IAGS-MARCH 1992-VOL. 40, NO. 3
LETTERS TO THE EDITOR
297
consultant pharmacist may be influenced by these and other standing drug use. However, tranquilizer use can occur for diverse reasons. Focusing on the residents to the exclusion of factors. Medical staff issues that may influence the use of tran- other factors ignores the fact that environmental and other quilizers in the long-term care environment include the fre- non-medical aspects may provide more powerful explanaquency of doctor visits, education and training, and recep- tions of poor quality use. Our purpose was to conceptualize 'facility resources" in a tiveness to consultant pharmacist suggestions.In addition the availability of psychogeriatic consultations may impact pre- more holistic fashion than previously attempted and to examine their relationship to quality of tranquilizer use. We scribing patterns. In short, an assessment of a 'facility resource effect" on view inclusion of nursing resources in this index as essential: medication use should control for important potential con- nursing staff provide the lion's share of all care in skilled founders in the medication loop, eg consultant pharmacy and nursing facilities. Further, informed analysis recognizes the medical services.We agree that tranquilizer misuse is a serious different roles played by licensed and unlicensed nursing problem in the institutionalized elderly and do not dispute staff and the need for separate consideration of these two the results or suggest the authors are placing the burden of groups. responsibility for appropriate use of tranquilizers on the JEANINE K. MOUNT, PHD, RPH nursing staff. However, in the effort to improve medication BONNIE L. SVARSTAD, PHD use in nursing facilities, we feel it important for providers, School of Pharmacy administrators, and investigators to recognize the interdeUniversity of Wisconsin pendence of medicine, nursing, and pharmacy in the drug Madison, WI use system. BECKYNAGLE, PHARMD REFERENCE CHARLES P. PULLIAM, MSPHARM 1. Svarstad BL, Mount JK. Nursing home resources and tranquilizer use UNC School of Pharmacy among the institutionalized elderly. J Am Geriatr Soc 1991;39:869-875. Chapel Hill, NC REFERENCE 1. Svarstad BL, Mount JK. Nursing home resources and tranquilizer use among the institutionalizedelderly. J Am Geriatr Soc 1991;39:869-875.
Editor's note:-The above letter was referred to the authors of the original, and Dr. Mount's and Dr. Svarstads reply follows.
In reply:-Nagle and Pulliam point out that physicians and pharmacists affect the quality of tranquilizer use in nursing homes. Certainly we agree that this is the case. Why, then, did we not focus our attention in these directions? Our reasons involve methodological, conceptual, and philosophical considerations. Interestingly, our study was initiated by the long-termcare pharmacy that served the nursing homes. Pharmacists were puzzled by wide variability in facilities' responses to pharmacy interventions. All facilities were within the same geographic area and presumably experienced the same general environment. All had multiple attending physicians, many of whom cared for residents in several of the study facilities. Like these pharmacists, we had no reason to anticipate that pharmacy services or physician practices could account for variability across facilities. Thus, we focused attention on the facilities themselves. Nagle and Pulliam identify variability across consultant pharmacy and medical services as 'potential confounders"of the relationship between facility resources and quality of tranquilizer use. Rather than reflecting spurious relations, these factors are more likely to intervene between facility resources and quality of tranquilizer use. For example, greater resources could enable a facility to contract for more intensive or extensive services from its medical director and consultant pharmacist. These relations require further consideration, both conceptually and empirically. The primary reason for focusing on facility resources in the manner we have, however, is that our investigation has a different purpose. As discussed in our paper,' most researchers analyzing tranquilizer use among nursing home residents have focused on influences of the residents' diagnostic and demographic characteristics on drug use. These studies reflect the dominant biomedical approach to under-
Halloween Psychosis To fhe Editor:-I would like to share a case with your readership in an effort to alert staffs of nursing homes of the potential for Halloween decorations setting off paranoid delusional thinking and behavior in nursing home residents. G.G. is a 70 year old Spanish American female resident of an ICF facility. She carries a psychiatric diagnosis of chronic bipolar illness. She had been psychiatrically stable for 1 year on Haldol lmg hs. Three days prior to Halloween this year she began to exhibit unusual behavior consisting of leaving the facility many times and eventually of lying on the floor expressing the fear that devils and witches were about to "get her." She was subsequently admitted to the Geriatric Psychiatric Unit at the University of New Mexico for evaluation and treatment. On rounds at the nursing home the following day, quite vivid, extensive, and frighteningHalloween decorations were observed (photos available on request). Questioning of nursing home staff revealed that a new recreation director had been hired 3 weeks prior and that this was her "first major project." A literature search (Medline, Psychilit) from 1967 to the present was performed without discovery of similar other 'case reports." The patient's paranoia in the undecorated hospital ward quickly resolved. JOHN SCHWARTZ, MD UNM SOM Albuquerque, NM 87131-5271 Editor's note:-The author submitted 12 photos with this letter. I can confirm that his description of them is understated. Beware of new recreation directors!
