Overdosing the elderly

My mom has always had a grateful attitude toward our medical system. She began suffering from heart problems more than 30 years ago, yet medical advancements such as stents have kept her heart’s blood flowing. But a couple of years ago, she felt the breakdown of her body was finally outpacing what doctors could fix.
Mom was so weak she could hardly walk, and her doctor — a top Phoenix cardiologist — couldn’t figure out what was wrong. All the tests showed her heart was okay. Her primary doctor was equally baffled. She was sent home from the hospital without an answer.
There was nothing they could do, she
was told.
But my mom, 77, a retired, registered nurse, wasn’t ready to give up. She took out the paperwork from her 14 medications (yes, 14), pulled out her magnifying glass, and studied their potential side effects.
Amazingly, the description which came with the eye drops she had used for a dozen years described the pain and weakness she was suffering. Her ophthalmologist gave her a substitute and she regained
her energy.
“It’s good to know you are not crazy or imagining things or wanting attention, like I’m sometimes made to feel,” she said.

A WRITER’S RESPONSE
This hits home with Jeanne Hannah, a Traverse City attorney who was profoundly saddened by the sudden death of her mother, Alice Schmittgen. She died
on Nov. 20, 2000, only 65 days
after being diagnosed with a simple
urinary tract infection.
Hannah studied the autopsy report and consulted with the internist who had provided care for Alice during the last two weeks of her life. The multitude of medical mishaps discovered early in her research led Hannah on a two-year journey, and ultimately to the publication last year of “Taking Charge: Good Medical Care for the Elderly and How to Get It.”
Her mother died a horrible, painful, and premature death, she said, and she wrote “Taking Charge” to help others avoid the same fate.

ALICE’S STORY
Alice was enjoying life, living with her youngest daughter in Saginaw, when she began seeing ‘monsters.’ Up until that time, she’d had nothing severe in the way of health problems except for the early onset of Parkinson’s disease. In fact, Alice had retired four years before at the age of 80 as a top-selling cosmetic clerk and was getting ready to host a bridge party for her friends.
Hannah’s sisters took Alice to a Saginaw hospital emergency room where she was evaluated. The emergency room doctor diagnosed the urinary tract infection, but mistook her delirium — caused by the fever from the infection — as dementia.
He transferred Alice to a psychiatric nursing home.
Alice was frightened that night and asked if she could call Hannah in Traverse City to help her get her out of the home. Her request was refused. Alice was still hallucinating the next day and told a psychotic patient that the monsters were frightening her. He suggested that she hit them with her cane, which she tried to do. She accidentally struck a staff person. That’s when they took away her cane and put her into a padded cell without a walker. Without her cane’s support, she fell and broke three ribs.

FROM BAD TO WORSE
What began as a simple urinary tract infection cascaded into a multitude of problems, as so often happens with the elderly. After her first two falls, Alice stopped drinking water so she wouldn’t have to risk a night trip to the bathroom or bother an aide. It was easy to do because she had been given a powerful anti-psychotic, Risperdal, which makes folks indifferent to thirst and hunger.
Yet water was critical to flush her kidneys, now overtaxed by nine medica-tions. Hannah’s once talkative, ambulatory and intelligent mom was no longer capable of even a simple conversation. She was wheelchair-bound, and her head fell limp onto her shoulder. Her hands shook with tremors.
Hannah and her sisters were reluctant to second-guess the doctors and nurses. But when they questioned the nurses about why their mother was declining so rapidly, Hannah says: “We were told, ‘This is to be expected.’ … ‘Your mother is debilitated,’ and… ‘There is nothing we can do.’”
Hannah later learned that with the evidence of kidney failure, a good gerontologist would have reduced the drug dosages and eliminated unnecessary drugs, particularly Risperdal, which is often fatal with the elderly.
“Hello… If she’s debilitated and confined to a wheelchair so she won’t fall, are we going to continue to give her the anti-osteoporosis drug so she won’t break a bone while falling?”
Hannah asked.

