In The Last 90 Days Of Life, Dementia Patients Face Burdensome Transitions

Main Category: Alzheimer’s / Dementia
Also Included In: Seniors / Aging;  Palliative Care / Hospice Care;  Medicare / Medicaid / SCHIP
Article Date: 30 Sep 2011 – 0:00 PDT

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A new study in the Sept. 29, 2011, edition of the New England Journal of Medicine reports that nearly one in five nursing home residents with advanced dementia experiences burdensome transitions in the last 90 days of life, such as moving to a different facility in the last three days of life or repeat hospitalizations for expected complications of dementia in the last 90 days of life.

“Such patterns of transitions are burdensome, particularly since the overwhelming majority of family members state the main goal of care is comfort,” said study co-author Joan Teno, professor of health policy and practice at the Warren Alpert Medical School of Brown University and a palliative care physician. “These transitions reflect the inefficiency of our health care system. Similar outcomes could be achieved by keeping these patients in the nursing home setting.”

An important reason for the prevalence of burdensome transitions might be embedded in the way Medicare pays nursing homes, said Brown health economist and lead author Pedro Gozalo. Nursing homes can earn higher payments for patients who have been transferred to a hospital for three days and they may qualify for skilled nursing services paid by Medicare rather than Medicaid upon their return. The current incentives under Medicare and Medicaid encourage nursing homes to send patients to the hospital, he said.

What makes the transitions burdensome, especially for patients with cognitive impairment, Teno said, is that they are often unnecessary, raise the risk of medical errors, and interrupt continuity of care for patients who can experience significant stress and disorientation when they are suddenly removed from familiar surroundings and people. When the patients become upset, their families experience more stress.

Because these financial incentives, market conditions, and the culture of end-of-life care vary by state, so do the rates of burdensome transitions. The authors, who also include researchers from Harvard University and Dartmouth College, found that the overall percentage of patients experiencing at least one burdensome transition was 19 percent. State-level rates varied from 2.1 percent in Alaska to 37.5 percent in Louisiana.

“These burdensome transitions are not only bad for the patient, they also drain the federal treasury, hastening the day when the Medicare trust fund runs out of money,” said economist Jonathan Skinner from Dartmouth College, a co-author on the study.

Blacks and Hispanics were also more likely than whites to experience burdensome transitions, the authors found.


Amiss before dying

To reach these conclusions, the team analyzed federal databases of nursing home and Medicare records accumulated between 2000 and 2007. In all, they found 474,829 patients who were older than 66, had advanced cognitive impairment, and lived in a nursing home 120 days before their death. Of these, 90,228 residents experienced at least one burdensome transition, defined as either a transfer in the last three days of life, returning to a different nursing home than the one they lived in before they went to the hospital, or multiple hospitalizations in the last 90 days of life.

Often these hospitalizations occur even though the condition prompting the hospitalization – pneumonia, urinary tract infection, or dehydration – could easily be treated in a properly equipped and staffed nursing home.

These variations were particularly wide across different geographic areas. In McAllen, Texas, 25.8 percent of patients had multiple hospitalizations for urinary tract infections, pneumonia or dehydration, compared to only 1.1 percent of patients in Grand Junction, Colo.

The regional rate of burdensome transitions also correlates with other indicators of poor end-of-life care, Gozalo noted. Compared to patients living in the health care markets with the lowest rates of burdensome transitions, those who lived in the regions with the highest rates were three times more likely to have a feeding tube inserted, more than twice as likely to be in the intensive care unit in the last 30 days of life, and more than twice as likely to have developed an advanced pressure ulcer.

Ultimately, Teno said, all of these problems are signs of care gone awry. The best care for a patient with advanced cognitive impairment near the end of life is often to maximize comfort. The burdens of hospitalization usually outweigh the benefits.

“Our research calls for efforts to reform health care payment that create incentives to improve advance care planning and care coordination,” Gozalo said. “Current reform efforts like accountable care organizations that bundle both the hospital and post-acute care payments could begin to address some of these perverse incentives. We need financial incentives to make sure that people are getting the right care in the right place at the right time.”

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The need of increase hospital bed

It is crunch time again at some hospitals, It also diverted ambulances to other hospitals almost on a regular basis.The current situation is not yet that hospital Bed.The hard-pressed hospitals have initiated contingency plans.

We expect demand for Medical beds to rise in tandem with a growing total population and a higher proportion of elderly residents.”

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While remained at the range of one to 1.5 hours with the occasional spike, these are happening more often. And only half the patients got a bed within three hours.

A follow-up article showed the situation, but also added that the increase in the number of patients seemed quite sudden:

Industry watchers attribute the high medical hospital bed demand to the rapidly ageing population. What is surprising is that this appears to have happened overnight.

