Moak Geriatric Psychiatry Blog

CUTE AS A BUTTON

Friday, September 8th, 2017

It happened again!   A psychiatric nurse, well experienced, well trained, and well meaning, described the newest admission to our service, a ninety-year-old, very frail looking woman with severe dementia, as “cute as a button”. Hearing this, I cringed. Not only because this nurse said it, but also because it’s commonplace in so many healthcare settings, including specialized geriatric programs, where staff members ought to know better. They don’t!

I know this nurse well. She really cares about the older patients on our geriatric psychiatric service. She’ll go out of her way to ensure their needs are met. I’m sure she means to treat them with the dignity and respect they deserve. So why does she not understand that describing geriatric patients as “cute as a button” is not a good way to do this? Why do so many other equally well-meaning healthcare professionals describe frail elders as cute? And is there anything truly cute about advanced, old age?

Toddlers, puppies, and kittens are cute, little old ladies and men not so much. I doubt that you know anyone hoping to be cute in old age? Quite the opposite, they want to avoid that fate, maintaining their dignity and independence. Think about what old-age “cuteness” signifies. It signifies that formerly robust, capable, independent adults have turned into shrunken, frail, feeble, confused waifs with elfin or gnomish qualities. Not an attractive picture.

My guess is that seeing such elders as cute is a defense mechanism for healthcare workers, a way they can ward off their own fears of decrepitude triggered by close proximity to frail patients nearing death. Emotional contact precautions, that’s what it is. It says, “You’re infected with old age, and I don’t want to catch it”. Contact precautions work by providing a barrier, blocking infection. “Cuteness precautions” provide a barrier too, blocking the emotional reality check staff members need to empathize with older adults and help them maintain their dignity. When you’re ninety years old, there’s nothing dignified about being cute.

We teach cultural competence to healthcare professionals to help them be more sensitive to the personal needs of all kinds of patients. Isn’t it about time we added elderly patients to the list?

DOES STICKING TO LOCAL TRIPS IMPROVE OLDER DRIVERS’ SAFETY?

Monday, March 20th, 2017

I’ve heard it hundreds of times: “But I only drive locally, in familiar neighborhoods!” That’s how my patients try to convince me that it’s still safe for them to drive. Their family members similarly rationalize, “But Dad only drives three places, the bank, the post office, and the supermarket. He knows the way very well and doesn’t get lost!” People assume that limiting driving to short, local, trips is a good way for older drivers with declining abilities to remain safe behind the wheel. It makes common sense, but it is not correct.

My patients and their families are always surprised to learn (and you might be too) that driving fewer overall miles, generally by sticking to local routes, doesn’t lower an older driver’s risk of having an accident, it raises it. Drivers over sixty-five years old, on average, have higher accident rates than younger drivers, but older drivers who drive more than 3,000 km (just under 1,900 miles) per year have lower accident rates, equivalent to those of middle aged individuals.

What’s going on here? Why isn’t driving fewer miles and keeping to shorter, local roads, safer? Shouldn’t short, familiar routes be easier for forgetful older adults to remember? Of course, but much more goes into safe driving than memory. Navigating local streets demands more of drivers than does highway driving. There’s more to deal with: more signs, more turns to make, traffic lights to obey, more intersections to negotiate, and more parked vehicles, bicyclists, and pedestrians not to hit; in short, more opportunities for error.

Being able to remember the route and recall details on the way, such as speed limit, of course, are important. But it is the ability to take note of, and quickly react to, a complex and rapidly changing landscape that determines safety most. Aging takes a toll on the mental abilities needed to stay vigilant, anticipate the unexpected, properly judge the speed and distance of other vehicles, and make quick decisions about passing, pulling out, and yielding the right of way. This shows in the types of crashes that older drivers most commonly have: left turns across traffic, failure to yield the right of way, failure to stop at a signal, and failure to judge speeds correctly. Intersection crashes account of two fifths of crashes involving senior drivers versus only one fifth of those of younger drivers.

So rationalizing that it’s still safe for an older adult to drive because he or she only drives locally may be just that, a rationalization. Each person’s abilities, fitness, health, and circumstances are different, and obviously there are exceptions. But if an older adult has given up longer distance driving due to worries about safety, then keeping to shorter, local routes may not be any better.

References

R Robertson and W Vanlaar, “Elderly Drivers: Future Challenges”, Accident Analysis & Prevention 2008; 40: 1982-1986.

J Langford and S Koppel, “Epidemiology of Older Driver Crashes: Identifying Older driver Risk Factors and Exposure Patterns”, Transportation Research 2006; Part F, 9: 309-321

Do Anticholinergic Medications Cause Alzheimer’s Disease

Monday, May 2nd, 2016

DO ANTICHOLINERGIC MEDICATIONS CAUSE ALZHEIMER’S DISEASE?

