Monday, August 22, 2011
Communication Impairments Contribute To A Nursing Home Patient's Confusion
According to MedPage Today, Two high-ranking senators asked the Centers for Medicare and Medicaid Services (CMS) to take a closer look at potential over prescribing of antipsychotics to nursing home residents. The drugs in question are being used in nursing homes to control behavioral problems related to dementia. Reportedly the senators are urging CMS to consider requiring that physicians, who off-label prescribe drugs with black box warnings to seniors, certify that a Part D provider will cover the drug.
If CMS followed the senators' advice, Medicare payments for antipsychotics that "lack a medically-accepted indication" should be drastically reduced, the senators said.
Although cost savings to Medicare seems to be the intent behind the senators request, and overuse and misuse of any sort of medication for nursing home residents desirable, one can't help but wonder what resources the Senators will be willing to suggest CMS provide to nursing homes so that they are better able to manage resident's maladaptive behavior in a non-pharmaceutical way.
For example, hearing aids are not a covered benefit to Medicare recipients, despite the fact that hearing loss is the third most prevalent chronic condition in older Americans, and it is the number one communicative disorder of the aged; between 25% and 40% of the population aged 65 years or older is hearing impaired and age related hearing loss ( presbycusis) as high as 80% in seniors 85 years or more.
If one adds to hearing loss a speech and language impairment resulting from stroke or other neurological diagnosis, or related to dementia, one might see that there could potentially be an escalation in behavioral problems among persons not able to communicate basic wants and needs, including pain.
Although an assessment of a resident's speech and hearing is required by nursing homes desirous of Medicare reimbursement, a speech-language pathologist, the best qualified to make judgements about an individuals communication abilities, is not always the one making that judgement.
I cannot tell you the countless times I have walked into an elderly patient's room in a hospital or nursing home and the patient is extremely hard of hearing, and without hearing aids. As I shout my way through the interview, I wonder how many more staff members have come in and out of the patient's room making comments, asking questions, and providing information that was never heard or understood by the patient. It is not hard to imagine how that sort of confusion along with an unfamiliar environment could easily lead to inappropriate patient behavior.
Management of Medicare spending is a reality, but decisions by CMS that are more politically driven than clinically motivated will not be good for anyone.
The International Classification of Functioning, Disability and Health (ICF) was established by WHO, 2001. It is a model that promotes evaluation of the interaction between a person's health condition (disease/disorder) and the environmental and personal factors (among them sensory functions) that serve as facilitators or barriers to functioning. Patient with dementia as well as other neurodegenerative diseases would benefit from periodic evaluations, which includes an assessment of their communication . Nursing homes would benefit from the resources to meet those needs, and in doing so, the role of medications, including the need for psychotropic drugs might be better elucidated..