook this study because successful efforts to reduce high-risk medication use in the elderly require knowledge of how prescribing of these agents varies geographically and the factors that predict their use. Half of persons aged 65 and older use three or more prescription medications a day. Therefore, potentially inappropriate use of medications in the elderly has important implications for health care spending and quality.
Tootsie’s Story, Continued: A Family Wonders Whether Nurse-Led Care Coordination Might Have Prolonged a Life
Jennifer Bellot, PhD, RN, MHSA, is an assistant professor at Thomas Jefferson University and a Robert Wood Johnson Foundation Nurse Faculty Scholar. Yesterday, she blogged about the death of her beloved grandmother, Tootsie, due to complications from medical error that began with an overdose of Synthroid. This is Part Two of Bellot’s blog post.
In 2010, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) joined resources and released The Future of Nursing: Leading Change, Advancing Health. This landmark report included many recommendations, and a full-scale Campaign for Action is in place that will transform nursing for years to come. Among the many themes advocated in this report is the tenet that nurses should be the very core of reinventing the American health care system. The report encourages the health care system to lean, and lean heavily, upon the skill set and resources of nurses to facilitate access to higher quality care at a lower cost.
At present, we have a health care system that is technology and intervention heavy when we know our population demographics are rapidly changing and technological intervention is not always the right answer. We have a growing need for a system that instead focuses on addressing chronic disease management, prevention and wellness care. Nurses are well positioned to support a system with these foci, managing care of the older adult in the community before inpatient care becomes necessary. Specifically in the outpatient setting, nurse coordinated care that is, by definition, proactive, holistic and comprehensive will help shift the focus of care from acute and episodic to chronic and preventive.
Comilla Sasson, MD, MS, FACEP is an attending physician at the University of Colorado Hospital and Assistant Professor in the Department of Emergency Medicine at the University of Colorado. Sasson was a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan from 2007 to 2010. Her latest study is published in the October 25th, 2012 issue of the New England Journal of Medicine.
Dead. How do you make someone “undead?” How, with just your two hands, can you prolong the time that paramedics have to restart a person’s heart? How can a normal, ordinary person make a difference and literally save a life?
We know that a person’s chances of surviving an out-of-hospital sudden heart arrest decreases by 10 percent for every one minute he/she does not get CPR (cardiopulmonary resuscitation). I had learned about hands-only CPR in my medical training. Hands-only CPR is where all you have to do is push hard and fast (to the tune of “Staying Alive”) at a 100 times a minute until helps arrives.
But time and time again, I cared for African-American patients in Atlanta who had laid in their families’ homes for critical minutes as their brains slowly died from a lack of blood supply from the heart. Their hearts had stopped and no one called 911. No one placed their hands on the chest and started doing hands-only CPR.
Maybe this is just Atlanta? Is it the color of a person’s skin or is the place where he or she collapses that makes the difference?
In my Robert Wood Johnson Foundation Clinical Scholars Program (RWJCSP) at the University of Michigan (2007-2010), I learned about the importance of neighborhoods in determining a person’s health. After wading through the literature, my a priori hypothesis was that having someone stop to provide CPR is completely dependent upon others; therefore, the neighborhood plays a large role in whether or not someone does CPR.
After consulting with my two RWJCSP alumni mentors, David Magid, MD, MPH, and Arthur Kellermann, MD, MPH, FACEP, the question became clear: What role does the racial and socioeconomic composition of a neighborhood have on an individual’s likelihood of receiving life-saving bystander CPR?
Cleopatra M. Abdou, PhD, is an assistant professor of gerontology at the University of Southern California, and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program. This post is part of a series on the RWJF Health & Society Scholars program, running in conjunction with the program’s tenth anniversary. The RWJF Health & Society Scholars program is designed to build the nation’s capacity for research, leadership and policy change to address the multiple determinants of population health.
