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Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Geriatrics. Show all posts
Showing posts with label Geriatrics. Show all posts

Friday, September 28, 2018

A Debate Over ‘Rational Suicide’

Paula Span
The New York Times
Originally posted August 31, 2018

Here is an excerpt:

Is suicide by older adults ever a rational choice? It’s a topic many older people discuss among themselves, quietly or loudly — and one that physicians increasingly encounter, too. Yet most have scant training or experience in how to respond, said Dr. Meera Balasubramaniam, a geriatric psychiatrist at the New York University School of Medicine.

“I found myself coming across individuals who were very old, doing well, and shared that they wanted to end their lives at some point,” said Dr. Balasubramaniam. “So many of our patients are confronting this in their heads.”

She has not taken a position on whether suicide can be rational — her views are “evolving,” she said. But hoping to generate more medical discussion, she and a co-editor explored the issue in a 2017 anthology, “Rational Suicide in the Elderly,” and she revisited it recently in an article in the Journal of the American Geriatrics Society.

The Hastings Center, the ethics institute in Garrison, N.Y., also devoted much of its latest Hastings Center Report to a debate over “voluntary death” to forestall dementia.

Every part of this idea, including the very phrase “rational suicide,” remains intensely controversial. (Let’s leave aside the related but separate issue of physician aid in dying, currently legal in seven states and the District of Columbia, which applies only to mentally competent people likely to die of a terminal illness within six months.)

The info is here.

Tuesday, December 6, 2016

Living with the animals: animal or robotic companions for the elderly in smart homes?

Dirk Preuß and Friederike Legal
J Med Ethics doi:10.1136/medethics-2016-103603

Abstract

Although the use of pet robots in senior living facilities and day-care centres, particularly for individuals suffering from dementia, has been intensively researched, the question of introducing pet robots into domestic settings has been relatively neglected. Ambient assisted living (AAL) offers many interface opportunities for integrating motorised companions. There are diverse medical reasons, as well as arguments from animal ethics, that support the use of pet robots in contrast to living with live animals. However, as this paper makes clear, we should not lose sight of the option of living with animals at home for as long as possible and in conformity with the welfare of the animal assisted by AAL technology.

The article is here.

Thursday, January 14, 2016

Blue Cross expands benefits for end-of-life care

By Priyanka Dayal McCluskey
The Boston Globe
First posted on December 28, 2015

Here is an excerpt:

And while the primary goal is not cost control, the effort also has the potential to lower health care spending by giving patients more options to replace hospital care with less expensive — and often preferable — alternatives, such as hospice and home care. Medical care at the end of life can be expensive; a 2010 study found that 25 percent of all Medicare payments go toward the 5 percent of people in the last year of their lives.

“The industry is now starting to take this seriously,” said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center. “The industry now not only understands the issues [around death and dying], but understands there are concrete things they can and need to do, and Blue Cross is showing us how to get started.”

The article is here.

Friday, December 20, 2013

Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting

Dedan Opondo, Saied Eslami, Stefan Visscher, Sophia E. de Rooij, Robert Verheij, Joke C. Korevaar, Ameen Abu-Hanna
Published: August 22, 2012DOI: 10.1371/journal.pone.0043617

Abstract

Background

Inappropriate medication prescription is a common cause of preventable adverse drug events among elderly persons in the primary care setting.

Objective

The aim of this systematic review is to quantify the extent of inappropriate prescription to elderly persons in the primary care setting.

Methods

We systematically searched Ovid-Medline and Ovid-EMBASE from 1950 and 1980 respectively to March 2012. Two independent reviewers screened and selected primary studies published in English that measured (in)appropriate medication prescription among elderly persons (>65 years) in the primary care setting. We extracted data sources, instruments for assessing medication prescription appropriateness, and the rate of inappropriate medication prescriptions. We grouped the reported individual medications according to the Anatomical Therapeutic and Chemical (ATC) classification and compared the median rate of inappropriate medication prescription and its range within each therapeutic class.

Results

We included 19 studies, 14 of which used the Beers criteria as the instrument for assessing appropriateness of prescriptions. The median rate of inappropriate medication prescriptions (IMP) was 20.5% [IQR 18.1 to 25.6%.]. Medications with largest median rate of inappropriate medication prescriptions were propoxyphene 4.52(0.10–23.30)%, doxazosin 3.96 (0.32 15.70)%, diphenhydramine 3.30(0.02–4.40)% and amitriptiline 3.20 (0.05–20.5)% in a decreasing order of IMP rate. Available studies described unequal sets of medications and different measurement tools to estimate the overall prevalence of inappropriate prescription.

Conclusions

Approximately one in five prescriptions to elderly persons in primary care is inappropropriate despite the attention that has been directed to quality of prescription. Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events while propoxyphene and doxazoxin are the most commonly prescribed medications with low risk adverse events. These medications are good candidates for being targeted for improvement e.g. by computerized clinical decision support.

The entire article is here.

