About Medical Care for The Elderly

by Thomas Day

Featuring Dr. Rob Stall

The American Perspective on Aging and Health
Treating Medical Problems
Medications and the Elderly
Geriatric Physicians or Specialists in Aging Medicine
eHealth Services For the Elderly
Learn About Geriatric Medicine From Dr. Rob Stall

 

The American Perspective on Aging and Health

Americans' Attitudes on Aging

American society in general glorifies youth and fears or even despises old age. This is not the case in many other societies where age is associated with wisdom, knowledge and special status.

We see evidence of this bias towards older Americans especially in the media. In films and on TV old people are very often depicted as weak, indecisive, bumbling or even comic. We laugh at their misdeeds and forgive their mistakes knowing in the back of our minds that they are old and can't help themselves. We view them not as capable as younger people. It is rarely that we see older people depicted as decisive, strong or as leaders. We see this same attitude with large corporations and government employers. At a certain age, employees are encouraged or expected to "retire" to a new phase of their lives where they are not required to work for a living any longer. Retirement is presumably a reward for many years of dedication and hard work, but the underlying philosophy is more likely based on the idea that older workers are no longer productive or useful.

As Americans age we fear the deterioration of our bodies and the possible lack of security due to low income -- a byproduct of old-age. Some people in our country fight old age through cosmetic surgery, use of supplements, aggressive weight-loss programs or through overzealous physical training programs. Other people accept old age gracefully and adapt as well as they can. Still others refuse to grow old and resist aging by adopting social strategies such as denial, refusal to participate in life or becoming belligerent. (The angry old codger image)

Instead of taking the role as leaders in their families or in the community as is the case in some countries, the elderly in our country, even after successful careers in earlier years, simply become invisible. They waste their prodigious talents traveling, entertaining, socializing, watching TV or playing golf. They are rarely asked to assume responsible roles in the community. And unlike other cultures, older Americans often abandon themselves to control by other people, often their children and their health care providers. Instead of taking responsibility for their own decisions they will rely on children or others to make decisions for them. Many of them seem to enjoy the role of becoming dependent on others. And it is all too often the case that family and others pander to this submissive role of the elderly and we begin treating them like children.

This generally accepted perception of aging in our country has resulted in the elderly themselves and in the community at large regarding older people as less valuable than younger people. The assumption is that the elderly have lost the ability to think clearly, to learn new things and they are generally incapable of any physical activity other than walking or sitting. This attitude also carries over into the health treatment that older Americans receive.

The Older Person's Attitude towards His or Her Own Health

Many elderly buy into the notion that they themselves are no longer useful and as a result make little attempt to keep themselves healthy and active. After all, they are getting closer to the end of their lives and have no desire to try new things or to challenge themselves or to eat or exercise properly.

There is a great deal of anecdotal and research evidence that demonstrates older people can learn, can retain memory and can be actively involved in business and in the community. The lack of physical exercise, social involvement and mental stimulation in older Americans often leads to these people losing the ability to use their minds and their bodies. The older person's negative attitude towards aging becomes self-fulfilling.

Many reason that they have missed their opportunities in life when they were younger and it's too late to start over. As a result, many older people are intimidated by new ideas or by technology such as computers, not because they are incapable but simply because of their attitude. The idea of not being able to "teach an old dog new tricks" is in most cases an excuse. Obviously this mindset of failure and inability to perform becomes self-fulfilling. Not surprisingly, depression and suicide are more common in the elderly than in the younger population.

The negative attitude towards aging on the part of an older person has a direct impact on that person's health. Many studies show that people who are physically active have less joint pain, lower blood pressure, less depression, fewer heart attacks and a lower incidence of cancer. Proper nutrition also has the same affect on the aging process; it delays the onset of debilitating illness or disability.

According to James S. Marks, M.D., M.P.H., Director of the National Center for Chronic Disease Prevention and Health Promotion

".... Research has shown that poor health does not have to be an inevitable consequence of growing older. Death is inevitable, but, for many people, it need not be preceded by a slow, painful, and disability- ridden decline. Our nation will continue to age -- that we cannot change -- but we can delay and in many cases prevent illness and disability."

A study in 2000 from the Journal of the American Geriatric Society reports that inactive women at age 65 have a life expectancy of 12.7 years whereas highly active, non-smoking women at 65 have a life expectancy of 18.4 years. A report from the CDC indicates that very few older Americans get 30 minutes or more exercise for five days a week or more. The report states that up to 34% of adults age 65 to 74 are inactive and up to 44% or almost half of adults age 75 are inactive. A study From the US Preventative Services Task Force reveals that regular exercise can reduce life-threatening falls in the elderly by 58%. Another study showed that regular exercise reduced pain and increased function in joints of older Americans suffering from osteoarthritis. (Reduced the need for pain medications) Yet another study found that strength training was as effective as medication in reducing depressive symptoms in older adults. Other studies from the Department of Health and Human Services support the idea that older people who are responsible for their own health and their own health decisions are healthier than people who rely on others to make decisions for them.

Lack of activity and poor nutrition often lead to obesity. More than any other problem facing older people, obesity can have the worst effect on their health. It leads to joint degeneration, heart problems, stroke, congestive heart failure, diabetes and a whole raft of other chronic medical conditions. And obesity among all ages is becoming a national crisis.

Another health problem with the elderly is the overuse of alcohol, cigarettes and addictive medicines such as pain killers or tranquilizers. It is assumed by the elderly and by their family that long-term use of these substances has gotten to a point where it would be pointless or impossible to get the elder person to discontinue or cut back on their use. In other words older people are no longer useful so let them have their bad ways. "Everyone dies at some point; what does it matter what causes the death." For instance it is assumed that smoking has already done its damage and little could be achieved in stopping. Actually recent evidence indicates that no matter what the age, cessation of smoking can reduce the incidence of chronic lung disorders and improve lung function even after a few weeks.

No one knows the extent of abuse of alcohol or other addictive substances among the elderly simply because no definitive studies have ever been done and older abusers remain hidden and invisible to the public. Again this is reflective of our society's attitude towards the elderly. It is commonly felt, especially by doctors who prescribe addictive medications, that we should,

"Let them have their vices, it gives them comfort and relief from pain and they are old and are going to die anyway".

Because of this public attitude many elderly people waste the remainder of their lives living in alcohol or drug induced stupor. And their health suffers as well due to lack of activity and poor nutrition.

The average 75-year-old suffers from at least three chronic medical conditions and takes five or more medications. Oftentimes older people have resigned themselves to a life of suffering and pain. They are not particularly interested in changing or improving their medical condition but are simply waiting out the rest of their life. These people often exhibit a phenomenon known as "the reluctant patient". They will not listen to medical advice, they have little interest in their own health and they often don't take their medications properly or they overdose. Doctors and other health professionals treating reluctant patients don't get the information they need in terms of symptoms or progression of treatment. The patient will typically lie about his or her condition. It requires a greater understanding from medical professionals and encouragement or sometimes forceful intervention from family to help the reluctant patient understand his or her attitude and participate in his or her medical treatment. The result can often be improved health and a greater quality of life.

Families or others involved with an elderly person must recognize the all too common attitude of worthlessness, defeat and resignation from elderly loved ones and take corrective action. They should encourage and possibly even prod the older person to be stimulated mentally, socially and physically -- to be actively involved; to give him or her a purpose for living. But families should also be very careful not to become patronizing or controlling but be genuinely supportive in this process. Here are some ideas.

