Massachusetts has a notable history. It’s given us Pilgrims, the Boston Tea Party, and a few Presidents. So, it’s no surprise that Massachusetts is one of the first to change their state’s view on dementia care.

The state is creating new rules to improve dementia care and memory care training for those who treat patients with dementia. The new rules would require nursing homes with memory care units to give staff eight hours of initial training time and four more hours each year. Regulators intend for every nursing home care worker in the state to receive this training, since an estimated 60% of nursing home residents have some type of dementia.

The state is continuing the push towards better memory care, last year they established minimum standards for dementia care units and there’s a push for licensing among all homes because some have patients with dementia. Nursing homes agree that training would be beneficial but do not want to pay for it.  However, the training is direly needed since more and more elderly patients are exhibiting signs of dementia. With the Baby Boomers reaching nursing home age, training and better memory care is needed now more than ever.

See article at Senior Housing News.

In a recent article by The Washington Post, the issue of how technology can help residents and caregivers were explored. There are several apps, programs, and tools that can help make life a little easier for caregivers.

Instead of a paper list of medications, time they should be taken, and refill times, a new app called Balance that allows users to create that list on their phones. The $3.99 app was released by the National Alzheimer Center. The medication list is just a part of what the app offers. It also provides caregiving tips, notes for doctor appointments, and a news feed about Alzheimer’s.

The Alzheimer’s Association has a program called Comfort Zone which is a tracking program. The person with Alzheimer’s wears a tracking device. As they go places, the data is sent to the program, which can be checked from a phone, an iPad, a computer, etc. The family member knows where the person is going. Tracking programs like these are especially useful because they provide freedom for people who don’t need to be under supervision. The tracking program allows family members to see the person’s patterns, and as the disease progresses, it can become clear that further action needs to be taken.

Autism Speaks has given iPads to low income families in an attempt to create better communication between autistic children and caregivers. There are a number of programs which can be used on the iPad and computer which help organize information about medicines, appointments, behavioral notes, etc. However, there are also programs designed to foster learning. Since many autistic children face issues with social communication and behavioral impairments, these devices can provide an outlet for their opinions and their thoughts without being physically taxing. iPads can also be a reward. When lessons are finished, children can play with the iPad or watch videos.

Vice President of the Alzheimer’s Association Beth Kallmyer suggests that we be cautious in moving forward with these tools. She believes that it’s too early to depend on these tools completely. As she says, the population affected with Alzheimer’s is the older generation and sometimes they don’t feel comfortable with this technology.

Dr. David Hilfiker is writing a blog at Watching the Lights Go Out about his Alzheimer’s.  He is attempting to chronicle his journey until he is no longer able to do so, at which point he has enlisted a friend who has agreed to take over. His perspective on the disease is invaluable.  It’s a unique insight into a disease that afflicts many.
 

 

The Hartford Courant had a great editorial recently about the off label use of antipsychotics in nursing homes.  Below are excerpts.

Antipsychotic drugs are prescribed too frequently in Connecticut nursing homes to keep patients who have dementia or mental illness under control.

Lisa Chedekel of the nonprofit Connecticut Health Investigative Team has reported that some nursing homes in this state significantly exceed the national rate of administering such drugs to long-stay residents. At some facilities, the rate is more than double the already high state average. At one nursing home, 68 percent of long-stay residents were getting antipsychotics.

Antipsychotic drugs are supposed to be given only to patients diagnosed as having a psychosis or related condition. But in many nursing homes, they are prescribed for those who are difficult to manage, regardless of whether there’s a diagnosis of a mental illness.

 

That’s not good for patients, and ought to be curbed. The U.S. Health and Human Services Department has urged taking action against inappropriate prescription. The state Department of Public Health is trying to develop ways to reduce the use of antipsychotic medications.

Critics say that nursing homes are tempted to overmedicate because agitated patients are easier to deal with when sedated. But there can be serious, perhaps fatal, side effects to giving these drugs to elderly people with dementia.

