#1: Why should people express their wishes about health care? Isn’t that for their doctor to decide?

Today’s health care technologies are pretty amazing. They can keep us alive even if we are suffering from a serious illness. People have different ideas about the treatments they would want to have. If they are able to state their wishes, they can say yes or no to questions like these:

• Would you want CPR or other resuscitation if your heart were to stop beating?
• Would you want to be put on a ventilator if you could no longer breathe on your own?
• Would you wish to have tube or needle feeding if you lost the ability to swallow?
• If you had a life-limiting illness, would you wish to receive antibiotics that might prolong life?
• If you had progressive dementia, what health treatments would you want?
• Would you want to be an organ donor?
• At what point would you want palliative care (care that focuses on pain control and quality of life) rather than aggressive treatment?

We like to think that we will always be capable of making these kinds of health care decisions. Sometimes, however, it doesn’t work like that. A stroke, an automobile accident, Alzheimer’s disease—any number of circumstances might limit or take away our immediate ability to make these decisions. The Gerontological Society of America reports that nearly one in four older

Americans today receives “excessive or unwanted medical treatment” because they had not earlier made their wishes known.

Creating advance directives makes it more likely that our wishes would be met, even if we could not speak for ourselves.

#2: What are advance directives?

These are documents that include statements about:

• What you would want. A health care directive or living will is a document that says what kinds of care—including the life-sustaining measures mentioned above—you would or would not want if you were nearing the end of your life. In some states, you can also create a document that would make it less likely that first responders would perform CPR or other procedures on you if you don’t want it. This is called a Physician Orders for Life-Sustaining Treatment (POLST) or something similar.

• Who you would want to speak for you. A durable power of attorney for health care, medical power of attorney or health care proxy is a document saying who you would like to make health care decisions for you, if a time were to come when you couldn’t speak for yourself.

#3: Who should I choose to serve as my health care proxy/durable power of attorney for health care?

This person would most likely be a relative or close friend. Think about the person you would most trust to make those decisions for you if you weren’t able to do so. That is the person you should appoint as your health care representative. If for some reason the person who would be your first choice were not available to act for you, who would be your second choice? Most forms designating a health care representative allow you to name an alternate.

#4: What should I tell my health care representative?

If you wish to name an individual as your health care representative, ask the person if he or she is willing to take on that responsibility. If the person agrees, then you should sit down with him or her and have a frank, detailed conversation about your feelings and values concerning health care and the kinds of treatment you would or would not want. Along with this conversation, be sure to give your health care representative copies of your health care directive.

#5: Why are these conversations so important?

Yale University researchers conducted a study of 349 older patients and their health surrogates. They asked the seniors about what treatment they would prefer if they had a serious illness. Then they asked the health surrogates what they thought the patient would prefer. They found that while the surrogates rated themselves as “extremely confident” that they knew their loved one’s wishes, in fact only 21% of their answers matched up with the patient’s!

Even though you’ve stated your wishes in writing, talking about your thoughts with your health care representative and other family members is important. The better understanding those close to you have about your wishes, the more likely it is that you will spend the end of your life in peace and comfort, and that your family will be spared anguishing decisions and conflict during a time that they would rather be focusing on saying goodbye. It is a loving legacy to leave.

#6: Where can I get these forms?

You can ask your doctor for the correct forms to use. Various organizations, including the AARP, offer free advance directive forms for the state in which you live.

#7: Who should have a copy of my health care directive?

Give a signed and witnessed copy to your primary physician, your health care representative, your hospital, your senior living community, and any other major health care institution or organization with which you are connected. It is also wise to share the information with all family and close friends. Doctors and hospitals report that family members are sometimes surprised by their loved one’s wishes as stated in a living will. Family members may disagree with the patient’s wishes, or among themselves. You can make it easier for everyone by talking openly with your loved ones about what you would want.

#8: What if I don’t know what I want?

Many people hesitate to express their health care wishes because they’re just not sure about what they think! They don’t feel qualified to decide. This is another time when having conversations is a big help. Talk to friends and family. Find out about presentations and discussion groups held at your faith community, senior center, local hospice or senior living community. Consult with a counselor, your spiritual advisor or a professional Life Care Manager.

#9: What if I change my mind?

Your right to complete advance directives includes your right to change your mind. In most states, you may cancel an advance directive any time and in any way that clearly shows your intent—for example, by tearing it up, marking it “revoked,” or telling someone you have changed your mind. It’s always a good idea to review your advance directives from time to time to be sure they reflect your current thinking. If you decide to update, let your representative and doctor know.

#10: Can my doctor talk to me about advance care planning?