• Make sure an elderly loved one has challenging activities throughout the day instead of simply watching TV or viewing videos. This might include trips to interesting places, visiting senior centers, providing challenging games or puzzles, doing volunteer work, providing an opportunity to be involved in church work, offering stimulating conversation or working on an adult education class or college degree.
• If the person is interested, encourage him or her to become involved in handcraft, genealogies, creative design, writing, scrap booking or other challenging home oriented activities.
• Give them responsibility for taking care of pets such as a dog, a cat or a friendly bird. In addition, if feasible, allow them to care for plants as well. This strategy is used often in nursing homes to reduce depression in the elderly and to actually improve their health as well. It really works.
• If a caregiver for an older person cannot be present, make arrangements to enroll a loved one in adult day care. These providers often offer the same strategies we are talking about here.
• Provide opportunities for family and friends to come by and visit and encourage or even arrange such encounters.
• Provide opportunities for the older person to interact, teach and nurture children such as grandchildren or children in a day care center. This is an extremely effective strategy for helping the older person feel that he or she has a meaningful existence. And it has a dramatic impact on improving and maintaining health.
• Design or arrange an exercise program and come up with a way to encourage the older person to follow it.
• Understand the nutrition needs of an older loved one, especially the need for vitamins and minerals including iron. Get some books on the subject or go to the Internet. Make sure the person takes care of him or herself and eats properly. Fixing special meals, providing treats, getting takeout or going out to dinner can be fun and exciting for anyone regardless of age. Many elderly people neglect their own nutrition. Poor nutrition can cause all kinds of mental and physical problems in the elderly.
• Make sure an older person has opportunity to look good and have nice clothing. Make sure the person gets out in public, and tries dining out or going to a public event and can feel good about his or her appearance.

Aging and the Attitude of Health Care Providers

It is natural that health care providers such as doctors, pharmacists or nurses will have the same attitude towards aging as other Americans. Without proper geriatric care training, these people can fall into the same trap of treating the elderly differently from younger people. According to the Alliance for Aging Research,

"In recent years evidence has been mounting to suggest that, at all levels in the delivery of healthcare, there is a prevailing bias -ageism - that is at odds with the best interests of older people. This prejudice against the old in American healthcare is evidenced by scores of recent clinical studies, surveys and medical commentaries, many of which are referenced here. In this report, we outline five key dimensions of the ageist bias in which U.S. healthcare fails older Americans:

•  Healthcare professionals do not receive enough training in geriatrics to properly care for many older patients.
•  Older patients are less likely than younger people to receive preventive care.
•  Older patients are less likely to be tested or screened for diseases and other health problems.
•  Proven medical interventions for older patients are often ignored, leading to inappropriate or incomplete treatment.
•  Older people are consistently excluded from clinical trials, even though they are the largest users of approved drugs."

A fictional story, often used in the training of geriatric physicians, goes this way:

A 90 year old man meets with his doctor and complains about pain in his right knee. The doctor tells him, "Well Henry, what do you expect? You're 90 years old."

Henry replies, "But doctor my left knee is the same age as my right knee, there's no pain and it feels just fine!"

Many in the health-care profession consider old age to be a disease itself. Any medical problems are inappropriately attributed to old age as if it were a medical condition. And since there is no cure for old age, appropriate tests and treatment are never performed. Thus, medical problems that may not be related to age and may just as frequently occur in younger people are often not treated. As an example a recent survey of physicians involved in the health-care of the elderly reported that 35% of the doctors considered hypertension a result of the aging process and that 25% of them felt that treating an 85-year-old for symptoms of hypertension would cause more harm than the benefits it would produce.

Consider these real-life examples.

First example
A 71 year old woman has surgery on her shoulder for a bone spur that is causing her considerable pain. The surgery is successful and she goes through several months of physical therapy to help her recover. But she is not recovering as expected. She continues to experience pain that radiates through her entire back. Her physical therapist does not know how to help her and attributes her failure to recover to old age. She visits her family care doctor at least twice over the next six months complaining of extreme tiredness and lack of energy. Her skin color is gray and she does not look healthy. Finally she visits her doctor and insists he check her for some problem since she is not recovering from the surgery and she feels awful. After her insistence he does a CBC blood lab and discovers she is severely anemic. He puts her in outpatient care and gives her four units of red blood cells and puts her on iron supplementation. Within two weeks the pain has disappeared and within a month she has recovered fully from the surgery. Numerous tests are done but there is no explanation for the anemia. Six months later she is healthy and active and her cheeks are ruddy. When she asks her doctor why he did not suspect anemia he tells her that she has never had anemia and based on her history he would never expect her to develop it. (He obviously has no training in geriatric care.) He then tells her, in an obvious contradiction of his previous position, that older people sometimes fail to absorb iron. Ironically, she defends the action of her doctor and does not feel he acted inappropriately.

Second example
Susan and John have been married for 46 years. Susan has always demonstrated a tendency for depression but it has generally been kept under control with medication. John's health begins to deteriorate and within a year he is dead. Several months after her husband's death, Susan is exhibiting signs of severe depression. She is given ever-increasing levels of various antidepressants but they have no effect. She is also exhibiting signs of a psychosis and is inflicting wounds upon herself. The family puts her in an assisted-living facility but they are unable to deal with their aberrant behavior. Her son who lives in New York decides to bring her to live with him and he admits her to a hospital in New York City . Tests indicate she is suffering from severe hypothyroidism and she is put on appropriate treatment. (Apparently no health practitioner had to this point suspected there may be another condition contributing to the depression other than old age.) The low thyroid undoubtedly was a significant factor in the development of her depression. But treatment of the depression is not addressed in the hospital and it has progressed considerably. She is transferred to a nursing home and wrongly diagnosed with dementia and placed in the dementia unit. She is deteriorating rapidly, she continues to abuse herself and she refuses to speak or acknowledge anyone. Within a few months she will probably be dead. At this point an experienced geriatric care physician steps forward and correctly diagnoses her condition as clinical depression. She is hospitalized for six months and undergoes aggressive treatment for depression. They also discover she is severely malnourished and correct that problem as well. She has now moved back into the home of her son. She is a normal functioning person and is even volunteering to work in the local library. The elderly health care system almost dropped the ball on this one.

Third example
A 65 year old woman, who has been active all of her life, has a small stroke which leaves her with some discomfort and pain in her right arm but does not limit her in any other way. She is anxious and nervous about her condition and the possibility of another stroke and the doctor prescribes pain pills and Valium to help her with her anxiety. Over a period of 15 years, she becomes addicted to Valium and does little else except sit in front of the TV all day long. She makes sure she maintains contact with a doctor who will provide her need for Valium. (No doctor or pharmacist would allow this abuse to go on with a younger person without intervention. Older people are often ignored and allowed their vices.) Early on, her family can see the problem and they decide to intercede. On the advice of friends they contact the geriatric care unit at a local university hospital. A geriatric care physician is alarmed at her addiction and insists they wean her off of the mood altering drug. He is willing to treat her and help her. She refuses to cooperate and in deference the family backs off. Over a period of 15 years she gets no exercise except for trips to the bathroom or trips to the living room to visit occasionally with her family. But family and grandchildren over the years visit less and less often.

After many years of sitting in the same position her knees deteriorate and she finds it difficult to walk. In order to avoid getting up from her chair to walk to the bathroom, she drinks very little fluid and becomes chronically dehydrated. This does not help her mental or physical condition. She has the joints in both knees replaced but does no exercise and the combination of the invasion of muscle tissue and lack of use of her legs causes muscles around her knees to atrophy. No follow-up is done by the orthopedic surgeon to make sure she remains active, after all she is old. She can now barely walk at all. She spends her final three years confined to one room in her daughter's house, refusing the use of a wheelchair and refusing to go anywhere beyond the bathroom.

