Ombudsman Quarterly An Elder Rights Quarterly Newsletter Region J Ombudsmen, Triangle J Area Agency on Aging Medications and by Frank Hielema, PhD, PT
Several types of medications have the potential to cause side effects that can contribute tothe risk of falling. The most common of these include anti-hypertensives (blood pressuremedicines), anti-depressants, hypnotics (sleeping pills), anti-anxiety drugs, and anti-psychotics (used to control abnormal thoughts). Blood pressure medicines can sometimeslower the blood pressure too much, so that you might get dizzy or lightheaded as you situp or stand. Anti-depressants, anti-anxiety drugs, and hypnotics can cause drowsiness anddecrease alertness or reaction time. Anti-psychotics (such as Haldol, Zyprexa, or Risperdal)can cause muscle rigidity, and make it difficult to initiate movements or cope with a suddenloss of balance.
A common misconception is that medications that can be purchased “over-the-counter”are safer than medications that require a physician’s prescription. This is not always thecase, particularly with medications used to promote sleep. The active ingredient in mostover-the-counter sleeping medicines is diphenhydramine hydrochloride, commonly knownas Benadryl. This includes Tylenol PM, Bayer PM, Excedrin PM, Nytol, Sleep-eze, andSominex. Benadryl can cause significant drowsiness and movement difficulties that maypersist beyond the normal time of awakening. We see several clients each year whose fallsare related to the use of Benadryl as a sleeping aid. Newer sleep medicines that stay activein the body for a shorter length of time, such as Ambien or Sonata, may be safer thanBenadryl even though they require a prescription and Benadryl does not.
If you think that a medicine you are taking is making you dizzy or lightheaded, or is affect-ing your balance, it is important to talk with your physician or pharmacist. Ask if you cantake a lower dose or even substitute a different medication with a lower risk for contributingto falls. [Frank Hielema, PhD, PT is the owner of SUREsteps, a rehabilitation practice in Raleigh, which specializes in the evaluation, treatment and prevention of falls.]Prescription Drug COSTS $ $ $ $ [from a News & Observer article by journalist David Ranii]
Helen Palmer is delighted that her new GlaxoSmithKline “Orange Card ” has cut the costof her 30-day supply of diabetes drug Avandia from $132 to $10. The 81 year old hopes tosave on the medicine Lipitor, that she takes for her cholesterol, by getting another discountprescription card from Pfizer, the maker of that drug.
The bad news is that the manufacturers of the five other prescription drugs she takes don’toffer similar discount programs for low-income seniors. Paying for all those drugs everymonth “is really bad when you don’t have any insurance,” says Palmer.
Consumer advocates say Congress should mandate prescription drug coverage underMedicare to ensure that seniors can get the medicine they need. The skyrocketing cost ofprescription drugs was a major political issue before the last national election. Unfortu-nately, lawmakers have been slow to act. But in the absence of Medicare coverage, severallarge pharmaceutical companies have jumped into the breach. Each pharmaceutical com-pany plan offers low-income seniors sizeable discounts, with different requirements foreligibility. For example, the GlaxoSmithKline Orange Card plan offers a price break thataverages 30%. To qualify, you must be at least 65 years old or disabled and enrolled inMedicare; have an annual income of less than $26,000 for an individual or less than$35,000 for a couple; and not have other prescription medicine coverage. The patient payseither $5 or $10 per prescription. But the company cards offer discounts only on their ownbrand-name drugs.
There are some local level programs that offer some relief with the prescription costs. Forexample, in Durham County call SeniorPharmAssist at (919) 688-4772. In Orange Co. callthe UNC Hospital prescription assistance counselor at (919) 966-5128. In Wake County,Resources For Seniors offers a program called MEDS (Medication Education for DrugSafety) which is committed to helping ensure older adults remain independent by promot-ing safe and effective use of medications. They offer individualized medication consulta-tion for seniors living in Wake County. The service is also designed to help seniors who arestruggling to pay for prescription medications. MAPS will apply for available medications
from various pharmaceutical companies for eligible seniors. The pro-gram obtains and files applications for medications approved by yourphysician and will continue to reapply as needed. Eligibility requirementsare that you must be Wake County resident, age 60 years or older, with amonthly income less than $1074, and a monthly medication expensegreater than $100. Call 872-7933 for more information. Wake CountyHuman Services, (919) 212-7000, and Urban Ministries, (919) 834-4707
administer a prescription costs program called program called FIGS (Filling in the Gaps).