Friday, October 11, 2013

When There’s No Family

By PAULA SPAN
The New York Times
Originally published September 23, 2013

I rarely write about advance directives and end-of-life discussions without a few readers asking, sometimes plaintively: What if you don’t have a family?

“The presumption is that everyone has someone available, someone most likely younger or in better health, and better able to carry out one’s wishes or make decisions with your guidance,” Cheryl from Westchester commented the last time the subject arose.

But not everyone does.

The entire story is here.

Friday, September 13, 2013

U.S. Nursing Homes Reducing Use of Antipsychotic Drugs

By Alan Mozes
MedicineNet.com
Originally published August 27, 2013

A year-old nationwide effort to prevent the unnecessary use of antipsychotic medications in U.S. nursing homes already seems to be working, public health officials report, as facilities begin to opt for patient-centered approaches over drugs to treat dementia and other related complications.

So far, the program has seen more than a 9 percent drop in the national use of antipsychotics among long-term nursing-home residents, when comparing the period of January to March 2013 with October to December 2011.

The entire story is here.

Tuesday, September 3, 2013

Inclusion of Ethical Issues in Dementia Guidelines: A Thematic Text Analysis

By H. Knuppel, M. Mertz, M. Schmidhuber, G. Neitzke, and D. Strech
PLOS Medicine - Open Access

Ethical issues were inconsistently addressed in national dementia guidelines, with some guidelines including most and some including few ethical issues. Guidelines should address ethical issues and how to deal with them to help the medical profession understand how to approach care of patients with dementia, and for patients, their relatives, and the general public, all of whom might seek information and advice in national guidelines. There is a need for further research to specify how detailed ethical issues and their respective recommendations can and should be addressed in dementia guidelines.

The entire article is here.

Wednesday, August 28, 2013

A Glut of Antidepressants

By RONI CARYN RABIN
The New York Times
Originally published August 12, 2013

Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.

Experts have offered numerous reasons. Depression is common, and economic struggles have added to our stress and anxiety. Television ads promote antidepressants, and insurance plans usually cover them, even while limiting talk therapy. But a recent study suggests another explanation: that the condition is being overdiagnosed on a remarkable scale.

(cut)

Elderly patients were most likely to be misdiagnosed, the latest study found. Six out of seven patients age 65 and older who had been given a diagnosis of depression did not fit the criteria. More educated patients and those in poor health were less likely to receive an inaccurate diagnosis.

The entire article is here.

Tuesday, August 27, 2013

Introducing deprescribing into culture of medication

By Catherine Cross
Canadian Medical Association
Originally published August 12, 2013

An Ontario pharmacist has received a government grant to develop clinical guidelines to help doctors determine whether patients are on medications they no longer need or that should be reduced.


"We don't normally test drugs in the elderly, but they are taking many drugs. As they get older and get more chronic conditions, the number of medications increases," says Barbara Farrell, a clinical scientist with the Bruyère Research Institute in Ottawa, Ontario.


Sometimes when medications are deprescribed or reduced, "confusion will clear, or they'll stop falling, and a lot of literature supports that," says Farrell, who received the $430 000 grant from the Ontario Ministry of Health and Long-Term Care.


The entire story is here.


Thursday, April 18, 2013

Elderly Patients Routinely Prescribed Risky Drugs

By Anahad O'Connor
The New York Times - Well Column
Originally published April 15, 2013

Doctors in the United States routinely prescribe potentially harmful drugs to older patients, and the problem is particularly acute in the South, a new study shows.

The analysis found that more than one in five seniors on Medicare in the South were prescribed medications that health authorities have specifically advised doctors to avoid giving to older patients because of their severe side effects. Compared with people 65 and older living in New England, those living in the southern region from Texas to South Carolina were about 12 percent more likely to be prescribed a high-risk medication.

The researchers suspected that factors like education, socioeconomic status and access to quality medical care might be driving some of the regional differences. And to some extent, that appeared to be the case. As socioeconomic status grew lower, for example, the likelihood of being prescribed a high-risk drug increased. But even after accounting for these factors, the researchers found that the disparity persisted.

The entire story is here.

Saturday, March 30, 2013

Do We Need 'Thanaticians' for the Terminally Ill?

By Ronald W. Pies
Medscape - Ethics in Psychiatry
Originally published September 26, 2012

My 89-year-old mother had been losing ground for some years, experiencing what geriatricians sometimes call "the dwindles." Toward the end of her life, she was beset by a deteriorating heart; an inability to walk; and occasional, severe gastrointestinal pain. My family got her the best medical treatment available -- eventually including home hospice care -- and she generally maintained a positive attitude throughout her long downhill slide.

But one day, as I sat beside her bed, she seemed unusually subdued. "Honey," she said, "How do I get out of this mess?" I had a pretty good idea of what she was really asking me, but I deflected her question with another question: "Ma, what 'mess' do you mean?" I asked. "It's all right," she replied, smiling sadly, "I'll manage."