In this case a general lack of concern by all involved demonstrates the apathy of family and the healthcare community to making sure elderly people can experience a meaningful existence in their remaining years. Had this been a younger person, say in her 40's, everyone involved would have been more aggressive in helping her solve her addiction and in making sure she had a better quality of life.

 

Treating Medical Problems

Lack of Proper Care
Below is a list of common medical conditions the elderly deal with. These are also conditions that may occur in younger people but some of them such as cataracts, congestive heart failure, chronic obstructive pulmonary disease, osteoporosis, diabetes, stroke, incontinence, dementia, and prostate problems are more unique to an older generation. Remember also that many of these conditions may coexist together in the older person.

• Cancer
• Hypertension
• Cardiovascular Disease
• Congestive Heart Failure
• Cataracts
• Pneumonia
• Chronic Obstructive Pulmonary Disease
• Back Pain
• Lack of Strength
• Eye Problems
• Osteoarthritis
• Rheumatoid Arthritis
• Other Immune Disorders
• Osteoporosis
• Parkinson's Disease
• Dementia
• Problems of the Prostate Gland
• Depression
• Diabetes
• Stroke
• Urinary Incontinence

Older Americans account for over one third of all medical spending in this country -- approximately $300 billion a year for their share of the cost. It costs about four times the amount of dollars to treat a 65 year old for health care in a given year than it does to treat a 40 year old. Even though people age 65 and older have their own health care insurance, called Medicare, Medicare simply pays the bills and up to this point has not been actively involved in promoting a better delivery system for this age group. Recently there has been much talk of Medicare supporting preventative, outcome based medicine but aside from a few minor changes little has been done. However, there is a possible change on the horizon. Medicare is currently conducting a test program and evaluating a number of hospitals for their outcome of care with patients. Instead of determining the wellness of patients by treatment protocols or medications the program is trying to identify hospitals that are more successful than others in having positive medical treatment outcomes. The intent is to reward these hospitals with a 20% bonus in Medicare reimbursements. Hospitals that are below average in meeting the standards will receive a 2% reduction in reimbursements.

Hospital admissions for the elderly are about three times those for the young. Older Americans visit a health provider at least twice as often as younger Americans. And Americans 75 years and older use hospital emergency rooms about twice as often as any other age group. With a different approach, Medicare could probably reduce older Americans' number of office visits, hospital admissions and emergency room visits.

All doctors are certainly aware of the differences in medical problems of the young and of the old. What doctors, who do not regularly treat the elderly, are not usually aware of is the fact that older people often have multiple problems at the same time and symptoms from one may be misleading or mask symptoms from the other. Consider the example above of the lady with low thyroid, malnutrition and depression. Her health care providers failed to test for or even recognize these combinations and the interplay they had on worsening her depression. They even misdiagnosed her depression as age-related dementia.

It is not to say that the healthcare profession does not treat the elderly aggressively for medical conditions that are diagnosed. The problem seems to lie with an undue focus on correcting specific problems and ignoring the underlying social, nutritional, psychological and physical activity components of an older person's health. As we have discussed previously, these components have a tremendous influence on the health of senior citizens. This is less true for younger people. Younger people are already active, socially stimulated and pursuing careers. Most healthcare practitioners don't recognize this difference and they treat the older patients only for their conditions assuming they will respond just like their younger patients. Once they have been treated many doctors, especially specialists, go on to taking care of a multitude of other patients and are unlikely to follow up over a long period with their older patients. And those practitioners who do want to provide follow-up are only reimbursed under Medicare if they can find an excuse for an office visit that doesn't include just a routine exam.

A Holistic Treatment Approach
Most practitioners who specialize in care for the elderly are aware of the above-mentioned problem with older patients and they take a holistic approach with the medical treatment of these people. An attempt is made not only to treat the specific condition or conditions but to make sure there are sufficient activity, proper nutrition and family support at home. They work closely with family members to make sure their loved ones are taking medications properly and are reporting their symptoms. They require those caring for the elderly to closely monitor health conditions and report any changes before things get worse. They meet with their patients regularly enough to monitor their health. This broad-based approach results in better health and in fewer visits to the emergency room because intervention for a worsening condition is achieved at an earlier stage.

A good example of this holistic approach is the Veterans Administration health care system. The VA system over the years has become the nation's largest geriatric care provider for older men. Almost all veterans are men and because most veterans hearken back to World War II, the Korean conflict and the Vietnam War most of them are older than age 60. Because of this the VA has found it necessary to adapt its health-care to this age group. The VA schedules regular exams at least every six months or yearly depending on available funds and personnel. A health examination always includes lab work. Screenings for cancer, cardiovascular problems, eye problems, hearing problems and many other conditions common to aging are a routine part of veteran's administration health-care. The VA was one of the first health providers in the nation to require its local hospitals to keep their records on computer and in a central database. This allows health practitioners in the system to quickly and efficiently access all information and avoid misdiagnoses and possible drug interactions. By taking a hands-on, preventative approach to the treatment of older men the system is able to keep its patrons healthier and avoid costly medical interventions due to lack of follow-up.

A significant problem with providing holistic treatment is many health insurance providers, including Medicare, will not pay for routine office visits without an underlying medical complaint. Some private health plans are starting to use so-called "pay for performance" or "outcome based care" where the overall health of the patient takes precedence over the procedures used to get there. But Medicare, up to this point, has not made this change. This makes it extremely difficult for the geriatric care provider to monitor his patients and intervene before a health problem becomes bad enough to require hospitalization or major surgery. Doctors practicing this type of medicine have to be inventive in order to provide adequate treatment. Family of the elderly can also help in this respect by "finding" medical complaints to justify setting regular appointments with the doctor.

Treatment of Depression
Older Americans have a suicide rate that is four times the national average. Much of this is a result of depression. It is estimated that 20% of the aging population suffers from depression. Practitioners not trained in geriatric care automatically assume that depression is a normal part of the aging process. This is not true. Depression can be treated just as effectively in older people as it is in younger people. But sometimes medications are not as effective in older people as they are in a younger population. Unfortunately, practitioners often rely too heavily on medications and don't try other non-medical therapies.

Many doctors simply don't choose to recognize depression and help their older patients with it. It is interesting to note that over 70% of elderly suicide victims committed suicide within one month of seeing their health care practitioner. Many of these people were not referred or treated for depression by that health care practitioner.

The Problem with the Nursing Home Care Model
Nursing homes serve two purposes. The first is to provide nursing and medical care for people recovering from illness or injury. The intent is to get these people well and return them back into the community. A second purpose for the nursing home is to care for people who have severe chronic medical or cognitive impairments and who are not expected to recover but only to get worse. These are often called long-term care residents. Rehabilitation patients and long-term care residents are typically segregated in different parts of a nursing home. Or it is often the case a nursing home will specialize only in rehabilitation or long-term care but not both.

The general attitude towards long-term care residents is they will never recover and will either die in the nursing home or be transferred to a hospital to die. Some might argue this is reality but it is also age discrimination. As we have seen in previous examples, sometimes long-term care residents are misdiagnosed or given improper medications which may make them candidates for long-term care but they may also respond to treatment and even recovery and as we saw in one example could even return home and lead a normal life. But because of the prevalent attitude towards "warehousing" long-term care residents, most nursing homes do little to try and rehabilitate these people other than treating acute conditions and making them comfortable.