Yes! And Medicare now covers advance care planning. Your doctor can counsel you as you make these decisions, and help you fill out the necessary forms. You can ask your doctor about the prognosis if you have health problems. It’s best to have these conversations well ahead of time. The American Academy of Family Physicians reports stories about “very sick patients who were admitted to the hospital and had end-of-life conversations in the midst of a crisis with unfamiliar doctors.” Said Dr. Nancy Shoenborn, a professor at Johns Hopkins University School of Medicine, “Wouldn’t it be better for patients to have these discussions earlier upstream with their regular doctor who knows them better?”

The professional Life Care Managers at Holistic Aging can help older adults and families as they navigate the health care system and put advance directives into place.

Source: IlluminAge AgeWise

The post Ten Important Questions About Advance Health Care Directives appeared first on Holistic Aging.

The ETF basics are extremely easy to learn and use, it is fully portable, requires no special equipment, no drugs, surgeries or other medical interventions. Relief can occur no matter what the diagnosis or how many other interventions have failed.

I would encourage anyone to experiment with it and try it both personally and professionally for assisting clients to heal. It makes sense that if your energy is balanced, you can better assist another person with their issues. At Holistic Aging/Options For Elder Care we have found it a beneficial tool to add to our clients repertories to empower them to heal themselves and contribute to their own well-being. We also have done tapping to those who cannot complete the manipulations themselves due to cognitive or physical restraints.

Emotional Freedom Technique can be used to:

• Remove negative emotions such as phobias or emotional trauma
• Reduce or eliminate pain and disease
• Implement positive goals
• Reduce food cravings
• And many more

There are two basic areas to learn in order to use EFT: the tapping locations and technique, and the positive affirmations. Per ETF originator Gary Craig, who provides the Gold standard in ETF techniques:

KC: The Karate Chop point

Emotional Freedom Technique Tapping Locations

KC: The Karate Chop point (abbreviated KC) is located at the center of the fleshy part of the outside of your hand (either hand) between the top of the wrist and the base of the baby finger or….stated differently….the part of your hand you would use to deliver a karate chop.

TOH: On the top of the head. If you were to draw a line from one ear, over the head, to the other ear, and another line from your nose to the back of your neck, the TOH point is where those two lines would intersect.

EB: At the beginning of the eyebrow, just above and to one side of the nose. This point is abbreviated EB for beginning of the EyeBrow.

EFT Tapping Locations

SE: On the bone bordering the outside corner of the eye. This point is abbreviated SE for Side of the Eye.

UE: On the bone under an eye about 1 inch below your pupil. This point is abbreviated UE for Under the Eye.

UN: On the small area between the bottom of your nose and the top of your upper lip. This point is abbreviated UN for Under the Nose.

Ch: Midway between the point of your chin and the bottom of your lower lip. Even though it is not directly on the point of the chin, we call it the chin point because it is descriptive enough for people to understand easily. This point is abbreviated Ch for Chin.

CB: The junction where the sternum (breastbone), collarbone and the first rib meet. To locate it, first place your forefinger on the U-shaped notch at the top of the breastbone (about where a man would knot his tie). From the bottom of the U, move your forefinger down toward the navel 1 inch and then go to the left (or right) 1 inch. This point is abbreviated CB for CollarBone even though it is not on the collarbone (or clavicle). It is at the beginning of the collarbone and we call it the collarbone point because that is a lot easier to say than “the junction where the sternum (breastbone), collarbone and the first rib meet.”

UA: On the side of the body, at a point even with the nipple (for men) or in the middle of the bra strap (for women). It is about 4 inches below the armpit. This point is abbreviated UA for Under the Arm.

Tapping Tips

• Some of the Tapping points have twin points on each side of the body. For example, the “eyebrow” point on the right side of the body has a twin point on the left side of the body. Years of experience have taught us that you only need to tap one of these twin points. However, if you have both hands free you can certainly tap on both sides for good measure.
• You can also switch sides when you tap these points. For example, during the same round of The EFT Tapping Basic Recipe, you can tap the “karate chop” point on your lefthand and the eyebrow point on the right side of your body. This makes the Tapping process more convenient to perform.
• The Tapping is done with two or more fingertips. This is so you can cover a larger area and thereby insure that your Tapping covers the correct point.
• While you can tap with the fingertips of either hand, most people use their dominant hand. For example, right handed people tap with the fingertips of their right hand while left handed people tap with the fingertips of their left hand.
• You tap approximately 5 times on each point. No need to count the taps because anywhere between 3 and 7 taps on each point is adequate. The only exception is during the Setup step (explained later) where the Karate Chop Point is tapped continuously while you repeat some standard wording.
• The process is easily memorized. After you have tapped the Karate Chop Point, the rest of the points go down the body (see the Sequence Points in the diagram above). The Eyebrow point, for example, is below the Top of the Head point. The Side of the Eye point is below the Eyebrow point. And so on down the body.