Serve the Elderly as a Medical Expert TOthe Editor:-Expectations of continued health and vigor in the elderly are often unrealistic and can lead to non-meritorious malpractice claims. While serving as medical experts we have found that problems commonly seen in geriatric practice, rather than unusual occurrences, often underlie such claims. Three recent cases provide examples. In one, an undertaker told the family that a large sacral decubitus "should never
298
LETTERS TO THE EDITOR
JAGS-MARCH 1992-VOL.40, NO.3
have happened.” The patient had never fully recovered after TABLE 1. abdominal surgery and perioperative stroke. She was elderly, Patients, No. (MenlWomen) 114 (37/77) immobile, sensory-deprived, diabetic, anemic, and hypoal- Age, yrs 82.5 buminemic. Counsel withdrew the case after receiving our Days of hospitalization 21.8 (16) report with appended pertinent literature which informed Total volume of blood (mL) drawn 172 (118) him that such patients may have skin breakdown despite during hospitalization appropriate (and, in this case, well-documented) skin care. A Volume of blood (mL) drawn per day 11.3 (9.1) second claim ascribed a pneumonia acquired in a nursing Number of phlebotomies per day 0.8 (0.6) home to Haldol administered for control of agitation. Counsel Values other than number (No) of patients are means (SD). terminated the case after learning from us of the many factors contributing to institutionally acquired pneumonia in the elderly, and that the drug wits used appropriately. In the BIZ.The difference between Hb, (mean 12.9 g/dL) and HbD third case, a nursing home resident with severe osteoporosis (mean 12.3 g/dL) was statistically sigxuficant (wilcoxon fell and sustained a hip fracture. There had been no harbin- matched pairs test P = 0.0001). There was a weak but gers, and the antecedent activity orders represented a well significant correlation (Spearman’s YS = -0.25; P = 0.015) documentedconsensus of medical and nursing opinion. After between the amount of blood loss and the change in Hb level learning from us of the high incidence and many factors (Hbo - H ~ A Of ) . the 61 patients not anemic upon admission, contributing to falls in the elderly’ and of the absence of 17 (28%) became anemic; 12 of these had an anemia of negligence in this case, counsel terminated the action. chronic disorder,’ two had gastrointestinalbleeding for which We have found that serving the elderly as a medical expert no specific therapy was needed, and three patients had a does not take inordinate time away from patient care, and mild (Hb > 11.5 g/dL) but unexplained anemia (blood loss we have found the experience of case review and teaching of 300, 180, and 80 mL). None of the 104 patients received to be a positive one. If the initial review finds that a case has transfusion. strong merit, an expert is expected to continue assisting the The measured total and daily blood loss is slightly lower legal system, whether initially called by the plaintiff or the than the results of Smoller and Kruskall’ and Mille? who defendants2This may demand more time than the initial observed a mean daily phlebotomy volume of 14.4 to 20.8 review, but such assistance to the legal system meets the mL in adult patients on a medical ward. Patients on intensive and provides an excel- care units have a considerably higher amount of blood rerecommendations of our lent educational e~perience.