Another problem is these people are typically receiving assistance from Medicaid or Medicare. These government programs only pay nursing homes to provide treatment such as dispensing medications, providing assistance with activities of daily living, treating medical conditions or giving psychiatric help. Nursing homes are not reimbursed for alternative therapies that might make patients better. Another problem is often the doctor assigned to the patient either has little interest in providing therapies to facilitate recovery or the doctor is inexperienced in geriatric care.

Unfortunately, another reason for not being more actively involved with residents is that many nursing homes in the country have large numbers of unoccupied beds. It is not in their best interest to cure a resident and return him or her to another living arrangement as that would result in a loss of revenue and there are no people standing in line to occupy the vacant bed.

This attitude in nursing homes becomes an age discrimination issue. The elderly are treated differently from other age groups. There are a small number of US nursing homes that don't rely on government reimbursement, are not concerned about occupancy rates and are free to use alternative approaches. Some of these facilities have been successful, in a number of cases, in improving the condition of their long-term care residents and allowing them to return to a community living arrangement. They typically use approaches we have already discussed such as involving residents in their own medical decisions, providing pets and plants, providing interaction with children, stressing activity and mental stimulation and in aggressively following up and properly treating medical conditions. This approach is often called "the holistic approach" to nursing home care.

 

Medications and the Elderly

Facts about Medications and the Elderly

• Older Americans comprise about 13% of the population but they consume over 30% of all prescription drugs.
• It is estimated that 30% of the older population taking medications have had an adverse drug reaction.
• Up to 20% of hospital admissions for the elderly are due to adverse drug reactions.
• It is estimated that over half of the deaths attributed to adverse drug reaction are for people age 60 and above.

The Journal of the American Medical Association recently reported that if adverse drug reactions were classified as a disease it would rank as the fifth leading cause of death in the United States .

People take medications in various forms. The most common is to swallow them and allow them to be absorbed through the digestive system into the bloodstream. But medications may also be injected into a muscle, infused through a vein or administered topically to the skin, nasal cavity, oral cavity, ear cavity or the eyes. Some medications are inhaled. Regardless of the method of administration most medications, but not all, end up circulating in the bloodstream. Dosage amounts and frequency of dosages are designed to provide an optimal amount of chemical to adequately treat the condition for which the medication was designed. This often results in chemicals circulating in the bloodstream as long as the medication is being taken.

The body regards these chemicals as foreign substances and tries to rid itself of them. This is commonly done by elimination through the kidneys, by metabolism in the liver, by utilization and uptake in the body tissues being treated or by absorption in body tissues such as fat cells. If not enough medication is provided to the cells that are to be treated for a condition, the medication may not have its intended effect. If too much medication is circulating in the bloodstream there may be unintended side effects such as dizziness, confusion, memory loss, cell damage, retention of fluids, hypertension or hypotension, dehydration, stroke or other brain damage, cardiovascular disease, internal bleeding, heart rhythm problems and sometimes even death. The medication may produce much more harm than the condition it is treating.

Since an optimal amount of medication is required and since the body is constantly counteracting that amount through elimination, dosage is extremely important. Unfortunately, dosage levels for younger people are often not appropriate for older people. The main reason for this is that some older people often have impaired kidney function, impaired liver function or their lean body mass or circulating fluids are different from a younger person with the same height and weight. Generally, older people absorb medications through the gut about the same as younger people but usually at a slower rate. These impairments and differences generally mean that normal doses and frequencies of dosage are too high for the elderly -- but depending on the physical condition of the older person normal dosages may be fine. Prescribed dosages intended for younger people may result in too high of a blood level of medication in older people. On the other hand, higher levels for the elderly may be needed because of a resistance in the cells being treated. There are also some situations where normal doses release smaller amounts into the bloodstream in older people.

Another problem with medications for the elderly has to do with the number of prescription drugs an older person is taking. This could be anywhere from two to six or more different medications. The average is about 4.5 prescription medications per elderly person. In addition at least 40% of the elderly are taking herbal supplements and they are taking on average two over-the-counter drugs as well. This high number of medications can sometimes cause problems. In many cases one drug will suppress or stimulate physiological processes that another drug is designed to affect. In other words drugs can interact with and interfere with each other. Sometimes a drug will heighten the effect of another drug being taken at the same time. Even herbal supplements and over-the-counter drugs can cause these problems. This may result in serious side effects as mentioned above or it may result in one or more of the drugs not being as effective because of the interaction. And because of not knowing the correct dosages this interaction may be more severe in the elderly. Doctors and pharmacists may not be aware of a drug reaction problem especially if the older person has a disorder with symptoms that may be masking symptoms from the drug interaction. Oftentimes an older person is reluctant to mention drug interaction symptoms. It is estimated that for every dollar spent on prescription drugs another dollar is spent on additional drugs to correct the problems created by the initial medications.

The most common problem with medications is that the doctor or the pharmacist may not be aware that a patient is taking a number of drugs prescribed by other doctors. Many older patients continue prescriptions with a number of doctors and specialists and no one doctor, not even the primary care physician, often knows the number or extent of medications being taken. Add onto this the fact that the elderly are most likely consuming a variety of over-the-counter medications as well as herbal supplements and it is not surprising to see the large number of adverse drug reactions and hospitalizations and deaths due to drug reactions among the elderly.

Elderly people also often fail to adhere to proper dosage and frequency of dosage with their medications. Some will take more pills than prescribed because they think more is better and will cure the condition faster. Others have a noncompliant attitude towards medical treatment in general and often refuse to take any drugs prescribed for them. Many are confused or have memory problems and aren't even aware they have taken pills or need to take pills. Oversight and administration of medications by a responsible person is an extremely important duty for caregivers of the elderly.

Controlling Problems with Medications
Here is a list of herbal supplements that may interact or interfere with prescription drugs.

•  Ginkgo Biloba

•  St. John's Wort

•  Saw Palmetto

•  Ginseng

•  Yohimbine

•  Senna Or Cascara

There are also a number of prescription drugs that should be avoided with the elderly. The elderly person or a responsible family member should always consult with the doctor and asked that doctor if he or she is sure that the medication is safe for an older person. It is not inappropriate to challenge a physician. If prescription drugs are bought through a trusted pharmacist, the pharmacist may also be willing to consult on the safety of the medications for an older person.

Doctors and pharmacists are generally careful about overdosing or using harmful mixtures of drugs but other than dosages based on body weight, most prescription drugs do not have recommended dosages for older people. Often the doctor must experiment to find the right dosage and the problem is that many older people or their families fail to recognize drug reactions or they fail to report them. Without the proper feedback, under-dosage or over-dosage might occur and effective treatment of the condition is not possible. And of course over-dosage may cause more severe problems than the condition being treated.

One would think that with the large use of prescription drugs by the elderly population that pharmaceutical companies would include older people in their drug trials in order to establish proper dosage. This is not so. As a general rule older people are avoided because the companies feel they may not be reliable participants or that they may have medical problems that would confuse the end results. As a result the lack of participation from the elderly has led to a dearth of information regarding side effects and proper dosage for that age group. It seems like hypocrisy that the drug industry would exclude the very people from their testing who are the largest users of their products.

Consider this real example.

A daughter is caring for her elderly mother at home. Mom has a variety of medical issues and is taking a number of medications. The doctor prescribes Paxil for mom's anxiety. Over a period of months the mother becomes sleepy all the time and can't seem to concentrate. She will even fall asleep while someone is talking to her. The doctor and family initially attribute it to her age. Finally the daughter decides there must be something wrong and she insists the doctor look into it. Tests are conducted and low blood level of sodium is confirmed. After some research the doctor suspects the prescription might be causing sodium depletion. He removes the mother from the medicine and she becomes normal again.