On the state level, the NC Health & Wellness Trust Fund Commission will begin a programthis year for people 65 and older, whose incomes fall below the poverty level and who donot have third party insurance. To apply for this program, call (800) 662-7030.
In general, always ask your doctor or pharmacist if you need help to afford the medica-tions prescribed for you. Presenting. “POLYPHARMACY”
~ Information from the UNC School of Medicine, Program on Aging,
website: www.med.unc.edu/aging/polypharmacy/What is polypharmacy?
Polypharmacy literally means “many drugs” and refers to the problems that can occurwhen someone is taking many medications at once. It is a special concern for older adults,who make up 13% of the population, but account for almost 30% of all prescribed drugs.
Who is at risk for polypharmacy? If you are aged 65 or older, then chances are that youare taking one or more prescription drugs as well as products that you can buy over-the-counter (OTC). While such medicines can help maintain health and prevent further illness,taking combinations of drugs means that you could be at risk for unwanted drug interactions. What is the risk of polypharmacy? Polypharmacy is sometimes overlooked when problems occur because the symptoms it causes can be confused with symptoms of normal aging or another disease. Sometimes this results in still more drugs being prescribed to treat the new symptoms! Some signs of inter- actions between drugs or side-effects of drugs can include:
—constipation, diarrhea or incontinence
—hallucinations (seeing or hearing things)
—tiredness, sleepiness or decreased alertness
—depression or lack of interest in usual activities
Sometimes side effects occur shortly after starting a new medication, but in other cases theytake a while to appear. Never assume that a symptom is “just a sign of getting old”. Talk toyour doctor, who is responsible for making sure that your medications are safe and effective. Also mention to your doctor if you feel that you are taking too many drugs. There are manyways that you and your health care providers can work together to reduce or avoid the risks. People are keeping their teeth longer. .and the cavities that come with them!
As the life span of Americans continues to increase and more people keep their natural teethwell into old age, the demand for dental services among the elderly is expected to surge,according to a report in the Journal of the American Dental Association.
Dentists are advised to prepare for this trend by learning about how conditions common inthe elderly, for example, multiple medication use, multiple chronic diseases and physical
limitations may affect treatment and procedures.
The report states that nearly all of the people in the study
In the past, few
over the age of 65 had decay on the surface of teeth, with
elderly people went to dentists,
23% of those individuals having untreated decay. because it was not
15% of that group had cavities affecting the roots of their
common to retain
teeth, and a greater percentage of men than women had
natural teeth into old age.
untreated decay of all types. People who still had a greaternumber of natural teeth were more likely to have seen adentist within the past year.
The study concluded that if population projections, and oraland general health trends prove true, this study sample mayrepresent the future of dental care.people in their 80s who
have many of their natural teeth, and who continue to be at risk of experiencing dental prob-lems. [Source: 12/5/00 NEW YORK (Reuters Health)]
In 1999, the Regional Long Term Care Ombudsmen surveyed all long term care facilities inNorth Carolina. Our region has the greatest need for dental services than any metropolitanarea in our state.
A task force has been formed to obtain a mobile Access Dental Care van for portions ofour region, which would visit Long Term Care facilities, Senior Centers, and Health De-partments. A number of agencies are working on this project with the Triangle J Ombuds-man Program, including the Orange Co. Dept. on Aging, the Chatham Council on Aging,Orange/Lee/Chatham Health Departments, Carol Woods and Carolina Meadows Continu-ing Care Retirement Communities, Brookshire Nursing Center, Dr. Bill Milner of Greens-boro, Florence Soltys with the Program on Aging, Bev Cowdrick, nursing home Adminis-trator, UNC-CH School of Dentistry, and others.
Access Dental Care is one of only two non-profit organizations in NC dedicated solely totreating the dental needs of older adults in long term care settings and those with mental
retardation and/or developmental disabilities living in the community. It will deliver carewithin each facility, using mobile dental equipment to provide comprehensive dentistryfrom cleanings to dentures, and offers outpatient surgery in the hospital setting for espe-cially difficult to manage patients. Its mission is dedicated to establishing special caredentistry standards of care, developing relevant professional education, and encouraginghealth services research, and developing policy.