~ m o ~ e d . ~Diagnostic ,~,~ blood loss influences inversely the Hb level during hospitalization but is not sufficient to cause SIDNEY FINK,MD TAPANK. C m m m , MD serious anemia, nor to induce an increasing transfusion need. V.A. Medical Center Nevertheless, caution is warranted in this population, which Hampton, VA has an altered hematopoietic response to stress factors such as minute bleeding6 E. JOOSIEN, MD REFERENCES M. b u ,MD 1. Brummel-SmithK. Falls in the aged. Primary Care 1989;16377-393. W. P n m s , MD 2. Clinical Practice Subcommittee 01: the American College of Physicians E. HAmm Health and Public Policy Committee. Guidelines for the physiaan expert witness. Ann Intern Med 1990;113:789. Department of Geriatric Medicine 3. Statement on qualifications and guidelines for the physician expert witUniversitair Ziekenhuis ness. Council of Medical Specialty Societies 1989 (CMSS address: P.O. Leuven, Belgium Box 70, Lake Forest, IL 60045). ~
4. Kunin CM. The expert witness in medical malpractice litigation. Ann Intern Med 1984;100:139-143.
Blood Loss from Diagnostic ILaboratory Tests in Elderly Patients To the Editor:-Anemia is a common problem among hospitalized elderly patients, but nothing is known about the influence of phlebotomy for diagnostic testing on the hemoglobin level during hospitalization in this population. The total amount of blood withdrawn and the frequency of phlebotomy were noted dally in 114 consecutive elderly (mean 82.5 years, range 65-98) inpatients, admitted to an acute geriatric ward. A hemoglobin (Hb)level was performed upon admission (HbA)and at the time of discharge (HbD). For patients who died, the last available hernoglobin value was taken. Anemia was defined according to the WHO criteria (HB c 13 g/dL for men and < 12 g/dL for women). No information about the study was released which might influence or alter the behavior of junior staff in ordering tests. Sixteen (14%) had 250 mL or more blood removed, of whom two gave more than 500 mL. Each phlebotomy averaged 11.3 mL (SD 9.1), and each patient was phlebotomized an average of 0.8 times (SD 0.65) per day (Table 1). Onehundred and four patients were eligible for further study. In three patients, only one Hb vdue was available (hospital stay c 72 h), and another seven, all with anemia upon admission, were given transfusion or treated with iron, folate, or vitamin
REFERENCES 1. Lipschitz DA. The anemia of chronic disease. J Am Geriatr Soc 1990;38:1258-1264. 2. Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med 1986;314:1233-1235. 3. Miller ES.Blood lost because of phlebotomy. N Engl J Med 1975;292:319. 4. Eyster E, Bernene J. Nosocomid anemia. J A M 1973;223:73-74. 5. Hashimoto F. Bleeding less for diagnostics. JAMA 1982;248171. 6. Hirota Y, Okamura S, Kimura N et al. Haematopoiesis in the aged as studied by in vitro colon assay. Eur J Haematol 1988;4083-90.