Gerontology, the study of aging, is a diverse field that integrates the biological, social-behavioral, and health sciences, as well as public policy. This means that gerontological research addresses a vast range of questions. One type of question asked by gerontologists, including myself, has to do with intergenerational processes. My own research investigates the intergenerational transmission of culture, social identities, conceptions of stress and success, and, ultimately, health. For example, how do our notions of, and relationships to, family affect our health at critical points in the lifespan? More specifically, how do familial roles and responsibilities, such as marrying, reproducing, and caring for grandchildren, correlate with life satisfaction and longevity?
My four siblings and I are the first American-born generation in our family. Our parents came to the United States from Egypt in 1969, and I am strongly identified as both an American and an Egyptian. Anyone who has complex or competing identities knows that it’s a mixed bag—a blessing and a curse. Recently, as I boarded a plane in Cairo to return to the United States, I found myself sobbing with what I think was a kind of homesickness. As happy as I was to return to my immediate family and orderly life in The States, I mourned leaving the land of my parents and all of our parents before them, especially during this important time in Egypt’s history.
Cautiously Optimistic about the Affordable Care Act - If Older Americans and Their Advocates Speak Out as It Is Implemented
This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Margaret P. Moss, PhD, JD, RN, FAAN, is associate professor, Yale School of Nursing and an alumna of the RWJF Health Policy Fellows program (2008 – 2009).
As I reflect upon the monumental decision by the Supreme Court to uphold the Affordable Care Act, I can’t help but be awed by how the branches of government are alive and well and operating just as they were designed to work. But as I filter what this decision will mean for the groups I am most closely tied with professionally and personally, I am struck at how the ‘system’—public and private—has largely let them down.
My professional focus has been in aging, and in particular American Indian aging. My profession is nursing, with a background in law. I am optimistic that these groups, both patient and provider, will be lifted and solidified by the spirit of this law. But I am cautious that the letter of the law must be handled with an eye toward impact, unintended consequences, short-term pilot and demonstration projects, and authorized but unfunded rules.
There can be no question that there are provisions in the Act that no-one would dispute are positive. The most cited are: 1) no more pre-existing condition exclusions, 2) the ability to keep adult children under parents’ plans until after college age, and 3) widening the net for coverage to include those now uninsured. The opposing point being moot now with the Supreme Court’s decision, we must look forward and responsibly carry out the law before us. Unfortunately, the devil, as they say, is in the details.
Hospital units designed specifically for the care of older patients could save as much as $6 billion a year, a study from the University of California at San Francisco (UCSF) finds. In a randomized controlled trial, patients in “acute care for elders units” had shorter hospital stays and incurred lower hospital costs than patients in traditional inpatient hospital settings. At the same time, patients’ functional abilities were maintained, and hospital readmission rates did not increase.
The Acute Care for Elders program (ACE) relies on a specially trained interdisciplinary team, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. The team assesses patients daily, and nurses are given an increased level of independence and accountability.
“Part of what ACE does is improve communication and decrease work. And that’s a strategy that’s generally popular with lots of folks involved,” Seth Landefeld, MD, senior author and chief of the UCSF Division of Geriatrics, said. “What we found was that ACE decreased miscommunication and it decreased the number of pages nurses had to make to doctors. Having people work together actually saved people time and reduced work down the line.”
The study was published in the June 2012 issue of Health Affairs.
With unprecedented numbers of Americans nearing old age, experts say the health care system will need tens of thousands more providers with training in geriatrics to handle the population’s increasing, and increasingly complex, needs. But too few physicians, nurses and dentists who specialize in geriatrics, or who have completed geriatric training, are in the pipeline.
Last week, the New York Times explored the problem, along with some emerging solutions. The story observes that geriatricians usually make much less money than other primary care providers or specialists, and Medicare reimbursements for geriatric care are comparatively low. For a doctor with debt from medical school, those factors can be a powerful deterrent to going into the field. “Geriatrics is also seen as a plodding area of medicine, set apart from the glamour of life-saving heroics,” the New York Times asserts. “That may be why the specialty has made little headway among nurses as well.”