My mother was doing what she had always done: sparing her children from pain. In this case, it was the pain of dealing with the waning days of her life and the frustration of knowing there was no easy escape from the burdens of dying slowly. "Ma, I'll always make sure you are getting enough treatment for your pain," I added, taking her hand -- knowing that the prospect of unremitting pain is often an underlying fear of terminally ill persons.

Yet, unspoken in my mother's question was the issue of so-called physician-assisted dying, sometimes called "physician-assisted suicide" -- an enormously heated controversy both outside and within the medical profession. In my home state, Massachusetts, the issue has come to the fore, owing to a November ballot initiative for a measure that would allow terminally ill patients to be prescribed lethal drugs. A closely related bill (H.3884) has also come before the Massachusetts Legislature's Joint Committee on the Judiciary.

The entire ethical dilemma is here.

Sunday, March 3, 2013

As Families Change, Korea’s Elderly Are Turning to Suicide

By Choe Sang-Hun
The New York Times
Originally published February 16, 2013

Here is an excerpt:

The woman’s death is part of one of South Korea’s grimmest statistics: the number of people 65 and older committing suicide, which has nearly quadrupled in recent years, making the country’s rate of such deaths among the highest in the developed world. The epidemic is the counterpoint to the nation’s runaway economic success, which has worn away at the Confucian social contract that formed the bedrock of Korean culture for centuries.

That contract was built on the premise that parents would do almost anything to care for their children — in recent times, depleting their life savings to pay for a good education — and then would end their lives in their children’s care. No Social Security system was needed. Nursing homes were rare.

But as South Korea’s hard-charging younger generations joined an exodus from farms to cities in recent decades, or simply found themselves working harder in the hypercompetitive environment that helped drive the nation’s economic miracle, their parents were often left behind. Many elderly people now live out their final years poor, in rural areas with the melancholy feel of ghost towns.

The entire story is here.

Friday, July 20, 2012

Aging Boomers' Mental Health Woes Will Swamp Health System

By Amanda Gardner
HealthDay Reporter
Originally published July 10, 2012

The United States faces an unprecedented number of aging baby boomers with mental health or substance use issues, a number so great it could overwhelm the existing health care system, a new report warned Tuesday.

"The report is sufficiently alarmist," said Dr. Gary Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York City. "I think [the report authors] are right."

Kennedy was not involved with the report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? It was mandated by Congress and issued by The Institute of Medicine in light of a "silver tsunami" of health care needs expected to accompany a senior population that will reach 72.1 million by 2030.

The "silver tsunami" is the result of simple supply-and-demand forces gone awry, the report authors explained.

The entire story is here.

Read the report online for free

Wednesday, September 21, 2011

Antipsychotics overprescribed in nursing homes

By M. Price
September 2011, Volume 42, No. 8
Print Version: Page 11

Physicians are widely prescribing antipsychotics to people in nursing homes for off-label conditions such as dementia, and Medicare is largely picking up the bill, even though Medicare guidelines don't allow for off-label prescription reimbursements, according to an audit released in May by the U.S. Department of Health and Human Services Office of the Inspector General.

The findings underscore the fact that antipsychotics are often used when behavioral treatments would be more effective, psychologists say.

The office reviewed Medicare claims of people age 65 and older living in nursing homes in 2007—the most recent data at the time the study began—and found that 51 percent of all claims contained errors, resulting $116 million worth of antipsychotics such as Abilify, Risperdal and Zyprexa being charged to Medicare by people whose conditions didn't match the drugs' intended uses. Among the audit's findings are:
  • 14 percent of the 2.1 million elderly people living in nursing homes use Medicare to pay for at least one antipsychotic prescription.
  • 83 percent of all Medicare claims for antipsychotics are, based on medical reviews, prescribed for off-label conditions, specifically dementia.
  • 22 percent of the claims for antipsychotics do not comply with the Centers for Medicare and Medicaid Services' guidelines outlining how drugs should be administered, including those guidelines stating that nursing home residents should not receive excessive doses and doses over excessive periods of time.
The report suggests that Medicare overseers reassess their nursing home certification processes and develop methods besides medical review to confirm that medications are prescribed for appropriate conditions.

Why such high rates of overprescription for antipsychotics? HHS Inspector General Daniel Levinson argued in the report that pharmaceutical companies' marketing tactics are often to blame for antipsychotics' overprescribing. Victor Molinari, PhD, a geropsychologist at the University of South Florida in Tampa, says that another important issue is the dearth of psychologists trained to provide behavioral interventions to people in nursing homes. While he agrees that people in nursing homes are taking too much antipsychotic medication, he believes nursing home physicians are often responding to a lack of options.

Many nursing home administrators are quite savvy in their mental health knowledge and would prefer to offer their residents the option of behavioral treatments, Molinari says, but when residents need immediate calming, physicians will turn to antipsychotic medication because it's quick and available. Additionally, he says, many nursing home staff aren't educated enough about nonmedical options, so they go straight for the antipsychotics.

"It follows the saying, 'If your only tool is a hammer, everything is a nail,'" he says. "Nursing homes are not just straitjacketing residents with medications as a matter of course, but because there are a host of barriers to giving them optimal care."