Low-SodiumDiet and Congestive Heart Failure in the Elderly To the Editor-In their comprehensive review article, Dr. Luchi et all did not address a point of great practical importance concerning the therapy of congestive heart failure (CHF) in the elderly. A low-sodium diet is usually prescribed early in the progress of CHF, prior to or together with drug therapy.’ In my experience, a low-sodium diet is often poorly tolerated in institutionalized elderly patients and may induce appetite loss, asthenia, hyponatremia, or confusion. In such patients, undernutrition is a common pr~blern,~ and a decrease in food intake as a result of a low-sodium diet may worsen the nutritional status and facilitatethe onset of cardiac cachexia, respiratory infections, or decubitus ulcers. Moreover, the tastelessness of low-sodium meals may impair the
LETTERS TO THE EDITOR
297
consultant pharmacist may be influenced by these and other standing drug use. However, tranquilizer use can occur for diverse reasons. Focusing on the residents to the exclusion of factors. Medical staff issues that may influence the use of tran- other factors ignores the fact that environmental and other quilizers in the long-term care environment include the fre- non-medical aspects may provide more powerful explanaquency of doctor visits, education and training, and recep- tions of poor quality use. Our purpose was to conceptualize 'facility resources" in a tiveness to consultant pharmacist suggestions.In addition the availability of psychogeriatic consultations may impact pre- more holistic fashion than previously attempted and to examine their relationship to quality of tranquilizer use. We scribing patterns. In short, an assessment of a 'facility resource effect" on view inclusion of nursing resources in this index as essential: medication use should control for important potential con- nursing staff provide the lion's share of all care in skilled founders in the medication loop, eg consultant pharmacy and nursing facilities. Further, informed analysis recognizes the medical services.We agree that tranquilizer misuse is a serious different roles played by licensed and unlicensed nursing problem in the institutionalized elderly and do not dispute staff and the need for separate consideration of these two the results or suggest the authors are placing the burden of groups. responsibility for appropriate use of tranquilizers on the JEANINE K. MOUNT, PHD, RPH nursing staff. However, in the effort to improve medication BONNIE L. SVARSTAD, PHD use in nursing facilities, we feel it important for providers, School of Pharmacy administrators, and investigators to recognize the interdeUniversity of Wisconsin pendence of medicine, nursing, and pharmacy in the drug Madison, WI use system. BECKYNAGLE, PHARMD REFERENCE CHARLES P. PULLIAM, MSPHARM 1. Svarstad BL, Mount JK. Nursing home resources and tranquilizer use UNC School of Pharmacy among the institutionalized elderly. J Am Geriatr Soc 1991;39:869-875. Chapel Hill, NC REFERENCE 1. Svarstad BL, Mount JK. Nursing home resources and tranquilizer use among the institutionalizedelderly. J Am Geriatr Soc 1991;39:869-875.
Editor's note:-The above letter was referred to the authors of the original, and Dr. Mount's and Dr. Svarstads reply follows.
In reply:-Nagle and Pulliam point out that physicians and pharmacists affect the quality of tranquilizer use in nursing homes. Certainly we agree that this is the case. Why, then, did we not focus our attention in these directions? Our reasons involve methodological, conceptual, and philosophical considerations. Interestingly, our study was initiated by the long-termcare pharmacy that served the nursing homes. Pharmacists were puzzled by wide variability in facilities' responses to pharmacy interventions. All facilities were within the same geographic area and presumably experienced the same general environment. All had multiple attending physicians, many of whom cared for residents in several of the study facilities. Like these pharmacists, we had no reason to anticipate that pharmacy services or physician practices could account for variability across facilities. Thus, we focused attention on the facilities themselves. Nagle and Pulliam identify variability across consultant pharmacy and medical services as 'potential confounders"of the relationship between facility resources and quality of tranquilizer use. Rather than reflecting spurious relations, these factors are more likely to intervene between facility resources and quality of tranquilizer use. For example, greater resources could enable a facility to contract for more intensive or extensive services from its medical director and consultant pharmacist. These relations require further consideration, both conceptually and empirically. The primary reason for focusing on facility resources in the manner we have, however, is that our investigation has a different purpose. As discussed in our paper,' most researchers analyzing tranquilizer use among nursing home residents have focused on influences of the residents' diagnostic and demographic characteristics on drug use. These studies reflect the dominant biomedical approach to under-
Halloween Psychosis To fhe Editor:-I would like to share a case with your readership in an effort to alert staffs of nursing homes of the potential for Halloween decorations setting off paranoid delusional thinking and behavior in nursing home residents. G.G. is a 70 year old Spanish American female resident of an ICF facility. She carries a psychiatric diagnosis of chronic bipolar illness. She had been psychiatrically stable for 1 year on Haldol lmg hs. Three days prior to Halloween this year she began to exhibit unusual behavior consisting of leaving the facility many times and eventually of lying on the floor expressing the fear that devils and witches were about to "get her." She was subsequently admitted to the Geriatric Psychiatric Unit at the University of New Mexico for evaluation and treatment. On rounds at the nursing home the following day, quite vivid, extensive, and frighteningHalloween decorations were observed (photos available on request). Questioning of nursing home staff revealed that a new recreation director had been hired 3 weeks prior and that this was her "first major project." A literature search (Medline, Psychilit) from 1967 to the present was performed without discovery of similar other 'case reports." The patient's paranoia in the undecorated hospital ward quickly resolved. JOHN SCHWARTZ, MD UNM SOM Albuquerque, NM 87131-5271 Editor's note:-The author submitted 12 photos with this letter. I can confirm that his description of them is understated. Beware of new recreation directors!