The co-chairs of the local task force are Jill Al-hafez Passmore, Long Term Care Ombuds-man and Dorothy Cilinti, Director, Chatham County Health Dept. “Old age is not a disease - it is strength and survivorship. triumph over all kinds of vicissitudes and disappointments. trials and illnesses.” ~ Maggie Kuhn, US Civil Rights Activist Talking With Your Doctor About Your Meds
Your doctor needs to know about ALL of the medicines you take, including over-the-counter (non-prescription) drugs, so bring everything with you to your first visit. Don’tforget to include eye drops, vitamins, and laxatives.
Be ready to tell the doctor how often you take each medicine,and describe any drug allergies or reactions you have had. Youand your doctor can review all your medicines together to see ifyou still need them all. Mention which medications work best foryou. Be sure your doctor has the phone number of your regular drugstore, where your records are on file.
Doctors can often help with the high cost of medicines. Sometimes they have samples ofcertain medications. Or you can ask your doctor to substitute a generic drug if that wouldbe an option for you. Generic drugs are less expensive. If a generic version is not available,ask your doctor if there is another less expensive brand that would work just as well.
It may be that your doctor can prescribe a larger doseage tablet which could then be split,because sometimes the larger doseage is a lot less expensive. Discuss this with your doctorto see if this would be a reasonable option for you. Drugs Meant To Protect Can Sometimes Cause Disaster
~ reprinted with permission from Joe & Terry Graedon, authors of “The People’s Pharmacy”
Safety conscious people expect their precautions to protect them. A fire extinguisher inyour home should put out a fire. If it spread the flames instead you would be outraged!Air bags are supposed to prevent injury, not cause death. That’s why so many people weredistressed when it was discovered that air bags sometimes injure or kill young children inthe front seat.
Medicines are supposed to prevent health problems such as a heart attack due to highcholesterol or a stroke brought on by high blood pressure. When a medication does moreharm than good, people feel betrayed. Older people are especially vulnerable to adverseeffects of drugs. We recently learned of one elderly gentleman’s horrifying experience fromhis son:
“My father is 90 years old. Several years ago he had surgery onhis carotid artery, and had been on Coumadin since then. He was ingood health except for occasional night-time leg cramps and afainting spell while attending an outing on a hot and humid June day.
When he reported this to his physician, the doctor prescribedquinine and Depakote, and increased Coumadin from 3 to 4 mg. Within two weeks my father fell at his assisted living home and was
hospitalized briefly for observation. After discharge he had increasing difficulty with visionin one eye. In early August an ophthalmologist found bleeding behind the retina and at-tempted unsuccessfully to correct the condition with a laser procedure.
In early September he was again hospitalized after a fall. In the hospital he was given moreCoumadin and quinine sulfate, along with aspirin, and approximately 10 other medicationseach day. The physician stated that my father’s systems were shutting down and his condi-tion was terminal. He was released to a nursing home in very poor condition.
At the nursing home my father’s medication regime included quinidine, diltiazem,metoprolol, aspirin, spironolactone and Levaquin. Later Coumadin was added and thenPaxil. Seven days later he was hospitalized with purple toe syndrome, low blood pressure,coagulation problems, and skin necrosis. After he was stabilized, his physician releasedhim to the nursing home, again indicating his condition to be terminal.
After looking in your book Dangerous Drug Interactions,*
we found that many of his medicines were incompatible. Since the doctor said he was terminal, my family decided we
had little to lose by taking him off all his medications gradu-
administered. families, friends
After a ‘drying out’ period of about ten days, my father
made a remarkable recovery. He was released from the
need to ask
nursing home to his assisted living home in early November,and his health has recovered to the same good condition as
it was in early June, except for the vision in one eye. Other
than an occasional laxative, he is currently not taking any
and nurses to Review and This brush with death had a happy ending, but it could Reevaluate the Rx easily have been a tragedy. No one should ever discon- Regimen! tinue medicines without medical supervision. But when so many incompatible drugs are administered, families need to ask physicians, pharmacists and nurses to review and reevaluate the regimen.