 

It is beyond doubt that anticholinergic medications cause cognitive impairment. Much evidence also has accumulated that these medications are associated with Alzheimer’s disease, but there has been no proof of a cause-and-effect connection. You can read the educational article elsewhere on this website to learn more about anticholinergic medications.

A new study now shows that taking anticholinergic medications increases the chance that healthy, older adults will develop mild cognitive impairment (MCI) or Alzheimer’s disease. MCI is a milder condition that often represents an early stage of Alzheimer’s disease. Researchers found that higher exposure to anticholinergic medication was associated with worse subsequent cognitive function.

The most damning finding of this study was that use of anticholinergic medications also was associated with brain structural changes on MRI scans and functional changes on PET scans. These changes are the type seen in Alzheimer’s disease, an apparent smoking gun proving anticholinergic medications are one risk factor for Alzheimer’s disease. This study provides the most compelling evidence yet that adults in mid or later life should avoid anticholinergic medications if at all possible.

 

Shannon L. Risacher, Brenna C. McDonald, Eileen F. Tallman, et al, “Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults”, JAMA Neurology. doi:10.1001/jamaneurol.2016.0580, Published online April 18, 2016. Accessed April 21, 2016.

PILL-COUNT LIMITATIONS: Backdoor Rationing?

Tuesday, July 28th, 2015

My patient needed 3-4 mg of aripiprazole per day for her bipolar disorder. She had lived with bipolar since her mid twenties, and now was in her late seventies. Most of the time she did very well on 3 mg per day. But during periods of stress, she needed 4 mg. She was going through one of those times, when she asked me to prescribe 4 mg.

The last time she needed such a dose increase it was simple. Not this time. In the interim, she had switched Medicare prescription drug plans, as many beneficiaries do each year. The new insurance company covered 3 mg but not 4 mg. “Why not?” you ask. Aripiprazole comes in 2 mg and 5 mg tablets, but not 3 mg or 4 mg tablets. To take 3 mg or 4 mg, you have to take one and a half or two of the 2 mg pills, respectively. Her new insurance company had, as many do nowadays, a pill count limitation. Some insurance companies call this a supply limit. My patient’s insurance company allowed 45 pills per month, the number needed for 3 mg per day, but not the 60 pills per month she now needed.

I could have gotten around this restriction by raising the dose to 5 mg per day. That would require only 30 pills each month, and her insurance company would have been happy to cover that. But we knew from past experience that she could not tolerate 5 mg; it gave her intolerable side effects. So this option was out of the question.

Geriatric psychiatrists and their elderly patients face such roadblocks frequently. Older adults are more sensitive to the adverse effects of medication. They also respond well to lower doses than typically given to younger patients. So geriatric psychiatrists take great pains to find the lowest dose that works. This amount may be a half or a quarter of the smallest pill on the market. Or, as was the case for my patient, it might require two smaller pills instead of one larger pill, triggering pill-count limitations.

In geriatric psychiatry practice you quickly realize that insurance companies write their coverage policies without considering the special needs of elderly patients. They are either ignorant or indifferent – I’ll leave it to you to decide. I ran into pill-count limitations at least several times each week. It represented a “hidden”, uncompensated cost of practice, which unduly burdened me financially. I don’t think my practice was unique in feeling this impact.

It’s also apparent that pill-count, or supply, limitations, represents a form of backdoor healthcare rationing. There, now I’ve done it! I’ve used the R-word, “rationing”.

Rationing of healthcare is a proverbial “third rail” of healthcare politics. Politicians, policy makers, and insurance executives, including Medicare administrators, don’t dare mention it. They adamantly deny it goes on and insist it never will. But Pill count limitations are one form of rationing. Insurance companies have others.

Of course, the insurance companies deny that pill supply limitations ration patients’ pharmacy benefits. They point out that patients who need pill supplies outside the policy limitations can get them. All it takes is for their doctor to call a 1-800 number to initiate an appeal and explain why the prescribed amount is medically necessary.

Sounds easy? Guess again. The 1-800 number appeal process is a time-consuming gauntlet for even the most patient clinicians. Here’s what happens. When you call the insurance company, the first thing they do is put you on hold for 10 minutes. Eventually you get to speak to someone who takes a lot of information about you and the patient. This person, for unexplained reasons, must then transfer you to another bureaucrat who will process your appeal further. But in the process you are again put on hold for 10 minutes. Sometimes it’s 20 minutes. The second person you speak to asks you for the same information you already provided, and then asks a few additional questions. Guess what happens next? You got it! You are transferred to yet a third person, and once again you are put on hold for 10 minutes. Assuming that you are not disconnected, finally you speak to a third bureaucrat. Lo and behold, without further questions or fanfare, this person informs you that your appeal has been granted. My experience was that insurance companies granted our appeals nearly 100% of time. That’s nice, but it takes between 30 and 45 minutes of time that doctors and other healthcare professionals cannot spare these days. Want to know why doctors have so little time to spend with their patients? This is one reason.