Three Independent studies in 1998, reveal Hyponatremia (low-sodium) as a problem with drugs like paxil. Here is a quote from Truestar Health Encyclopedia concerning these studies.

SSRI drugs, including paroxetine (paxil), have been reported to cause sodium depletion. The risk for SSRI-induced sodium depletion appears to be increased during the first few weeks of treatment in women, the elderly, and patients also using diuretics. Doctors prescribing SSRI drugs, including paroxetine, should monitor their patients for signs of sodium depletion.

Apparently someone forgot to tell the doctor in the example above that elderly women taking diuretics are susceptible to this problem with Paxil.

In a technical document describing Paxil, GlaxoSmithKline, the manufacturer, states the following:

"Geriatric Use: In worldwide premarketing clinical trials with PAXIL, 17% of patients treated with PAXIL (approximately 700) were 65 years of age or older. Pharmacokinetic studies revealed a decreased clearance in the elderly, and a lower starting dose is recommended; there were, however, no overall differences in the adverse event profile between elderly and younger patients, and effectiveness was similar in younger and older patients"

GSK reports up to 3.4% of higher dosage users experienced somnolence. But the company makes no mention of this sleepiness being a problem or being caused by electrolyte imbalance. Looking at the test data more closely means that out of the entire trial panel over age 65 perhaps 20 to 30 of these people experienced sleepiness. This number was probably not significant enough to follow up on the issue of Hyponatremia. We also believe that this drug is probably prescribed to a higher proportion of the elderly than the population as a whole since anxiety and depression are a major problem with the elderly. But with elderly trial participants representing only 17% of those tested we feel this is an example of how the drug companies avoid using the elderly and as a result gain little insight into elder medication problems with their drugs.

Controlling the Problem of Multiple Medications
In order to control the problem with an older person taking multiple prescriptions from many doctors, the older person or a responsible family member should bring all medications being taken by the patient to a doctor's appointment. This definitely includes all herbal supplements and over-the-counter medications as well. It is useful to go over with the doctor what each medication is for. If there is no reason to take that medication or if it may be causing interaction the doctor should indicate that and should withdraw the prescription. As a general rule the more the medications the more the potential problems. A concerted effort should be made to prescribe the fewest medications possible to control a medical problem.

One way to combat the problem with an older person not complying with taking pills at the proper time or not taking enough or taking too many is to use the popular "pill calendar box". Most people have adopted this idea but for those who haven't this is an extremely effective way to administer medications.

Many elderly order their medications through the mail and some may even obtain prescriptions on the Internet. Internet prescriptions might be a common practice for very popular medications such as phetermine or Viagra. It is recommended that all medications be ordered through one pharmacist particularly a pharmacist that has a certification in geriatric pharmacy. By controlling all medications through one database, the pharmacist can alert the older person or his or her family about a possible drug interaction or adverse drug reaction. This central database approach should become much easier for those older people who enroll under the Medicare part D drug program. Presumably the company offering the drug benefit will have a database for its insureds.'

 

Geriatric Physicians or Specialists in Aging Medicine

Geriatric Physicians
There is currently little incentive to encourage established doctors or students in medical school to specialize in geriatric medicine. Even though it is a recognized specialty, according to the American Geriatrics Society, there are only about 9,000 M.D. Geriatricians and several hundred osteopathic physicians (DO) certified in geriatrics, as well as some 2,400 board-certified geropsychiatrists in the United States . (A geropsychiatrist it is a psychiatrist trained to deal with the mental health needs and specific syndromes faced by older adults).

According to the statistical abstract of the United States there are approximately 770,000 practicing doctors of medicine in the United States . This means there is roughly 1 doctor, including specialists, for every 300 persons in the United States . Based on the numbers above there is only about 1 Geriatrician for every 3,000 elderly persons in this country. Because there are so few of them, it may be impossible to find a physician specializing in geriatric care in some areas of the country.

There are probably many more family physicians or internists who specialize in treating older people and from experience they have probably learned many of the issues associated with treating the elderly, but many of these practitioners could probably benefit from more specialized geriatric training if it were available.

Out of 145 medical schools in the United States only five have geriatric care departments. Many more medical schools offer elective courses in geriatrics but only 3% of all medical students ever enroll for such classes.

Helping elderly people who are nearing the end of their lives and who suffer from multiple, incurable and chronic disorders is often not an appealing prospect to family doctors or to young medical students. Besides, geriatric care typically does not produce as much income as other specialties.

Most doctors who treat the elderly are reimbursed either through Medicare or sometimes through Medicaid or sometimes a combination of both. These government programs have become more and stingier over the years. Many doctors who in the past have accepted Medicare find that they have better paying opportunities treating younger patients and they will no longer accept new Medicare patients. And as long as those younger patients are available for treatment, few doctors are going to go out of their way to seek out Medicare or Medicaid reimbursement.

There are doctors who derive satisfaction from working with older people. And they may be taking a cut in pay by doing this. These doctors are most likely going to be Geriatricians. An older person or his or her family should seek to find these geriatric care specialists in their area or if that is not possible an effort should be made to locate a geriatric clinic in the area. Geriatric clinics are becoming more popular and even though the doctors who staff them may not always be geriatric physicians they are likely to be well aware of the problems associated with treating elderly people. Many geriatric clinics include a team of specialists to help older people. Here are some of the specialists who may be available in a geriatric clinic.

•  Geriatrician

•  Nurse

•  Social worker

•  Nutritionist

•  Physical therapist

•  Occupational therapist

•  Consultant pharmacist

•  Geropsychiatrist

If there are no Geriatricians or geriatric clinics in the area, an attempt should be made to find those doctors who specialize in elderly care. This can be done by making phone calls to various doctor's offices or by checking in the Yellow Pages. Too often, the elderly or their families are content to work with the doctor whom they like but who has little experience in geriatric care. Personality is an important issue but it is more important to find a qualified doctor to care for an aged loved one.

Home Visiting Doctors
Many doctors are returning to the practice of medicine a hundred years ago and are making house calls. Health insurance plans including Medicare will now reimburse a doctor and possibly a staff member, if test equipment is involved, to visit homebound patients in their homes.

To qualify for a home visit the patient must have to experience great difficulty in leaving the home in order meet with the doctor in his or her office. This does not however mean the care recipient need be totally disabled. It simply means that transportation requirements or help needed to get to a doctor might be very expensive or difficult to provide or the patient's safety might be jeopardized by leaving the home. Doctors are willing to visit in the home and provide service because they are paid more money by health insurance providers to compensate them for their time and their loss of efficiency in meeting patients in their offices. Probably the insurance providers reason that the additional cost of meeting with patients at home, before major medical problems evolve, is more cost effective than paying for ambulances and treatment in emergency rooms.

Doctors who make home visits are more likely to be experienced in geriatric care. This is because most homebound patients are typically older. This is a positive advantage for a family using a home visiting physician since we have been making a point that it is better for the older person to be treated by a doctor with experience in this area. It will typically result in better care.

There are also a number of advantages to using home visits as opposed to office visits. The patient will be more relaxed and cooperative in familiar surroundings. Older people are thrilled that a doctor would take time to visit them in their home. They will be more compliant, more open and as a result receive better treatment as opposed to receiving care in the doctor's office. Typically the doctor will take more time and be able to establish a better rapport with his patient. The idea of the doctor not having to hurry off to another patient in another room is comforting to an older person.