* [The book, Dangerous Drug Interactions, was written by the Graedons, in 1999] DOSING: DO IT RIGHT! Ever wonder what some of the “shorthand” symbols mean that your doctor writes on your prescription? If you’re not sure.ask the pharmacist! In general. NKA = “no known allergies OD = “once a day” BID = “twice a day” TID = “three times a day” QID = “four times a day” QOD = “every other day” HS = “at bedtime” PRN = “as needed” PO = “by mouth” NPO = “nothing by mouth” Most of these abbreviations come from the original Latin medical term. For example: PO = “per os” = “by mouth”. There is a growing call for doctors to write out instructions in “plain English” in order to decrease the chance for misunderstanding and mistakes! WISDOM FROM THE FRONT LINES OF CARE
~from an article by Carol Teal, Executive Director, Friends of Residents in Long Term Care
Sixty people spent four hours together on March 1, 2002 to honor and thank the direct-care workers in Orange County's nursing homes and assisted living facilities. The event,called Conversations with Friends, was sponsored by Friends of Residents in Long TermCare, the Triangle J Ombudsman Program, the Orange County Dept. on Aging, and theOrange County Community Advisory Committees. The Carol Woods Retirement Commu-nity hosted the event and provided funding.
This is my favorite event because we not only honor direct-care workers for the importantjobs they do, but we also have a conversation with them about the nature of their jobs. Workforce issues are arguably the most challenging realities facing long term care today. Everyone, from policy makers to family members, is talking about the staffing crisis, highturnover rates and the inadequacy of current staffing levels. This event gives us the oppor-tunity to hear from direct care workers about what needs to change to improve the qualityof their jobs and, therefore, improve the quality of care provided to residents.
The conversation was rich with substance, honesty, and great suggestions. Amid thesocial interaction of the meal, entertainment, hilarious skit and door prizes, the heart of theconversation went like this:
o Question: What do you like most about your job?
* Sense of responsibility in caring for residents (providing love and
feelings, feeding, bathing, dressing, applying make-up).
* Giving folks dignity, respect, and a sense that they are not alone. * Families satisfied with the job you've done. * One big family - we work as a team. * Learning from residents' life experiences (many different cultures).
o Question:What makes your job difficult to do?
* Lack of support system, especially dealing with death. * Expectation to be "super human."* Not enough staff; not enough pay; not having proper equipment; lack of advancement.
* Combative/difficult residents; residents who abuse medication.
* Lack of appreciation/recognition/rewards/respect.
o Question: What would improve your job and help you provide better quality care to
the residents?* Better staffing ratio, especially for feeding. * More salary; pay differential; pay based on experience and knowledge; and
benefits, including mental health, paid vacations, benefits for dependents.
* Include CNAs on State Survey Team, with residents' Care Plans, and upon
* Ongoing training that promotes teamwork; training in dementia care,
* Union or advocacy group for CNAs; support groups; listening sessions
Direct care workers in long term care settings want what we all want. They want to beadequately compensated for the work they do. They want benefits so that they can takecare of their families. They want a reasonable workload so that they can do what is ex-pected of them. But most of all they want to be valued and appreciated for the workthey do.
Those attending the Conversations With Friends event promised to share these commentsand suggestions with policy makers. We also pledged our commitment as an organizationto work to improve the jobs of direct care staff in long term care settings. We acknowl-edged the direct link between the quality of the caregiver'sjob and the quality of care provided to residents. Thesewonderful suggestions from frontline workers shape muchof our public policy advocacy, from improving staffingratios to working for adequate compensation. A big thankyou goes to all the wonderful frontline workers who sharedtheir time and knowledge with all of us. We thank you fortaking care of our family members and friends, and wepledge to work hard to improve the quality of your jobs soyou can deliver the kind of care you want to provide. [Comment by Jill Al-hafez Passmore, Orange County’s Ombudsman]In Orange County, per the Master Aging Plan approved by the Orange County Commis-sioners, a follow-up to this event will be the development of a Long Term CareRoundtable, with one subcommittee for Administrators of Adult Care Homes, and onesubcommittee for Administrators of Nursing Homes. The purpose of the Roundtable is tobring together Administrators, the County Commissioners, the Ombudsman, the Commu-nity Advisory Committee members, the Department of Social Services, the Department onAging, and other community groups to address common areas of concern related to longterm care. We must work together, as a team, in order to tackle these difficult issues. We all strive forthe same things—quality of care and quality of life for our long term care residents.