Many residents of long-term-care facilities are neither elderly nor frail, but mentally ill. In 1995, the state closed two of its three mental institutions — Fairfield Hills and Norwich State Hospital — and some residents ended up in nursing homes. They may need to be treated with antipsychotic drugs. Still, that doesn’t excuse prescribing medication without a proper diagnosis, as some nursing homes do. That must stop.

Increasing staff and training has been suggested as a way to lower the need to use medication — but those are expensive, and for facilities that rely on Medicaid reimbursement, the funding may not be adequate. This problem, as so many in health care, is linked to money.

Long-term solutions to overmedication should involve alternative ways to care for those with mental illness, perhaps in supervised group homes.

 

WNYC also had a recent article on the overuse of antipsychotics in New York City nursing homes. “There is widespread and poorly regulated use of anti-psychotic medications by several New York City nursing homes, according to a new investigation by the Gotham Gazette.” The series found that one-in-four nursing home residents in the city were given anti-psychotics in 2011, and one-in-three homes dose more than a third of their residents.

Anti-psychotics are sometimes known as “chemical restraints” because of their sedative effect. Under federal law, anti-psychotic drugs can only be given on doctors’ orders, and not so nursing home staff can better manage difficult patients.  They are frequently prescribed for difficult patients, such as those suffering from dementia. Yet research has found that the drugs can also lead to falls, strokes and even death.

 

The New Hampshire News had an interesting article about the “Battle Against Chemical Restraints in Nursing Homes”.  Nursing homes around the country are under pressure from the Federal government to reduce their use of antipsychotics.  This powerful class of prescription drug is meant for mental illnesses such as schizophrenia. But they are being used on people with Alzheimer’s Disease at startling rates.

MedPageToday also had an article stating that more than one in five U.S. nursing home residents are given antipsychotic medications — generally off-label, a national analysis revealed. In a sample of more than 1 million patients in nursing homes, 22% were given at least one prescription for an antipsychotic agent, according to Becky A. Briesacher, PhD, and colleagues from the University of Massachusetts in Worcester.  The researchers analyzed data on dispensing during 2009-2010 by the long-term care pharmacy Omnicare, which provides medication services across the country and for up to half of all residents.

The prescribing of antipsychotic medications persists at high levels in U.S. nursing homes despite extensive data demonstrating marginal clinical benefits and serious adverse effects, including death,” Briesacher and colleagues wrote in a research letter in the Feb. 6 issue of the Journal of the American Medical Association.  “The most common antipsychotics prescribed are often used for off-label indications related to dementia, and the extended durations of use raise concerns about the care of frail elders residing in [nursing homes],” the researchers stated.

In more than two-thirds of cases, the agents used were from the atypical class of antipsychotics, which are primarily indicated for the treatment of schizophrenia and bipolar disorder:

Quetiapine (Seroquel), 31.1%
Risperidone (Risperdal), 24.4%
Olanzapine (Zyprexa), 13.1%

Meanwhile, the Hartford Courant reported that the Westside Care Center nursing home in Manchester, two-thirds of long-stay residents are receiving antipsychotic drugs, even though they do not have a psychosis or related condition that regulators say warrants their use. Westside’s rate of dispensing the drugs to 68 percent of its residents without a diagnosis is the highest in the state, according to federal data — and more than double the state’s average of 26 percent, which already ranks in the top-third of states nationally.  The December data — newly disclosed by federal nursing home regulators — show that more than half of Connecticut’s nursing homes — 128 of 233 — were dispensing antipsychotics without a clinical diagnosis at rates exceeding the national average.

 

Forbes had a great article on the benefits of music to assist memory.  Music therapy, a relatively new form of cognitive therapy has been recently applied to patients suffering from Alzheimer’s or dementia.   However, most nursing homes have no music for residents to listen to.  This lack of music could be a missed opportunity to invigorate patients and help them gain better control of their cognitive functions. Music creates strong psychological implications – with certain songs connecting with memories.

Music is a part of our everyday lives; we hear sounds wherever we go.  How many times have you heard a song that brought you back to a time or place? Maybe it was the song that played at your wedding, maybe it was the song that played at your prom.  Whatever it is, music holds a very powerful connection with memories. For patients suffering from memory impairment, music can allow them to regain a sense of themselves.