A very important benefit is that a physician can see the environment in which his patient is living and have a better understanding of how that environment may affect his patient's health. By seeing it first-hand he can make recommendations for care that would have been impossible in his office. In essence the doctor learns much more about a patient in her home and he can achieve a personal connection that would have been difficult to establish in the office. The ultimate outcome of a house call is that the doctor can provide a greater degree of holistic medicine.

A home visit patient can receive house calls on a periodic or ongoing basis. The patient need not give up other doctors if the reason for being homebound is temporary. Testing equipment in the past few years has become more portable and the doctor can bring an assistant who might provide tests on site. Heart function, lung function and simple blood tests performed on site can give the doctor an immediate feedback on the needs of his patient and allow him to make treatment decisions without the delay of waiting for test results.

Health Care Advocates
Sometimes it's easier for a person to hire someone to walk through the maze of finding doctors, making sure treatments are appropriate and working with insurance companies. There is a growing industry designed to help people in this area. It is also important to remember that area agencies on aging can provide counseling services for Medicare at no cost. But the services of health-care advocates are typically broader and can save a great deal of time for people who have the money to hire someone to be their advocate. Here is an example from one company, called Health Care Advocates, and the services it provides. Its URL is http://www.healthcareadvocates.com/

"Healthcare Advocates brings together the talents of doctors, nurses, lawyers, insurance specialists, social workers and healthcare policy and ethics professionals to make sure members get the best healthcare possible. Workings as a team, Healthcare Advocates' professionals see to it that your health insurance works the way it's supposed to. We'll work closely with you and your healthcare insurance company to resolve issues quickly. What's more, you'll be able to tap into the wealth of knowledge and experience of the Healthcare Advocates group through several services offered as part of Healthcare Advocates' membership.

The Benefits of Membership
As a member, whenever you or your loved ones need help, Healthcare Advocates will be there for you. When you have medical questions, insurance disputes, questions about coverage, even if you've been denied access for a certain medical procedure, Healthcare Advocates can help. We've combined the strengths of our experts to offer members such valuable services as medical research, insurance dispute resolution, bills and forms consolidation services, health counselors and more.

We've also put together a unique package of information that covers everything from choosing the best healthcare plan to preparing for your hospitalization to your rights as a patient. And we've negotiated special discounts for our members to receive health-related books and other medical publications.

It's all here. One source for all the healthcare advice and information you need. At Healthcare Advocates, we'll see to it that you and your loved ones get the very best healthcare.

Physician Referral Service
Good healthcare starts with a good physician. But where do patients find physicians? Often they will seek the advice of friends, look in the Yellow Pages or possibly use a hospital's physician referral service. While these methods are a good first step, Healthcare Advocates wants to help patients find the physicians who specialize in treating the patient's specific ailment(s). To accomplish this, Healthcare Advocates has created a physician listing which includes specific information on physicians. It is Healthcare Advocates' hope that with more specific information, members will be able to find the best physician(s) for their needs.

Insurance Disputes Services
If you've ever been denied coverage/payment, access to a specialist or you've been turned down for a medical procedure by your health insurance, you need Healthcare Advocates Insurance Disputes Services. Our team of professionals will work on your behalf to help you get the care you require. And if you're covered by a PPO, traditional indemnity plan, Medicare or MediGap, we'll also be there for you to handle problems of non-payment, being dropped from your health plan, outstanding charges, bills that were incorrectly sent to you, and charges that should never have been made.

Fee Negotiation Service
Patients are often faced with high medical bills when uninsured or they go out-of-network. When faced with high medical bills, Healthcare Advocates helps by negotiating the fee. Healthcare Advocates may even arrange financing if needed.*

Rx Price Comparison
If you are on Medicare, or your insurance has limits on the maximum they will allow for medications (i.e. $1,500 max. coverage for prescription per year) then Healthcare Advocates might be able to help. Healthcare Advocates will research your medications and locate the most cost effective place to purchase the medications. The cash saving to you can be large so let Healthcare Advocates help you to find the most cost effective place to purchase your medications.

Medical Research
When you or a loved one is diagnosed with a disease or illness, it seems you can't get enough information. With just one call to Healthcare Advocates, we'll research the disease for you, investigate treatment options, provide lists of doctors and medical facilities that specialize in such treatment and identify support groups. We'll do as much research as you need so that you can make informed decisions about your next steps to recovery.

Prescription, Dental and Vision Plans
If you want to save money on prescriptions, dental or vision care, these plans are for you. A person's average savings is 10% to 30% off the price of prescription drugs; 35% off on dental costs; 20% to 60% off eye wear and 20% off on contact lenses. Most importantly, there are no forms. Simply show your card to the physician or pharmacy and they will automatically deduct your savings.

Health Counselor
As a member, you'll have access to expert advice through the Health Counselor. Your counselor can help you with everything from understanding how your insurance works, to choosing a doctor, to what to do if you have a problem.

It can even answer questions like, what is a defined contribution plan. Your counselor can guide you through all parts of the healthcare system and point you in the right direction when you have questions.

Bills and Forms Consolidation Services
Healthcare Advocates Bills and Forms Consolidation Services takes the hassle out of paying your medical bills. We'll sort through bills, figure out what's covered by insurance and return to you a simple, easy to understand statement that clearly tells you what you owe. Whether you are covered under an HMO, traditional indemnity plan, Medicare or MediGap, Healthcare Advocates has the expertise to completely understand your situation. And if during the review process they find money is owed to you, we'll even submit a claim on your behalf. Healthcare Advocates Bills and Forms Consolidation ensures you receive the full benefit of your insurance and simplifies matters.

Nursing Home, Assisted Living & Hospice Services
As our loved ones age we often find the need for a nursing home, assisted living facility or even hospice care. The questions are, which facilities are best? How can you pay for an assisted living facility? And what does Medicare cover? Healthcare Advocates can help you select a facility and finds ways to pay for it."

 

eHealth Services For the Elderly

Ehealth is a nebulous word to describe a trend to use computer technology in the delivery of medical care. We will use the word in the context of our discussion below to describe technology initiatives that promise better health care for elderly Americans. Some of these initiatives are already in use but not yet widely supported through payments from Medicare. Others are in the process of formation and will bring future benefits. The most effective tool available to all today is the use of the Internet for healthcare information and to some extent interactive health-care treatment.

Using the Internet
A recent survey reveals that 19% of all Internet users "often" use the Internet for healthcare information and another 31% "sometimes" search for information related to health care. The Internet is a major new source of information for the public to research health care issues. Here some are ways in which people are using the Internet:

• People are able to educate themselves in medical vocabulary.
• Thousands of sites allow users to research and understand medical conditions and how they're treated.
• New information being posted daily helps people to research new treatment options that their health provider may not be aware of.
• Hours of research and study empower individuals and allow them to confidently discuss medical issues with their doctors.
• About 7% of Internet users actually interact with their health care provider on the Internet to manage their care. We expect this number to grow in coming years.

Electronic Health Records
A major impediment to quality care is the current paper system for medical records. Elderly patients often generate a large number of office visits, hospital visits and prescriptions. An older person' s file could end up being an inch thick or more. No doctor can remember all the details of every patient and in many cases must spend a great deal of time reviewing records. Former treatments and medications can be missed, previous consultations are not easily tracked and referrals to other specialists may be difficult to pinpoint.