We expect demand for beds like electric medical hospital bed to rise in tandem with a growing total population and a higher proportion of elderly residents.

Now, it so happened that we had a census in 2010, and the Statistics Department even published a neat little table titled “Elderly population”.

As you can see, the total number of elderly persons grew 48.7 percent over the decade, or about 4 percent per year on a compounded rate. The number of the very elderly (i.e. over 75 years old) grew even faster, at about 5.5 percent per year, to total about 70 percent over ten years.

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In Obese Mice, Exercise Eases Arthritis, Even Without Weight Loss

Main Category: Arthritis / Rheumatology
Also Included In: Obesity / Weight Loss / Fitness
Article Date: 28 Sep 2011 – 3:00 PDT

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Adding another incentive to exercise, scientists at Duke University Medical Center have found that physical activity improves arthritis symptoms even among obese mice that continue to chow down on a high-fat diet.

The insight suggests that excess weight alone isn’t what causes the aches and pains of osteoarthritis, despite the long-held notion that carrying extra pounds strains the joints and leads to the inflammatory condition.

Published Sept. 27 online in the journal Arthritis Rheumatism, the findings are now being tested in people.

“What’s surprising is that exercise, without substantial weight loss, can be beneficial to the joints,” said Farshid Guilak, Ph.D., professor of orthopaedic surgery at Duke and senior author of the study. “Ideally, it would be best to be fit and lose a little weight, but this shows that exercise alone can improve the health of your joints.”

Even modest improvements could have a major impact if the findings are borne out in people. The Arthritis Foundation reports that one in five adults in the United States have been diagnosed with arthritis, and the annual cost of treating it and other rheumatic conditions has been tabbed at $128 billion.

Many cases of arthritis are associated with obesity and inactivity, so the Duke researchers set out to determine whether a high fat diet induces knee osteoarthritis, and then whether exercise provides a protective effect.

Using two sets of male mice – half fed a high-fat diet and the other fed regular chow – the researchers noted significant differences among the two groups. The mice on the high-fat food gained weight rapidly, processed glucose poorly and had much higher blood levels of molecules that trigger the chronic inflammation associated with osteoarthritis.

But when these animals got regular running wheel workouts, many of the harmful effects diminished – even though the mice ate the same high-fat food and shed no weight. Glucose tolerance improved, while the inflammatory response was disrupted among key signaling molecules called cytokines, easing the development of arthritis.

If the extra weight on the joints had been the cause of the arthritis, the researchers noted, exercise would have exacerbated the problem. Instead, it helped.

“We’re trying to understand the interaction of physical activity and obesity,” said Timothy M. Griffin, Ph.D., lead author of the study. Griffin was formerly at Duke and is now at the Oklahoma Medical Research Foundation. “Even though there was the same amount of body fat, the fat was different.”

Griffin said the fat cells still produced inflammatory molecules associated with arthritis, but they lost their punch because they could not organize into a force: “I don’t want to say exercise is turning off that inflammatory signal, it just impairs it.”

The findings add to a growing body of research exploring fitness vs. fatness. Ongoing studies at Duke and elsewhere are examining the role of diet, exercise and inflammatory diseases.

“This shows that if you are obese, it’s better to exercise,” Guilak said. “Sometimes pain can be a barrier to starting exercise, but if you overcome it, in the long term, it’s better.”

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Rise In Prostate Biopsy Complications And High Post-Procedure Hospitalization Rate

Main Category: Prostate / Prostate Cancer
Also Included In: Medicare / Medicaid / SCHIP
Article Date: 25 Sep 2011 – 0:00 PDT

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In a study of complication rates following prostate biopsy among Medicare beneficiaries, Johns Hopkins researchers have found a significant rise in serious complications requiring hospitalization. The researchers found that this common outpatient procedure, used to diagnose prostate cancer, was associated with a 6.9 percent rate of hospitalization within 30 days of biopsy compared to a 2.9 percent hospitalization rate among a control group of men who did not have a prostate biopsy. The study, which will be published in the November 2011 issue of The Journal of Urology, was posted early online.

The researchers emphasize that this new data should serve as a reminder to physicians to carefully weigh the risks and benefits of biopsy for individual patients and take all precautions to prevent infections and other complications.

The Johns Hopkins team’s findings are the result of the largest analysis ever performed of Medicare records of American men age 65 and older who underwent prostate biopsies in the last two decades. They found that having a prostate biopsy makes patients more than twice as likely to need hospitalization in the immediate post-procedure period. Those hospitalized had a range of complications, such as bleeding and infection, as well as flare-ups of underlying medical conditions, such as heart failure or breathing disorders.

