South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

Reuters had an article discussing the overuse of feeding tubes with demented residents. Whether or not a person with advanced dementia winds up with a feeding tube  have more to do with economic concerns than his or her wishes, suggests a new study out in JAMA (Journal of the American Medical Association).  Dr. Joan M. Teno of Brown University in Providence, Rhode Island, and her colleagues found that hundreds of patients who had specified, in writing, that they did not want a feeding tube received one anyhow.

Feeding tubes don't extend survival for people with advanced dementia who can no longer swallow, and provide no other apparent benefits to these patients, according to two reviews of the medical literature, Teno and her team note in their report.

Tube feeding can also cause harm, the researcher added in an interview; demented patients who are bothered by the tube and try to remove it may be physically restrained or placed on heavily sedating drugs.

Up to a third of nursing home patients with advanced dementia have a feeding tube, Teno and her colleagues note in their article. In two-thirds of these cases, the tube was inserted while a patient was in the hospital.

To investigate what factors might influence whether or not a hospital would use feeding tubes in people with advanced dementia, Teno's team looked at 2000-2007 records for nearly 2,800 hospitals, all of which had admitted at least 30 patients who were 66 or older, had advanced dementia, and were living in nursing homes. Their analysis included Medicare claims for 163,000 patients and nearly 281,000 hospital admissions.

Twelve percent of the hospitals didn't insert a feeding tube in a single patient with advanced dementia throughout the eight-year study period, the researchers found. But at one quarter of the hospitals, patients had a 1 in 10 chance of feeding tube insertion; hospitals with the highest rate of feeding tube use inserted them nearly 40 percent of the time.

For-profit hospitals were more likely to use feeding tubes, as were larger hospitals and those with the highest level of intensive care unit use for patients in their last six months of life.

Recognition is growing that dementia is a terminal illness that affects the body as well as the mind, Teno told Reuters Health. And when a patient with dementia begins having trouble eating, she said, this indicates the final stage of the illness has arrived. For these patients, she added, careful hand feeding can offer a safer and more comfortable alternative to feeding tube insertion, "but it takes staff time and effort."

According to Buchman, the amount of caregiver time and effort to work with patients and try to feed them by mouth and to do it safely is "substantial."

Emory University Hospital's 2006-2007 rate of feeding tube insertions for patients with advanced dementia was 24 per 100; Buchman said he did not want to comment on those figures, given that he has only been working at the hospital since July 2009.

The hospital had one of the highest rates of feeding tube use in patients with advanced dementia, according to Teno's study, with 37.5 insertions for every 100 admissions of such patients in 2006-2007.

Although her study didn't investigate why hospitals opted for feeding tube insertion, Teno said it's likely that cost concerns are a factor. Most of these older patients are on Medicare and Medicaid, and the way that reimbursement works means nursing homes tend to ship them to hospitals when they get sick. Then, hospitals will try to discharge these patients back to the nursing home as quickly as possible. Inserting a feeding tube allows the hospital to discharge a patient faster, Teno added, while for nursing homes, tube feeding is less time consuming than hand feeding.

It's questionable, Teno noted, whether hospitalizing these patients in the first place is helpful. "It can be very disruptive and very stressful to take someone who is in the throes of dementia and put them in an acute care hospital," Teno said. "I'm really concerned that the financial incentives now are aligning with hospitalizing these people rather than trying to keep them in a less restrictive environment and treat them in a nursing home."

For a person with advanced dementia, the onset of eating difficulties should be "a stop sign to say listen, we need to talk about what are the patient's wishes and values for future medical care," she added. "Helping people make the best decision for their loved one is very important."

Teno and her team have compiled a list of hospitals and their rate of feeding tube insertion in patients with advanced dementia, which is available online here

SOURCE: Journal of the American Medical Associations, February 10, 2010.

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Long term Living Magazine had an interesting article on the increase of dementia based on the 2009 World Alzheimer Report.  Perhaps the increase is caused by better diagnostics and understanding of the condition.  According to the World Alzheimer Report, released by Alzheimer's Disease International (ADI), an estimated 35.6 million people worldwide will be living with dementia in 2010. This is a 10% increase over previous global dementia prevalence reported in 2005. According to the new report, dementia prevalence will nearly double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050.