Music & Memory, a Long Island organization, is a program dedicated to allowing patients with dementia to be able to experience themselves again.  Music & Memory brings nursing homes iPods which they fill with patients’ favorite music, as provided by family and friends.  More than 60 nursing homes participate in Music & Memory, although none in SC.

The program has become so popular that a documentary was made about the organization.  Alive Inside: The Story of Music and Memory¸ showcases the work done by the organization and the effects on patients. In a clip in the article, an elderly man named Henry can be seen before and after listening to his iPod.  Before, he is barely responsive and mostly immobile. Afterwards, he is moving his feet, crooning along with the tunes. The benefits don’t end there. When the nurse takes off the headphones, Henry is much more responsive to questions, able to answer in sentences where before he could hardly manage yes or no.

People can donate to the program by sending in their gently used iPods and power cords.
 

 

NPR reports that doctors my have found a means of better and earlier detection for Alzheimer’s. Researchers have been testing any experimental radioactive tracer called Amyvid that helps identify clumps of proteins in the brain associated with Alzheimer’s disease.

Although there is a tendency to correlate Alzheimer’s with the amyloid plaques, there is still much we do not know about what causes the disease and how to prevent. A panel of experts is deciding if this $1,600 drug per exam should be payed for by Medicare. Experts have a lot of skepticism in moving forward with approving the drug for medicare coverage because there is not a solid link connecting the the two and the costs don’t necessarily out weigh the benefits.

The most difficult factor in determining the cost-effectiveness of using this drug is how effective it is in determining early signs of Alzheimer’s disease because experts agree that early detection is the most cost-effective method of dealing with the disease. The panel determined that the drug was not yet worth the high costs of the drug or most helpful in determining early signs of the disease.

The drug does show promise, however, in the move forward to find ways to better detect early signs of Alzheimer’s even if there is no proven cure for the disease yet.

Kaiser Health News reported a study from the National Institute of Medicine that shows that the U.S. health care system is not prepared for future mental health needs based on demographics and lack of specialists. Aging patients will not receive treatment for depression, dementia and other conditions. “In addition, some experts are concerned that the baby boomer population, which is a growing component of the nation’s older demographic, have an unaddressed problem with substances – namely misuse of prescription medications.”

The Institute of Medicine report says all health workers who see older patients — including primary care physicians, nurses, physicians’ assistants and social workers — need some training to recognize the signs of geriatric mental health problems and provide at least basic care. To get there, it called for changes in how Medicare and Medicaid pay for mental health services, stricter licensing requirements for health workers, and for the government to fund appropriate training programs.

The government is pushing to improve mental health staffing for military veterans, an especially vulnerable subset of the elderly population. In April, the Department of Veterans Affairs announced that it would add around 1,900 psychologists and other staff.

The Washington Post also had an article on the study.  The article states at least 5.6 million to 8 million Americans age 65 and older have a mental health condition or substance abuse disorder

The Daily Beast and About.com have published interesting articles that address the tricky subject of sex in nursing homes. As the article on About.com explains, many long term care residents will spend the remainder of their lives in a nursing home so the responsibility falls to the facility to ensure that their residents live the rest of their lives with as much dignity and enjoyment as possible.  The nursing home is their home.

However, nursing home residents face many obstacles to enjoying themselves in a safe environment.  Doors without locks, single beds, and roommates all serve as structural obstacles to normal consensual sexual activity.  Additionally, as The Daily Beast explained, residents of nursing homes are frequently treated as children and their sexual desires are ignored or discouraged.

Dementia further complicates things.  Residents suffering from the disease may be more aggressive and violent, and are a greater risk of being impulsive.  Also, memory loss from dementia can cause a resident that has been married for years to forget that he or she has a spouse or cause them to mistake another resident for an intimate partner.  More importantly, the inevitable problem of sexual abuse of a vulnerable adult makes sex in a nursing home even more difficult to control.

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