Two more Conversation with Friends events are planned for September 2002 in Durhamand Moore Counties.
Medication: Changes, Choices & Communication
Older bodies do not tolerate drugs in the same way young bodies do. Changes as weage.in hormones, body fat and water content, metabolism, blood flow, and kidneyfunction.all affect the way our bodies absorb and use drugs. Sometimes these changescan cause problems.
Sometimes problems with medication can start with problems in communication. Peoplemay not tell the doctor all of their symptoms and medical history because they feel it is toolong or too complicated. Or maybe they see several doctors for different ailments, and thepatient and the doctors don’t get around to telling each one what the other has prescribed.
Then there can be problems with taking medicine correctly. Vision impairments can make ithard to tell differently colored but similarly shaped pills apart. Or the high cost of manyprescription medication may tempt someone to skimp on the number of pills taken eachday, or even worse, force them to go without filling a prescription.
Receiving medicine from someone else can lead to problems. In a long term care facility,one nurse may be administering medication for 30, 40 or more residents. Every time medi-cation is administered presents an opportunity for a mistake to be made.
To resolve problems with medication, good communication is required, whether the mis-takes stem from dosage errors, adverse side-effects, interactions between the differentmedicines or just in evaluating how well a medicine is working. Drugs can do wonderfulthings and can improve your or your loved one’s quality of life, but be smart and learn allyou can about the medication you take! The Internet is a helpful tool to find information.
For example, the following sites contain information about medications. what they areused for, doseage, side-effects, interactions, the best way to take the medicine, and when itwould be important to call your doctor:
If you or your family members don’t have a computer at home, most public libraries havecomputers available, and the staff can show you how to find these sites on-line!
“The great secret that all old people share is that you really haven’t changed in seventy or eighty years. Your body changes, but you don’t change at all. And that, of course, causes great confusion.” ~Doris Lessing, British novelist A Note from the Ombudsman:
You should always have access to your medical records and what medications
you are currently taking. Any questions you have should always be answered.
As a resident, you have the right to refuse medical treatment which includes medi-
cations. Before doing so it is advised that you know the consequences of your refusal,however, your choice should be respected.
Most facilities do not have a pharmacist on staff, however they do have consult-
ing pharmacists. If you would like to speak to your facility’s pharmacist, ask to set upan appointment for the next time he or she is in the facility.
You have the right to choose your own pharmacy, however, the pharmacy must
agree to the facility’s policy for providing medicines for the facility.
Why I Work At IHS ~ by Reginald C. Wilson, Restorative Aide
It’s not about the co-workers, that I come into this job. It’s not about Mary, Bill, Catherine or Bob. Although they are good people with really nice things to say,They are not the reason I come to work each day.
It’s not about the families that say, “How do you do?”Although they are a major part of how the day goes through. It’s great they visit their loved onesand try to comfort them while they are alive,But they are not the reason I work my nine to five.
You see, caring comes from a special place way back deep in your heart,And if you want peace and serenity, caring is the place to start.
It’s not at all about the money,why I work at this place. It’s about the contentment and look of well beingthat’s on my patients’ face. And if you have encountered such a look,I’m sure you will agree,That big wide grin on a patient’s faceis pay enough for me!!!
Jill Al-hafez Passmore, Greg Tanner, Nancy Murphy
Summer 2002 CONTENTS
Medications and Falls, by Frank Hielema, PhD, PT
Prescription Drugs: Protection? or Disaster!
Medication Changes, Choices, & Communication
Please share this newsletter with all residents, staff and family members of the facility,community volunteers and other interested agencies.
EYE INJURIES IN BOXING Jean-Louis Llouquet Introduction The era of blindness as a result of boxing is past. However boxing doctors have become more aware of ocular damage: retinal detachment being the most frequently observed serious injury in professional boxing. Ocular injuries as a result of boxing mainly affects professional boxers The eye is relatively well pr
Economic Common Sense About Prescription Drugs We have observed elsewhere that medical outlays in advanced2000) provides some needed perspective on the public’s apparenteconomies can be expected to increase both in absolute terms and asalarm over drug expenditures. The following findings seem mosta percentage of GDP as a nation’s wealth increases. The reason isthat consumption for life