Complete information is critical in the treatment of patients who have large medical files. A computerized medical records system tied to a database allows the doctor or nurse to pull up selective information such as a list of drugs, the dates of previous consultations, a history of lab results, potential drug reactions and treatment outcomes or referrals to other doctors. The computer also allows staff to follow up on treatment, to electronically submit prescriptions to pharmacies, to schedule appointments and to provide proper treatment codes and automatic billing.

One witness in a recent Senate subcommittee hearing points out the power of using electronic health records. According to Dr. Robert Kolodner, chief health informatics officer at the U.S. Veterans Health Administration,

"As U.S. health-care costs rose dramatically, the U.S. Department of Veterans Affairs (VA) doubled the number of patients served in the past 10 years, while increasing its health-care budget by only 50 percent."

Kolodner attributed the VA's ability to hold down costs directly to its use of electronic health records. He states, "I have used VA's electronic health record system for years. As a doctor and as a patient I am very enthusiastic about the benefits of this technology."

Kolodner continues, "Recent Hurricanes Katrina and Rita showed the need for electronic health records that follow patients. The VA began rolling out an electronic health records system in the mid-1990s, and today, all 1,300 VA medical facilities use electronic records. Katrina had a "significant impact" on the operation of a dozen VA facilities, destroying one and forcing another to be evacuated, and the two recent hurricanes scattered Gulf Coast evacuees across the country," he continued. "But the VA was able to get access to basic medical data such as medication information for patients treated at those facilities a day after Katrina hit, with full medical records available in about a week," Kolodner added.

But converting the current paper system to computers may end up being a very difficult task to accomplish. For small clinics or individual doctors' offices the cost and effort of switching from a paper system to a computer system can be overwhelming. Procedures must be redesigned, doctors spend considerable time retyping previous histories and existing paper records must be transcribed into the system. The implementation often represents a major increased commitment in time sometimes over a period of a year to get the system implemented. Personnel and workflow procedures must be completely reorganized and the consequence is usually longer patient waiting times and a high frequency of mistakes made during the changeover. There is also a need to hire or contract with a technology expert to handle equipment failure, virus attacks, system failures and software glitches.

Once accomplished, the results are outstanding. Prescriptions and renewals are handled more efficiently and safely, appointments and checkups are handled automatically, lab results from cooperating ewired labs are immediately added to electronic files, prescriptions are data based and potential interactions avoided, patient questions are answered on the spot and expensive duplication in testing and treatment is avoided. In the end there is also a cost savings to the clinic or office due to improved efficiency.

But very few small practices or small clinics are willing to change over because no one reimburses them for the cost or time. And no one is giving them an incentive to change the current system. Insurance companies still pay the same regardless of the system used to deliver the care. And many of the savings in the cost of care are passed on to the insurance company and are not realized by the health-care providers.

The message to the public desiring better care from ehealth initiatives is to use larger clinics or hospitals that have the resources to implement this new technology.

Telemedicine Services
The use of computers and the Internet in a hospital setting is also improving the efficiency and quality of care. Here are some examples.

Preventive telemedicine services allow nurses at a central station to monitor patient vital signs. But these records are also automatically added to the patient's database and a history of input is available to the treating staff which might be the personal physician, a medical specialist or someone else in the hospital. Instead of a bed chart and an in-room visit from the medical provider, all information can be accessed on the computer and any changes in condition can be dealt with immediately. The data accumulated from the patient's daily monitoring and interactive healthcare sessions can be used for early diagnosis of general deterioration in the patient's health. This feature allows for preventive actions to be taken before the patient develops a major health crisis, which can save the patient unnecessary suffering, the necessity of drastic and expensive medical intervention and prolonged hospitalization. All of this early intervention due to electronic monitoring and data storage results in lower costs and better quality care.

Interactive Consulting is proving beneficial in some settings. Using a mobile computer monitor and a video camera, a specialist can make a "virtual" visit to any patient anywhere in the world. With the help of an assistant, the specialist can observe any physical problems, query the patient about symptoms and at the same time access online records from the patient's file. Any simple tests can be done and immediately transmitted. This allows specialists or professors in teaching hospitals to see more patients and to effectively use their time better. Considerably more patients can be consulted from the specialist's office as opposed to the specialist driving to various locations or consulting on the phone. This service would probably not currently be used by hospital staff or the personal physician visiting his patients in the hospital. But it may not preclude these providers using such a service in the future

Videoconferencing is about connecting surgeons and other medical professionals with the information they need. Systems can link operating rooms with facilities around the world. These systems exchange MRIs, X-rays, live pictures and other kinds of information between operating rooms, doctors' offices and teaching institutions everywhere. The goal is making telemedicine a reality, in real time, with worldwide access.

Telehomecare or Home Telehealth
Telehomecare is a more effective way to deliver home care under certain circumstances. Since it is a rapidly developing field, it's difficult to define all telehomecare applications. It usually involves two-way electronic communication between the patient and the formal caregiver such as a nurse or doctor. Communication can occur with two-way radio, telephone or as is usually the case, two-way interactive video using a computer and phone lines, cable Internet , wireless Internet or satellite Internet downlink. This electronic face-to-face home visit also requires some means for the care provider--who might be hundreds of miles away-- to access patient vital signs and receive patient-initiated medical tests. The patient or her in-home informal caregiver has been trained to use electronic monitoring or test equipment that sends the relevant video snapshots or numeric data via phone line, or radio wave to the formal caregiver.

Telehomecare is often more cost-effective in rural areas. And in many cases it provides a higher quality of care. Here are some of the ways telehomecare is proving to be beneficial:

• reducing number of visits to the emergency rooms
• reducing unnecessary visits to physician's offices
• avoiding unnecessary costly visits by health providers
• providing education of the patient in early symptom management
• monitoring vital signs on a 24-hour basis, therefore providing a potential for early intervention and/or prevention of repeat hospitalization

A Typical Day In The Life Of A Home Telehealth Patient
(A Composite Case Drawn From Many Examples)

63-year-old Mary Smith of Gatesville , Kansas has lived with diabetes for 15 years and has had many complications during that time. Travel to hospitals and specialists has been difficult and the visits expensive. On her last discharge from hospital to home, her doctor approved home telehealth service and monitoring.

It's 6:30 AM in Mary's rural farmhouse. A house where she has lived most of her life. Mary is awakened by her alarm going off reminding her to measure her blood glucose and blood pressure and to check her weight and to send those readings through her telephone to her telenurse, Susan Brown, who works 200 miles away in Wichita. Susan will receive the information and contact Mary if there is a change of health status or if help appears to be needed.

Mary sends her first report at 8:00 AM but she doesn't do it with a regular phone call. She does it by using three telemonitoring devices-a blood pressure cuff with a telecommunications plug-in, a similar device to monitor blood glucose and a body weight sensor. These devices are all attached to a telehealth, computer workstation. The telehealth work station is connected to Mary's phone line and is linked through the line to Susan's computer in Wichita . After Mary's computer sends its data, Susan receives the information on her own computer and can instantly interpret the state of Mary's health. In addition, an inexpensive camera perched on top of Mary's telemonitor can take snapshots of Mary as she measures her insulin, inserts her syringe, and rotates injection sites, and will send the pictures along to her nurse so that Susan can actually see Mary and how she is doing. If she needs to, the nurse can give her patient a phone call and coach her along. Using her telemonitoring machine and a telephone, Mary can be connected with a nurse, ask a question, or be reminded of a routine on a 24/7/365 basis.