Completing geriatric training after medical school can also pose financial challenges, as providers may be reluctant to take a financial hit for programs that would keep them out of the workplace for longer. With that in mind, the geriatric residency required for board certification has been reduced from two years to one, and the federal government and several private groups offer funding for geriatric education fellowships. The American Geriatrics Society also offers a variety of flexible training options, including weekend workshops and online courses.
Similar barriers keep nurses from specializing in geriatrics. Fewer than 1 percent of registered nurses and fewer than 3 percent of advanced practice registered nurses are certified in geriatrics, according to the American Geriatrics Society.
Geriatrics should be integrated into nursing school curricula, experts say, as a stand-alone component or included in clinical practice.
By Jennifer L. Wolff, PhD, and Robert Wood Johnson Foundation Physician Faculty Scholar Cynthia M. Boyd, MD, MPH
It is widely recognized that family members and trusted friends make an enormous difference by assisting disabled older adults with daily household and personal activities. There is less awareness, however, that families and trusted friends also often help older adults navigate our complex and fragmented health care system to get the best care possible—by scheduling and arranging transportation to appointments, engaging in medical decision-making, or overseeing adherence to health care treatments. As we learn more about how older adults navigate the health system, it is becoming clear that they often do so with the support and active engagement of a “family companion” —and that this role is enduring.
In a study we published in the January issue of the Journal of the American Geriatrics Society (JAGS), we found that nearly one-third of adults over age 65 were accompanied by what we called a “family companion” during routine physician visits. These companions were almost always family members (93.3 percent), and they typically accompanied their loved one to physician visits on a regular basis—70.3 percent were identified as “always” present.
We were surprised by the persistence and consistency of family companion involvement. Three quarters (74.5 percent) of older adults continued to be accompanied by a companion at one year follow-up, nearly always the same family companion (87.1 percent).
By RWJF Executive Nurse Fellows alumna Keela Herr, PhD, RN, FAAN, Professor and Associate Dean for Faculty, The University of Iowa College of Nursing, Co-Director, Iowa John A. Hartford Center of Geriatric Nursing Excellence
A recent article in the New York Times highlighted an important study by Tim Platts-Mills, MD, and his colleagues that examined pain treatment of older adults in emergency departments across the country. They found that people over age 75 are about 20 percent less likely to have their pain treated than are middle-aged patients. More importantly, the researchers found that in the over-75 group, only 53 percent of those who reported pain received an analgesic or a prescription for one. In patients with severe pain, only 65 percent received an analgesic.
These findings indicate that we still have a lot of work to do to address the under-treatment of pain in older people. The findings contribute to data collected in other care settings (such as hospitals, nursing homes and hospices) that also show inadequate treatment of pain in older people.
Attention was first drawn to the problem in the early 1990s, and researchers and clinicians have since contributed knowledge to guide provider practices to improve pain care. Yet, here we are 20 years later, and the picture hasn’t improved much.
Many organizations and groups (such as the International Association for the Study of Pain, the American Pain Society, the American Society for Pain Management Nursing, the American Geriatric Society, and the American Pain Foundation) are committed to quality pain care for all people. These groups work to raise awareness, provide education and resources, develop clinical practice guidelines and advocate for research and policies that support good care.
Jennie Chin Hansen, R.N., M.S., F.A.A.N. is the chief executive officer of the American Geriatrics Society (AGS) and past president of the AARP. Prior to joining the AGS, she was CEO for OnLok, Inc., a nonprofit family of organizations providing integrated and comprehensive care community-based services in San Francisco. Read more about her work.
Since the release of the October 2010 Institute of Medicine (IOM) report on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, there has been significant interest in the key report recommendations: having nurses practice to the full extent of their education and training, ensuring a strong anchor in baccalaureate nursing education, positioning nurses as strong and full partners in the redesign and leadership of an effective health care system, and creating a sound approach to projecting nursing workforce needs.
My particular interest in each of these areas is to see that our profession, as well as other providers and caregivers, will implement these recommendations with full consideration of our rapidly expanding aging population. It is this growth of age, diversity, and chronicity, separately and together, that will shape and define the type of workforce and the competencies needed for nurses to be effective stakeholders in and contributors to our health care system.