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Showing posts from February, 2014

Surrogate Decision Making in the Hospital (Or, That Family Member By the Bed is Much More Than a Visitor)

An innovative study in JAMA Internal Medicine on surrogate decision making has profound implications for how we take care of older hospitalized patients.  The study, by Lexy Torke and colleagues at Indiana University, systematically described the involvement of surrogates in decision making for hospitalized patients.

Surrogate decision making refers to the phenomenon in which someone other than the patient is making or helping to make the key medical decisions.  In older patients, the surrogate decision maker is usually a family member, either a spouse or adult child.

Torke proves that surrogate involvement in decision making is much more common and extensive than previously described.  Most prior work has focused on surrogate decision making in the ICU and at the end of life.  But Torke shows that surrogates are extensively involved in decision making in less severely ill patients on the general medical wards.  Further, surrogates are involved in much more than end of life decisio…

Tell CMS to protect appropriate palliative care prescribing

Attention all Geriatric, Palliative Medicine, and Primary Care Providers:
Act now to prevent the adoption of strict, punitive regulations impacting opioid prescribing.  The proposed Center for Medicare and Medicaid Services (CMS) regulations will significantly hamper our ability to provide individualized care for patients with serious or life-limiting illnesses. Porter Storey, Executive Vice President for the American Academy of Hospice and Palliative Medicine (AAHPM), recently highlighted this urgent need at a University of Colorado Palliative Medicine Grand Rounds, and AAHPM is currently drafting a letter of comment for CMS. We thought it important enough to share with the Geripal community because your stories matter. Time is of the essence.
This is a call to action to comment on CMS-4159-P. The proposed rule revises the Medicare Advantage program (Part C) regulations and prescription drug benefit program (Part D) regulations. As stated in the Executive Summary, one of the goals is …

Ramelteon for the prevention of delirium in the hospital

About half of the patients that I saw on or palliative care consult service last week were delirious. This is in line with reported incidence of delirium in the medical wards (30-50%) and in the ICU (up to 80%). One aspect that many of these individuals had was a disruption of their circadian rhythm with sleep-wake reversals, so much of what we recommended was good sleep hygiene. This though is tough in the hospital where infections, medications, and environmental factors all wreck havoc on a good night's sleep.

It's thought that melatonin synchronizes the circadian rhythm that regulates the sleep-wake cycle, so maybe prophylactic use of this medication may help prevent delirium from occurring in these hospitalized older adults?  Hatta and colleagues published a study that reportedly showed that it indeed did.  In the JAMA Psychiatry publication, the conclusion was that ramelteon, a melatonin receptor agonist, significantly decreased the incidence of delirium in elderly med…

Why is Forest Laboratories discontinuing Namenda?

Why is Forest Laboratories discontinuing Namenda (memantine HCl) 5 mg and 10 mg tablets on August 15, 2014? Is it because there were no significant benefits of the combination of donepezil and memantine over donepezil alone in a study published in the NEJM in 2012?  Maybe, just maybe, Forest Labs is discontinuing Namdena because even the most positive trials of Namenda show only a very small statistically significant benefit that may very well be clinically insignificant?  Wait, I know.  Can it be that Forest is discontinuing Namenda 5mg and 10mg tablets because they are worried that individuals are being prescribed this medication earlier in the course of Alzheimers despite the fact that memantine is only approved for moderate to severe disease and despite a growing body of evidence that it provides no benefit in this population of patients?

Sadly, Forest Laboratories is discontinuing Namenda mg and 10mg tablets for none of these reasons.  They are discontinuing it because Namenda i…

An Older Pedestrian Fights Back

Older pedestrians are more likely to be killed while walking than those under 65 years of age.  A lot has been said about reasons why (for a good read check out "Dangerous by Design") including factors such as the timing of traffic lights.

However, for a good laugh, check out this way to combat these high mortality rates:



by: Eric Widera (@ewidera)

Note: a big thanks to Paul Tatum for the link!

The Long Term Care Insurance Con Game

Consider this scenario:

You are getting older, and are concerned about the costs of nursing homes and long term care.  So, you decide to get expensive long term care insurance to protect your family from these costs.  The policy will pay some of the cost of long term care if you develop cognitive or physical disability.  All you have to do is keep making payments on the policy until you have a need for services.  But make sure you make the payments.  If you don't, your policy gets cancelled, you lose all the money you put into premiums, and you get nothing when you need the services you thought you were paying for.

But wait, there is a catch.  One of the first problems that happens in persons who are developing the very cognitive problems that lead to the need for long term care services is trouble managing finances.  One of the first signs that someone needs their long term care insurance is that they can't keep track of bills, forget to make payments, and make bad financia…