Mary, who lives alone, also suffers from hypertension and has had some bouts of depression related to living with multiple chronic diseases. Until now, her children had felt that sending her to live in a nursing home was a good choice, but, with telehealth, Mary can monitor herself regularly and learn lifelong self management routines. Currently, nursing home placement is not necessary; she can get the assistance she needs at home. And the challenge of monitoring and managing her own health on a daily basis has given Mary focus and helped her with her depression. In addition, with the regular counseling she receives from her nurse and careful management of exercise routines, she has already reduced her number of medications and has not made any emergency room visits in a long while.

Mary also notes: "I'm able to stay at home with my books, my music, and my birds."

Here is how Medicare currently treats the payment of home Telehealth.

"201.13 Telehealth.--An HHA (home health agency) may adopt telehealth technologies that it believes promote efficiencies or improve quality of care. Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR 409.48(c) and the telehealth services may not be counted as Medicare covered home health visits or used as qualifying services for home health eligibility. An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan of treatment (i.e., may write requirements for telehealth services into the POT). Medicare eligibility and payment would be determined based on the patient's characteristics and the need for and receipt of the Medicare covered services ordered by the physician. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished."

Telehospice Care
The delivery of hospice care requires the coordinated effort of a team of skilled medical personnel, spiritual counselors, volunteers and family. Telehospice is a promising new approach to helping the hospice team better do their job. By using a high-tech means of communication and monitoring, telehospice allows busy care providers to use their time more efficiently and to respond to patient needs more quickly.

Due to a burgeoning elderly population, government funding and available skilled care providers for the elderly are becoming more scarce. Telehospice can help support this growing lack of resources.

Tele hospice and home Telehealth are quite similar in the fact that they monitor health conditions in the home and Telehospice may use similar remote monitoring equipment as a Telehealth workstation, but the emphasis with hospice is on comfort and support. Currently, Telehospice is being tried on a limited basis mostly in rural communities where it is difficult for the providers to make regular visits.

This new concept is designed primarily to augment and not replace the services of the hospice team. For instance if a crisis occurs in the middle of the night and the nurse on duty is a long drive away, a consultation over the phone and using computer video could probably substitute for a personal visit. Or perhaps the doctor needs to see how his patient is doing but is busy on a particular day or his practice is a long distance away. A Telehospice visit using computer video may be adequate to helping him assess the situation. Or another use might be in remotely monitoring and controlling IV pumps for pain management. Uses of Telehospice are only limited by imagination and we suspect as more uses are identified it will become a common part of all hospice treatment.

National Health Information Network
In 2004 the Bush administration created the Office of the National Coordinator for Health Information Technology (ONC) a part of the Department of Health and Human Services. The purpose of this agency is to create the National Health Information Network. The network is to be a national Internet database of all medical records in the United States . In order to achieve this, all health-care providers will have to convert from paper records to electronic records. There will also have to be a national standard for all records to be shared across providers using the Internet database. It is estimated this initiative will cost the private health-care sector $150 billion over the next five years. This may seem a formidable task but HHS awarded its first six contracts for networks in October 2005. Even without the initiative some 100 or so local network projects have already been started by hospitals and large clinics across the country. But so far there is no standardization for linking these networks together.

Initial estimates are a national network could save $120 billion a year by eliminating duplicate tests, shortening hospital stays and improving care for chronically ill patients. Total savings estimates for all sectors of health care run as high as $600 billion a year or about a third of the current $1.9 trillion being spent on health care in this country. The government, particularly Congress, is solidly behind this initiative because it could be a major factor in saving Medicare from running out of money. Here are the goals the network plans to achieve by the year 2014.

Eliminate Medical Errors According to Business Week, dated October 31, 2005, "Medical errors, which cause as many as 195,5000 deaths a year, are an unmitigated epidemic. The doctors and medical technology that go into American medicine may be the best in the world, but the care that comes out the other side is beset by woeful inefficiency, dizzying bureaucracy, and enough mistakes to make medical care the third leading cause of death, behind heart disease and cancer." Eliminating medical errors will be a primary goal of this database.

Eliminate Duplication There is a great deal of duplication in medical tests. Sometimes previous tests are not available in time for a doctor to make a decision or the care provider may not even be aware of tests that were done previously. As a result duplicate or even triplicate tests are often ordered. The network would prevent this problem and allow instant access to any tests that have been performed.

Track Prescription Drugs We have mentioned in a previous section that many health-care providers are unaware of the number of prescription drugs and over-the-counter drugs their elderly patients are taking. A central database would identify these drugs and also automatically raise a warning flag if there is a potential for drug interaction.

Online Medical Records Currently everyone is entitled to a copy of his or her medical records but actually obtaining those records is a difficult and cumbersome task. The network would allow anyone to access his records on the Internet. The projection is to make this available nationwide by 2014.

Sort out Best Treatments This is one of the key elements of the database and one of the key sources of cost savings. The idea is that a national database would allow the health-care system and insurers to track the effectiveness of various treatments and discard those that were ineffective and promote those that work the best. It would also help standardize treatments across the country where there currently appears to be a great disparity in the amount of care provided individually in various sections of the country. In some sections the elderly receive twice as much care for the same types of conditions as they do in other parts of the country but yet there seems to be little difference in the outcome or the death rate.

Allow for Performance-Based Health Care A central data base would make it possible to track the cost/benefit outcome of hospitals, clinics and doctors offices and would result in a long-sought innovation in the health-care system to reward those providers who achieve the best medical outcome for the least money and penalize those providers who cost the system a great deal of money.

Manage Chronic Diseases Chronic diseases such as diabetes, congestive heart failure and asthma, consume a third of all medical spending in this country. Home monitoring systems would feed vital sign health readings into the central database. A nurse or doctor could periodically check the vital sign readings of their patients and if it appeared that the condition was worsening, the providers could intervene with treatment before more costly care was necessary.

Three major obstacles may stop this initiative in its tracks.

•  Cash-strapped hospitals, small doctors offices and small clinics won't foot the cost to convert since most of the savings go to insurance companies and not to the providers themselves.

•  Medical records privacy advocate groups are very concerned about the security of online records and without adequate assurance or even with it they may seek to stop the initiative.

•  Advocacy groups and most Americans in general are concerned that a central database could be used by the government or by large corporations to spy on people or to gain control over this country's citizens.

 

Learn About Geriatric Medicine From Dr. Rob Stall

Dr. Rob Stall is passionate about the area of geriatric health care. Dr. Stall is a board certified geriatrician and he maintains a private practice as well as being medical director for a number of health care facilities. He has a popular web site that provides pertinent information on health care for the elderly. He is very interested in empowering older persons and their family caregivers to advocate their own needs to the medical community. Towards this end Dr. stall provides articles, advice, instructions and a self-assessment worksheet for the patient to complete before visiting his or her doctor. In addition to his practice, he has a popular monthly radio program and he speaks frequently to local groups about care for the aged.

Please go to his web site at http://www.acsu.buffalo.edu/~drstall/

Here is a link to a page of resources explaining the concept of geriatric health care http://www.acsu.buffalo.edu/~drstall/geriatriccareinformationbydrstall.html

Here is the link to his self-assessment worksheet http://grassrootsgeriatrics.org/selfassessmentbooklet.pdf

Here are his links to online assessment tools for cognitive impairment, physical impairment, nutritional needs and mental health. http://www.acsu.buffalo.edu/~drstall/assessmenttools.html

Here is a link to his philosophy of geriatric health care http://www.acsu.buffalo.edu/~drstall/keyprinciplesofgeriatrics.html

Dr. stall also offers consultation services and can be reached at http://stallgeriatrics.com/

Below are links to individual radio programs that can be downloaded and enjoyed on your computer.