TOO FAR GONE
Concerned about her mom’s treatment at the Saginaw nursing home, Hannah moved her mom to Tendercare in Traverse City. She received excellent care, yet
was already too far gone to save. Her
body had become so rigid that it was
hard for her to sit comfortably in a wheelchair, and spasms wracked her
body. Her body was irreparably damaged from malnutrition and dehydration,
Hannah said.
Alice was unable to feed herself, and one morning lapsed into a coma. She was transferred to Munson Medical Center, where Hannah spent every day and some overnights at her bedside. Two weeks later, her mother died.
“I was so absolutely devastated and felt so guilty that I needed to know why she had died. I didn’t work for two years,” Hannah said.
Hannah asked for an autopsy, which revealed that Alice died from brain death. The reason: her kidneys were so compromised, they could not eliminate all the drugs she’d been prescribed. The build-up of drugs in her body ultimately destroyed her brain.
“In short, my mom was poisoned by her medications,” Hannah said.

BLACK BOX WARNING
Risperdal, a second-generation anti-psychotic, should only be given as a last resort to elderly patients. Hannah knew that her mom wasn’t psychotic and asked the Saginaw nursing home to discontinue the drug immediately.
The drug is so dangerous for the aged that the FDA put a “black box” warning in 2005, warning of the mortality risk. Studies show that newer anti-psychotics nearly double the risk of premature death in elderly people, and older anti-psychotics are equally as dangerous.
To give this historical context, there has been long-standing concern about the abuse of psychotropics with the elderly. Used for unruly and psychotic nursing home patients, anti-psychotics make elderly folks prone to falls, fuzzy thinking, over-sedation and permanent body ticks like neck twisting, a clenched jaw and slurred speech. Sometimes anti-psychotics spark deadly heart attacks and strokes, and they often don’t work any better than a placebo, several studies showed. A federal law was passed in the late 1980s requiring nursing homes to use anti-psychotics only as a last resort and to monitor the patient’s health.

FATAL DECISION
Only after her mother’s death did Hannah discover that the Saginaw nursing home never discontinued the Risperdal until she transferred to Tendercare. Her mother was dosed with the drug for seven weeks.
With the realization came a deep pang of guilt for never following up. “Shame on me,” she said. “I was her patient advocate.”
Hannah learned early during her research into the cause of her mother’s death that Risperdal is particularly fatal to Parkinson’s patients. While Parkinson’s medication stimulates dopamine production, Risperdal blocks it. When her body no longer could produce dopamine, Alice began shaking and getting more rigid.
The doctors thought her Parkinson’s was getting worse.
“An educated family caregiver could have said, ‘Hey. She was okay last week. This change is too sudden.’ It should not have been viewed as a normal progression of this disease. This is where an empowered family caregiver could have really made
a difference — particularly in providing continuity for the patient who transitioned between four sets of caregivers in seven weeks.”
The pieces now fit together: Risperdal, an electrolyte imbalance, dehydration, protein-energy malnutrition, crippling falls, a build-up of toxins, and brain death.