In my practice, we dealt with 4-6 pill-count limitation appeals per week. I suspect most practices face the same challenge. For many years I was able to pay a nurse to handle these appeals for me. Most geriatric psychiatrists cannot afford this luxury. As it turns out, neither could I. If you have been following my blog, you know that my practice became untenable financially, and I closed it. Whether the doctor personally makes these appeals or delegates them to a staff member, it still subtracts from the bottom line.

Insurance companies know that medical practices these days cannot afford the time for these appeals. They use the hassle factor to keep doctors from advocating for coverage on behalf of their patients. Sadly, this rations healthcare, either by rationing access to prescription drugs or rationing doctors’ time with patients.

Rain, Rain Go Away… Weather and the Added Costs of Sub-Specialty Geriatric Practice

Sunday, August 24th, 2014

Hard rain doesn’t just wash out baseball games…it seems that it also puts the kybosh on geriatric practices. A few weeks ago the meteorologists forecast torrential rain and possible flooding in our area. It did rain, hard at times, but nothing terribly out of the ordinary, and by noon it was merely drizzling. Yet four out of ten afternoon patients cancelled out of fear that it would be unsafe to come out in the storm. If you practice geriatrics in the northern latitudes, you expect a stampede of cancellations when it snows. I wonder whether we’ve crossed a Rubicon – do we now have to worry about rain too?

What’s going on? The answer seems fairly clear. The geriatric patient population has gotten older, sicker, and frailer. These more fragile patients worry more about injury, and they are more easily daunted by inclement weather, especially if they must drive.

Why am I whining about this? Isn’t a high rate of weather-related cancellation par for the course in geriatric subspecialty practice? Isn’t this just a cost of doing business? That’s the point! Such cancellations represent an added, unappreciated cost of doing business as a geriatric specialist, one that Medicare does not take into consideration in its physician fee schedule.

The Centers for Medicare and Medicaid Services sets its Part B physician fees using a complex formula that includes separate factors for the intensity of physician work and the practice expense that go into each physician service. These estimates are made with input from the American Medical Association, which performs reviews of physician services every five years to ensure that the fees reflect the real-world costs of practice.

Several years ago, I participated in one such 5-year review. I was quite dismayed by the questionnaire the AMA used to capture practice expenses: It recognized only expensable items such as instruments, diagnostic equipment, examination tables, in-house laboratory, and medication storage facilities while completely ignoring patient-related sources of lost revenue, higher costs, and operating inefficiencies.

Cancellation is no small problem for geriatric practice. In addition to staying home when the weather threatens, geriatric patients miss appointments at a higher rate due to medical illness, lack of transportation (the son who was going to drive the patient had an unexpected business meeting), and confusion about the appointment time or forgetting it completely (despite telephonic and e-mail reminders). The AMA’s methodology was insensitive to the practice expense of cancelled or missed appointments.

You might argue that this problem cuts across all adult practices. This is true, to some extent, but younger patients dilute the financial impact on non-geriatric practices. In psychiatry, the effect is magnified many times since most adult psychiatric practices serve very few geriatric patients. Other expenses, intrinsic to geriatric practice, such as the need for more floor space and higher billing costs, further amplify the difference between geriatric practice and the field as a whole.

Here’s why this is so important: Trained geriatric specialists are in woefully short supply and the situation is getting worse, not better, as the population ages. According to the Institute for Medicine (Retooling for an Aging America: Building the Healthcare Workforce, and The Mental Health and Substance Abuse Workforce for Older Americans: In Whose Hands?) a geriatric workforce crisis jeopardizes the healthcare of older Americans. The reasons for this workforce shortage are many and complex, but inadequate reimbursement far and away tops the list. My argument is that one major reason for reimbursement being inadequate is that the fees Medicare pays geriatric specialists do not reflect the added costs of geriatric practice.

Many argue that, given the greater clinical complexity of geriatric patients, the problem with the fee schedule is that physician work is undervalued. This is true, but, in my opinion, undervaluation of the practice expense component is as great a problem for geriatric providers. I’ll make this case repeatedly in subsequent posts in which I’ll describe the types of added expense of geriatric sub-specialty practice.

The plain truth is that if we want more geriatric specialists in our healthcare system we’re going to have to find a way to make geriatric sub-specialty practice financially viable for more providers. I hope that my posts will resonate with fellow geriatric specialists who will comment about their own experience. But I really hope that policymakers and regulators will take note and become part of the dialogue. In addition to reading our blog, if you are interested in receiving our quarterly clinical newsletter, the Moak Aging and Mental Health Report, fill out our contact form, including e-mail address, and ask to be added to our distribution list.