Serve the Elderly as a Medical Expert TOthe Editor:-Expectations of continued health and vigor in the elderly are often unrealistic and can lead to non-meritorious malpractice claims. While serving as medical experts we have found that problems commonly seen in geriatric practice, rather than unusual occurrences, often underlie such claims. Three recent cases provide examples. In one, an undertaker told the family that a large sacral decubitus "should never
298
LETTERS TO THE EDITOR
JAGS-MARCH 1992-VOL.40, NO.3
have happened.” The patient had never fully recovered after TABLE 1. abdominal surgery and perioperative stroke. She was elderly, Patients, No. (MenlWomen) 114 (37/77) immobile, sensory-deprived, diabetic, anemic, and hypoal- Age, yrs 82.5 buminemic. Counsel withdrew the case after receiving our Days of hospitalization 21.8 (16) report with appended pertinent literature which informed Total volume of blood (mL) drawn 172 (118) him that such patients may have skin breakdown despite during hospitalization appropriate (and, in this case, well-documented) skin care. A Volume of blood (mL) drawn per day 11.3 (9.1) second claim ascribed a pneumonia acquired in a nursing Number of phlebotomies per day 0.8 (0.6) home to Haldol administered for control of agitation. Counsel Values other than number (No) of patients are means (SD). terminated the case after learning from us of the many factors contributing to institutionally acquired pneumonia in the elderly, and that the drug wits used appropriately. In the BIZ.The difference between Hb, (mean 12.9 g/dL) and HbD third case, a nursing home resident with severe osteoporosis (mean 12.3 g/dL) was statistically sigxuficant (wilcoxon fell and sustained a hip fracture. There had been no harbin- matched pairs test P = 0.0001). There was a weak but gers, and the antecedent activity orders represented a well significant correlation (Spearman’s YS = -0.25; P = 0.015) documentedconsensus of medical and nursing opinion. After between the amount of blood loss and the change in Hb level learning from us of the high incidence and many factors (Hbo - H ~ A Of ) . the 61 patients not anemic upon admission, contributing to falls in the elderly’ and of the absence of 17 (28%) became anemic; 12 of these had an anemia of negligence in this case, counsel terminated the action. chronic disorder,’ two had gastrointestinalbleeding for which We have found that serving the elderly as a medical expert no specific therapy was needed, and three patients had a does not take inordinate time away from patient care, and mild (Hb > 11.5 g/dL) but unexplained anemia (blood loss we have found the experience of case review and teaching of 300, 180, and 80 mL). None of the 104 patients received to be a positive one. If the initial review finds that a case has transfusion. strong merit, an expert is expected to continue assisting the The measured total and daily blood loss is slightly lower legal system, whether initially called by the plaintiff or the than the results of Smoller and Kruskall’ and Mille? who defendants2This may demand more time than the initial observed a mean daily phlebotomy volume of 14.4 to 20.8 review, but such assistance to the legal system meets the mL in adult patients on a medical ward. Patients on intensive and provides an excel- care units have a considerably higher amount of blood rerecommendations of our lent educational e~perience.