"The information in the 2009 World Alzheimer Report makes it clear that the crisis of dementia cannot be ignored," says Debbie Benczkowski, Interim CEO of the Alzheimer Society of Canada. "Unchecked, dementia will impose enormous burdens on individuals, families, healthcare infrastructures, and global economy."

The report also focuses on the impact of dementia. For example, statistics cited in the new report suggest that 40% to 75% of caregivers have significant psychological illness as a result of their caregiving, and 15% to 32% have depression.  This article is interesting because it states that 40-75% of caregivers for people with Alzheimer's have significant psychological illness as a result of their caregiving. This statistic is a good explanation when nursing homes try to claim that the resdient's family should have cared for the person at home despite their lack of education and expertise. It is also indicative of the need for additional staffing for dementia residents so burn-out, turnover, abuse, and neglect do not occur.

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The New England Journal of Medicine recentl published a study on how to handle dementia in the elderly.  The conclusion was that dementia may lead to complications that may lead to death.  The problem with the study is that they did not determine the cause of the complications or the ability to prevent these foreseeable complicatons.  Could it be caused by abuse, self-neglect, negligent care?

The study's conclusion is that pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are
also common among such patients. Patients with health care proxies who have an
understanding of the prognosis and clinical course are likely to receive less aggressive
care near the end of life.

The last line is scary.  It implies that if a residents' "proxy" (which in many situations is the government) was aware of the study, they would decide not to provide care to someone with dementia.  Also, the study did not consider falls a significant complication in dementia residents.

Time Magazine had an article stating the study was "redefining" dementia as a terminal illness.  "Dementia is not a single illness but a collection or consequence of many, including Parkinson's disease, vascular dementia and Alzheimer's disease (which accounts for some 70% of all dementia cases). In the advanced stages of dementia, it is often impossible to tell which disease the patient had at the outset, as the end result is the same, according to Mitchell's study: a syndrome of symptoms and complications — eating problems (86%), pneumonia (41%), difficulty breathing (46%), pain (39%) and fever (53%) — caused by brain failure. "Dementia ends up involving much more than just the brain," says Dr. Claudia Kawas, professor of neurology at the University of California, Irvine. "We forget the brain does everything for us — controls the heart, the lungs, the gastrointestinal tract, the metabolism."

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The NY Times had a great article about an alternative way to treat residents with dementia who are at risk for wandering at night.  The article discusses the success of a night-care group that takes care of demented residents at night including supervised strolls around the facility.

The article specifically discusses seven women with Alzheimer’s disease or dementia, and are part of the Hebrew Home’s ElderServe at Night, a dusk-to-dawn drop-off program intended to strengthen their decaying minds while sating their thirst to be active after dark.  Alzheimer’s is an irreversible brain disease that destroys memory, and it is one form of dementia, a disorder marked by the loss of mental functions. Nighttime can be treacherous for people with dementia, who are often struck by sleeplessness or night terrors and prone to wandering about. This agitation and disorientation, called “sundowning,” is especially vexing for relatives trying to care for them at home, and often hastens their placement in nursing homes.

ElderServe at Night began a decade ago, and is the only one of its kind in the country.  It should be the standard.   Participants spend 7 p.m. to 7 a.m. painting, potting plants, dancing and talking — or, for those immobilized by their disease, relaxing amid music, massage and twinkling lights. The patients rest as they need, for a few minutes or a few hours. 

The program was born in 1998, after Daniel A. Reingold, now president and chief executive of the Hebrew Home, began hearing horror stories from people who jury-rigged alarm systems or slept on mattresses pulled across thresholds to stop their sleepless parents from wandering at night. Sleep deprivation, he learned, was causing many guardians to put relatively high-functioning patients into nursing homes rather than day care programs.

The activities mirror those done during the day: arts, crafts, exercise, and holistic remedies like meditation and pet therapy. Rather than give agitated patients mood-altering drugs, ElderServe aides might lead them by the hand into a softly lighted room, slip off their shoes and socks and massage their feet with a warm washcloth.