MIMI’S STORY
Lija (pronounced Leea) Ditmar said the advice in Hannah’s book was invaluable. It saved the life of her mother, Mimi, when she went to the hospital in Grand Rapids last summer.
Ditmar had gone downstate to pick up Mimi, then 84, to take her on a camping trip. But her mom fell down while she was getting ready.
It was about the fourth time her mom had fallen, so Ditmar took her to the emergency room. The doctor ordered 15 tests, including an MRI and a CAT-scan,
but didn’t find anything. So Ditmar suggested he test for a urinary tract infection — one of the top seven reasons that Hannah lists in the book for falls.
Bingo!
It turns out that the urinary tract infections can cause dizziness from fever and dehydration due to sweating. After the first fall, her mom stopped drinking water to cut down on trips to the bathroom. The doctor treated her for the urinary tract infection, and Mimi slowly regained
her health.
Unfortunately, one March evening, Ditmar’s mom wore some slippers with no rubber traction (the elderly should always wear shoes indoors, Hannah says) and slid on a well-polished floor. The next morning she was in excruciating pain, and was taken again to the emergency room.
Ditmar, who arrived an hour later, has no explanation for the multiple failures of the hospital staff. Her mom was dehydrated when she arrived, and managed only two sips of water. Despite that, she received no water intravenously during her nine-hour stay. She was diagnosed with a broken back, and couldn’t sit up or even transfer to a wheelchair. She was throwing up the pain medication, causing even further dehydration.
Nonetheless, the doctor decided to send her home, saying she would be fine with pain medication and 24-hour care (which was impossible to get on a Saturday night). It took Ditmar 15 minutes just to rouse her, and then her mom told her that her pain was an “eight” on a scale of one to 10 — this from a stoic woman who survived a World War II relocation camp.

MIMI’S DEATH
Ditmar begged a social worker, a nurse and the doctor to reconsider and let her stay in the hospital — but to no avail. The social worker gave her a small shrug and said nothing. The next morning, her mother’s body collapsed. The same doctor who sent Mimi home the night before saw her die of a heart attack 16 hours later.
As Ditmar grieved over her mom’s body, a nurse asked her to leave the room to make way for the next patient. “I felt disrespected, ignored, frustrated, and saddened,” she said.
Ditmar believes the nurse and doctor didn’t see her mom as a real person — a woman who 24 hours ago was cooking for her daughter, cleaning the house and socializing. What they saw was an old woman with heart and lung problems whose time had run out. They “reassured” Ditmar, saying, “She’s old, and they go downhill fast... She’s had a good long, life. Be grateful for that.”
“But isn’t every life of value? Isn’t every life worth trying to save? I hope I never get to be 85 because then I’m a write-off,” Ditmar said.

NO EASY FIX
There is a lot that Hannah has learned, but her most profound lesson isn’t easily fixed. Only two percent of U.S. doctors are certified in geriatrics and many have no training at all. And the problem is getting worse instead of better.
Doctors have little incentive to care for the elderly who lack private health insurance because Medicare reimburses only a fraction of their usual fees.
“Medicare reimbursements are hor-rible, and Medicaid is worse,” Hannah says. “Most elderly people have two or three things wrong with them, if not eight or nine, and the doctor has to spend up to an hour to understand it all. Yet
Medicare is only enough to cover, at most, a 15-minute appointment. Geriatrics is not a popular field, and it’s getting smaller
and smaller.”
Hannah’s first draft of the book was understandably angry, but she toned it down for publication. Her mentor for the book, Wendy Harpham, advised against scaring people. Harpham is an internist in Dallas, Texas, a cancer survivor, and an author of five books about cancer.
“She told me that caregivers are already stressed and that I need to give them the right amount of information and support to empower them, but not so much that I overwhelm them,” Hannah said.
The book details the six most com-mon medical complications that are often
fatal — complications that family caregivers can learn to recognize so that they can get early medical intervention.
“‘Taking Charge’ is not an indictment of nursing homes,” Hannah said. “I don’t want to criticize doctors, nurses or nursing homes. I just want to help caregivers feel confident as members of the care-giving team.”
The most important thing a caregiver brings to the table is his or her intimate knowledge of their mom or dad’s normal health and behavior. A sudden change in either one is a red flag that there’s a crisis needing swift medical attention.
While writing this article, I gave the book to my mom to review and she said it was “very good, very honest, very direct.” She was reading it when she had to go to the hospital for still another stent and angioplasty. I’m happy to report she’s doing fine.
“She told it the way it is. I don’t think people realize how important it is to have a caregiver who is knowledgeable and watching out for you,” she said.

“Taking Charge” is available at Leelanau Books and Horizon Books, as well as by directly ordering from
www.goodmedicalccare.com.

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