Overall, mortality rates in men undergoing prostate biopsies did not increase. However, men hospitalized with biopsy-related infections had a 12-fold higher risk of death compared to men who did not have a biopsy.

“Prostate biopsy is an essential procedure for detecting prostate cancers,” says Edward Schaeffer, M.D., Ph.D., a Johns Hopkins urologist and oncologist and the study’s senior investigator. “Coupled with appropriate screening, prostate biopsies save lives. However, it is important for men to be aware of the possible risks of prostate biopsies, which are often described as simple outpatient procedures,” adds Schaeffer, an associate professor at the Johns Hopkins University School of Medicine and its Brady Urological Institute.

In their study, the researchers examined the frequency of biopsy related complications that required hospitalization in more than 17,400 men age 65 and older from 1991 to 2007. They compared these rates to a cohort of 134,977 men during the same time period with similar characteristics who did not undergo a prostate biopsy. The researchers only looked at hospital admissions, not men whose complications were treated in an emergency department or outpatient setting.

While the rate of hospitalization following prostate biopsy has declined steadily since 1991, the researchers found that the rate of hospitalization during the time period was still two-fold higher among the men who had a biopsy (6.9 percent compared to 2.9 percent).

There was also a steady rise in the rate of serious infection-related complications. At the onset of the study in 1991, fewer than 0.5 percent of men were admitted to the hospital because of an infection diagnosed following a prostate biopsy. This rate remained stable until 2000, when rates of infection-related complications began to increase to more than 1.2 percent in 2007.

“Antibiotics are routinely given to men at the time of biopsy, and the fact that infections serious enough to cause hospital admissions have been on the rise makes us think that these types of complications are occurring because of a steady increase in antimicrobial resistance rates in America,” says Schaeffer.

Co-author H. Ballentine Carter, M.D., professor of urology and oncology at the Johns Hopkins University School of Medicine, says, “Based on these findings, we believe that more needs to be done to reduce potential complications. It is important for urologists to determine if a biopsy is appropriate for an individual patient and also if the patient is at increased risk for a biopsy- related complication.”

The researchers say that prostate biopsies should only be performed with strict adherence to medical guidelines, and after all potential risks and benefits have been reviewed with patients. More than 1 million prostate biopsy procedures are performed each year in the United States to diagnose and monitor prostate cancer, which is the second most common cause of cancer death among men.

Funding for the study was provided by the Howard Hughes Medical Institute, the U.S. National Institutes of Health, an American Urological Association Astellas Research Star Award, and the Patrick C. Walsh Prostate Cancer Research Fund at Johns Hopkins.

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I love hospital socks…

I love hospital socks…



I love hospital socks.

by Jaeda Barbie

It is something about comfy, yet sturdy; blue, pink, red shoe socks. I have kept the ones from the birth of my daughter, as well as my numerous stays in the hospital. There is something uniquely reliable about them. I can find positives in almost anything now in my life. I was not always this way. I know some readers are probably laughing out loud at such a silly post, but we must be able to find happiness in even the little things.

The pretty ceiling fan than blows cool air over my head, is a reminder that it helps me not to have to turn on the expensive a/c. I am encouraging my readers to look at every little thing as a blessing, and watch how peaceful and happy your life can be. And you didn’t think you could get anything out of a post about hospital socks.

Luke 16:10(Bible in Basic English) He who is true in a little, is true in much; he who is false in small things, is false in great.

Copyright 2011 JaedaBarbie

 



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Extending Life Of Arthritic Joints

Main Category: Bones / Orthopedics
Also Included In: Arthritis / Rheumatology;  Clinical Trials / Drug Trials
Article Date: 23 Sep 2011 – 0:00 PDT

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A medication already approved to build bone mass in patients with osteoporosis also builds cartilage around joints and could potentially be repurposed to treat millions of people suffering from arthritis, according to orthopaedic research at the University of Rochester Medical Center.

The study authors hope their laboratory findings, published in the current issue of Science Translational Medicine, will set the stage for the first human clinical trials to test human parathyroid hormone (brand name: Forteo) in this growing patient population.

Since 2005, arthritis has been ranked as the leading cause of disability in the United States by the Centers for Disease Control and Prevention. And by 2030 an estimated 67 million people, or 25 percent of the adult population in this country will have osteoarthritis (OA), a painful, degenerative joint disease that often begins with an injury and results in the progressive loss of cartilage. Current treatments for OA do not help improve the cartilage in the diseased joint, they only make the pain more bearable. Examples include oral anti-inflammatory agents (such as Advil or Naproxen), narcotics, or steroid injections into the affected joint. Surgical replacement of the joint and cartilage is usually required, although this major intervention often carries its own set of complications.