The staff indulges the urges that dementia and Alzheimer’s induce, walking with patients who crave a 2 a.m. adventure or taking evening trips to the circus or restaurants.   Mr. Reingold has made presentations to professional associations, hoping others might copy the program. But a spokeswoman for the Alzheimer’s Association, a nonprofit research and education group based in Chicago, said she knew of no other nighttime drop-off program like it. Though it has not been independently evaluated, organizers say the program has helped patients maintain a discernible alertness even as their minds erode. It has also given their relatives desperately needed breaks.

I wish all long term facilities could have this type of program. 
 

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The Illinoishomepage.net had the story of a nursing home employee who punched a demented resident in the face.  Sharoia Hill is now behind bars.  She is an aide at the nursing home. She works in the Alzheimer’s unit.  Police arrested 28-year-old Sharoia Hill when they discovered that she punched an 87-year-old Alzheimer’s patient twice in the face.

“Apparently the patient had an item that she wanted back and that prompted her to assault him," said Lt. Ed Ogle from the Champaign County Sheriff's Department.

Now Hill could face up to 5 years behind bars and 25 thousand dollars in fines.  It is unlikely she will get anything except a slap on the wrist.   Nothing in the article mentions if she was reported to the Board of Nursing or if she will lose her certification. 
 

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The Daily Herald had a story about another woman found dead outside a nursing home.  Nursing homes have a duty to properly staff and supervise the residents especially when they know a resident is demented or confused and attempts to wander off the premises. 

The article mentions that authorities are investigating the death of an 89-year-old Itasca nursing home resident, found in her nightgown and bare feet outside in subfreezing temperatures.  Sarah Wentworth died last week at the Arbor of Itasca.

Police said they received a 911 call and rushed to the private facility at 5:43 a.m.  By that time, the resident was unresponsive but covered in blankets, lying on a gurney inside the facility.  Nursing home staff reported they tried to revive Wentworth after finding her in an outdoor courtyard. She was pronounced dead shortly later. She had dementia, but the nursing home never documented a history of wandering off.

The circumstances that led to her tragic preventable death have sparked at least three investigations. Itasca Police Chief Scott Heher said police uncovered conflicting information after interviewing the nine Arbor employees who were on duty. He said police were told Wentworth was sleeping in her bed during a 3 a.m. well-being check, but that she disappeared by 5 a.m. when staff looked in on her again. An employee reported hearing an alarm door sound, but Heher said it was not investigated beyond a cursory hallway check.

Police question whether the 3 a.m. check ever occurred. Furthermore, Wentworth was not dressed in the same clothing when police arrived as she was earlier that morning.   Her clothing could not be found.

"I think she wandered out there alone," Chief Heher said. "It's an absolute tragedy. There are a number of mechanisms in place at the Arbor to ensure these things don't happen. Obviously, there was a systems breakdown that night. We're investigating to see if criminal charges apply."

Reports on more than a dozen other unrelated Arbor complaints are listed on the state's Web site.  The facility has a one-star rating, much below average, based on prior complaints, staffing levels and the results of its three most recent inspections, according to the Federal Centers for Medicare & Medicaid Services.

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Wisconsin State Journal had an article about a nursing home employee charged and arrested for abusing residents.  Eric Larrabee slapped an 85-year-old hospice patient only 10 days before she died at a Stoughton nursing home.  The resident suffered from Alzheimer's disease. He had only worked there for about two months before he was fired on Feb. 12. The woman died on Feb. 20.

The complaint states that another worker at the home heard Larrabee yell at the woman telling her to be quiet before seeing him slap her with an open hand. The woman appeared to be stunned by the blow, the complaint states.

State Department of Health Services Investigator Michelle Dutkiewicz said Larrabee admitted that he struck the woman out of frustration but said he only "tapped" her face.

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I saw this article about a nursing home resident with dementia who killed his roommate and thought "how could this happen?" but then I read an article where a murder suspect was moved to a nursing home.  The suspect was charged in connection with a quadruple homicide. See story here

With the graying of the population and the incarceration of so many citizens on Medicaid, nursing homes will need to adapt at receiving dangerous criminals into facilities. This may lead to violence and tragedy in many nursing homes.

On a related note, there have also been issues with registered sex offenders becoming residents of nursing homes.  More often than not, neither family members nor residents are aware that this is occurring.  We found a website recently that family members and residents can use to search by facility, city or state to see which nursing homes sex offenders are currently living in, and I thought that was a great thing to have - for more information, click here.

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