~ m o ~ e d . ~Diagnostic ,~,~ blood loss influences inversely the Hb level during hospitalization but is not sufficient to cause SIDNEY FINK,MD TAPANK. C m m m , MD serious anemia, nor to induce an increasing transfusion need. V.A. Medical Center Nevertheless, caution is warranted in this population, which Hampton, VA has an altered hematopoietic response to stress factors such as minute bleeding6 E. JOOSIEN, MD REFERENCES M. b u ,MD 1. Brummel-SmithK. Falls in the aged. Primary Care 1989;16377-393. W. P n m s , MD 2. Clinical Practice Subcommittee 01: the American College of Physicians E. HAmm Health and Public Policy Committee. Guidelines for the physiaan expert witness. Ann Intern Med 1990;113:789. Department of Geriatric Medicine 3. Statement on qualifications and guidelines for the physician expert witUniversitair Ziekenhuis ness. Council of Medical Specialty Societies 1989 (CMSS address: P.O. Leuven, Belgium Box 70, Lake Forest, IL 60045). ~
4. Kunin CM. The expert witness in medical malpractice litigation. Ann Intern Med 1984;100:139-143.
Blood Loss from Diagnostic ILaboratory Tests in Elderly Patients To the Editor:-Anemia is a common problem among hospitalized elderly patients, but nothing is known about the influence of phlebotomy for diagnostic testing on the hemoglobin level during hospitalization in this population. The total amount of blood withdrawn and the frequency of phlebotomy were noted dally in 114 consecutive elderly (mean 82.5 years, range 65-98) inpatients, admitted to an acute geriatric ward. A hemoglobin (Hb)level was performed upon admission (HbA)and at the time of discharge (HbD). For patients who died, the last available hernoglobin value was taken. Anemia was defined according to the WHO criteria (HB c 13 g/dL for men and < 12 g/dL for women). No information about the study was released which might influence or alter the behavior of junior staff in ordering tests. Sixteen (14%) had 250 mL or more blood removed, of whom two gave more than 500 mL. Each phlebotomy averaged 11.3 mL (SD 9.1), and each patient was phlebotomized an average of 0.8 times (SD 0.65) per day (Table 1). Onehundred and four patients were eligible for further study. In three patients, only one Hb vdue was available (hospital stay c 72 h), and another seven, all with anemia upon admission, were given transfusion or treated with iron, folate, or vitamin
REFERENCES 1. Lipschitz DA. The anemia of chronic disease. J Am Geriatr Soc 1990;38:1258-1264. 2. Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med 1986;314:1233-1235. 3. Miller ES.Blood lost because of phlebotomy. N Engl J Med 1975;292:319. 4. Eyster E, Bernene J. Nosocomid anemia. J A M 1973;223:73-74. 5. Hashimoto F. Bleeding less for diagnostics. JAMA 1982;248171. 6. Hirota Y, Okamura S, Kimura N et al. Haematopoiesis in the aged as studied by in vitro colon assay. Eur J Haematol 1988;4083-90.
Low-SodiumDiet and Congestive Heart Failure in the Elderly To the Editor-In their comprehensive review article, Dr. Luchi et all did not address a point of great practical importance concerning the therapy of congestive heart failure (CHF) in the elderly. A low-sodium diet is usually prescribed early in the progress of CHF, prior to or together with drug therapy.’ In my experience, a low-sodium diet is often poorly tolerated in institutionalized elderly patients and may induce appetite loss, asthenia, hyponatremia, or confusion. In such patients, undernutrition is a common pr~blern,~ and a decrease in food intake as a result of a low-sodium diet may worsen the nutritional status and facilitatethe onset of cardiac cachexia, respiratory infections, or decubitus ulcers. Moreover, the tastelessness of low-sodium meals may impair the