“We believe that a potential alternative to this cycle of pain and reduced quality of life has gone unnoticed for the past decade,” said study co-author Michael J. Zuscik, Ph.D., associate professor, Department of Orthopedics Rehabilitation, Center for Musculoskeletal Research at URMC. “Given that Forteo is already FDA approved, our experimental findings make a compelling case for further clinical study of this drug in the context of arthritis.”

The Food and Drug Administration approved Forteo a decade ago as a bone-building therapy for osteoporosis patients with severe bone loss. Although Zuscik and co-author Randy N. Rosier, M.D., Ph.D., professor of Orthopaedics Rehabilitation, lead a laboratory that investigates osteoarthritis, through collaborative clinical work their group made an interesting observation: Occasionally, when a patient suffered from both disorders – osteoporosis and osteoarthritis – the symptoms of arthritis would improve after taking Forteo for osteoporosis.

This observation led the OA researchers to question whether the drug would have an impact on the molecular pathways that govern chondrocytes, the cells responsible for maintaining cartilage, and the changes that take place during joint degeneration. The team used a mouse model for post-traumatic knee osteoarthritis and demonstrated in several laboratory experiments that when Forteo was given daily for one month, the injured cartilage became as much as 32 percent thicker, cell production was enhanced, and genes and molecules associated with the degeneration of cartilage were suppressed.

The study was designed to mimic a common clinical situation in which injury to the meniscus and collateral ligaments result in the development of osteoarthritis later in life. Since the hallmark problem in osteoarthritis is the progressive and irreversible loss of cartilage, Zuscik said, the ability of parathyroid hormone to add new cartilage while blocking its degradation makes it a viable therapy.

In addition to the laboratory research, Zuscik and Rosier reviewed OA patient information from government databases. Of 4,000 people diagnosed with knee arthritis, they found 14 who were also taking Forteo for osteoporosis. This small group of people reported less arthritis pain and a higher ability to function than a matched population of patients who were not taking Forteo.

Although this data involved a very small number of people and is therefore not conclusive, Rosier said, it does confirm observations made by him and other URMC orthopaedic specialists.

Future studies are still needed to address several important questions. There is some concern, for instance, about the safety of Forteo, which is made by Eli Lilly and Company and carries a black-box warning because it has been found to cause an increased risk of the bone cancer osteosarcoma, in rats. Due to this potential long-term risk in humans, Forteo is prescribed for short-term use up to two years. Thus, researchers will need to determine how long the protective/regenerative effect on cartilage persists after treatment is stopped.

The National Institutes of Health and the Arthritis Foundation funded the research.

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Article adapted by Medical News Today from original press release.

Visit our  bones / orthopedics section for the latest news on this subject.

The corresponding author is Erik R. Sampson, Ph.D., of the URMC Center for Musculoskeletal Research. Other collaborators from the Center include: Matthew J. Hilton, Ph.D.; Ye Tian, Ph.D.; Di Chen, Ph.D.; Edward M. Schwarz, Ph.D.; Robert A. Mooney, Ph.D.; Susan V. Bukata, M.D.; Hani Awad, Ph.D.; J. Edward Puzas, Ph.D.; and Regis J. O’Keefe, M.D., Ph.D., associate Dean for Clinical Affairs, director of the Center for Musculoskeletal Research, and chair of the URMC Department of Orthopaedics Rehabilitation.

University of Rochester Medical Center

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Take a day off, help save a life

Do you have a mission when out on the greens? We invite you to join ours!

Monday, September 26, 2011
The Bridgewater Club, 3535 E. 161st St., Carmel, IN
11 a.m.: Lunch Registration
Noon: Shotgun Start
5 p.m.: Reception Awards

Join us for TriMedx Foundation‘s 2011 Mission On The Greens golf outing, the Foundation’s main fundraising event. Our golfers enjoy lunch prior to a shotgun start and a traveling beverage cart, followed by a reception and brief award ceremony. Last year’s event raised a record $51,000 for medical missions.

This year’s event will be hosted by The Bridgewater Club in Carmel, set in a beautiful, private housing community. For more information on the course, you can visit their website at thebridgewaterclub.com.

All event profits go directly to missions, enabling TriMedx Foundation to improve healthcare in impoverished communities by repairing broken medical equipment in mission hospitals and clinics and educating locals to perform basic equipment repair functions.

Please mark your calendar now and plan to join us on September 26th. Event registration, volunteering and other details will come your way soon! If you have any questions about this event or TriMedx Foundation in the meantime, please comment below or contact me at mary.owens@trimedxfoundation.org.

All the best,

Mary Owens
Development Director, TriMedx Foundation
mary.owens@trimedxfoundation.org
(317) 275-1555

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