The 5 Steps to Emotional Freedom Technique Tapping per Gary Craig:

1. Identify the Issue:

All you do here is make a mental note of what ails you. This becomes the target at which you “aim” the EFT Tapping Basic Recipe. Examples might be: Sore shoulder, traumatic experience in childhood, or inability to stop eating in the evening.  Be sure you are only targeting one issue at a time.

2. Test the Initial Intensity:

Here you establish a before level of the issue’s intensity by assigning a number to it on a 0-10 scale where 10 is the worst the issue has ever been and 0 is no problem whatsoever, similar to the pain scale used in a medical setting.  This serves as a benchmark so we can compare our progress after each round of The EFT Tapping Basic Recipe. If, for example, we start at an 8 and eventually reach a 4, then we know we have achieved a 50% improvement.

• For emotional issues, you can recreate the memories in your mind and assess the discomforts.
• For physical ailments you can simply assess the existing pain or discomfort.
• For performance issues you can attempt the desired performance level and measure how close you come to it.

3. The Setup:

The Setup is a process we use to start each round of Tapping. By designing a simple phrase and saying it while continuously Tapping the KC point, you let your system know what you’re trying to address.

When designing this phrase there are two goals to achieve:

1)  acknowledge the problem
2)  accept yourself in spite of it

We do this by saying:

“Even though I have this _______________, I deeply and completely accept myself”.

The blank above represents the problem you want to address, so you can just insert things like:

This sore shoulder:
“Even though I have this sore shoulder, I deeply and completely accept myself.”

This fear of spiders:
“Even though I have this fear of spiders, I deeply and completely accept myself.”

This humiliation at my eighth grade graduation:
“Even though I have this humiliation at my eighth grade graduation, I deeply and completely accept myself.”

This difficulty falling asleep:
“Even though I have this difficulty falling asleep, I deeply and completely accept myself.”

Not all of the issues will fit neatly into “Even though I have this ____________,” so you can use some flexibility when designing your Setup phrase. For example, instead of “this sore shoulder” you could say “Even though my shoulder hurts, I deeply and completely accept myself”. Or instead of “this humiliation at my eighth grade graduation” you could say “Even though my dad humiliated me at my eighth grade graduation.”

We do not want to use EFT on someone else’s problem. For example, rather than, “Even though my son is addicted to drugs, I deeply and completely accept myself,” it’s better to focus on your own reaction which might be, “Even though I’m frustrated by my son’s drug addiction.” Or instead of “Even though my husband works too much…,” better to try something like, “Even though I feel alone when my husband stays late at the office…” We want to aim EFT at our part of the problem rather than trying to fix someone else’s problem.

Important, Important, Important:

The language that we use always aims at the negative. This is essential because it is the negative that creates the energy that The EFT Tapping clears. This allows our natural positives to bubble up to the top.

4. The Sequence:

This is the workhorse part of The EFT Tapping that stimulates/balances the body’s energy pathways. To perform it, you tap each of the points shown in the Sequence Points diagram (see above or below) while saying a Reminder Phrase that keeps your system tuned into the issue. Listed below are the points followed by a description of the Reminder Phrase:

• Top of the Head (TOH)
• Beginning of the Eyebrow (EB)
• Side of the Eye (SE)
• Under the Eye (UE)
• Under the Nose (UN)
• Chin Point (CH)
• Beginning of the Collarbone (CB)
• Under the Arm (UA)

The Reminder Phrase is quite simple as you need only identify the issue with some brief wording. Depending on your issue, you might say the following at each tapping point….
“This sore shoulder”,
“My father embarrassed me”,
“This difficulty in falling asleep”

5. Test the Intensity Again:

Finally, you establish an “after” level of the issue’s intensity by assigning a number to it on a 0-10 scale. You compare this with the before level to see how much progress you have made. If you are not down to zero then repeat the process until you either achieve zero or plateau at some level.

EFT restores awareness and trust in the natural healing abilities of our mind, body and spirit, providing ground-breaking opportunities to achieving physical and emotional well-being in a faster time frame.

Because the techniques are so simple, they can be used effectively as a self-help tool, which empowers people to actively contribute to their own healing and development process. This facilitates a much faster relief process, previously believed impossible by healthcare professionals who advocated lengthy (& often painful) hours in psychotherapeutic or medical care, often with limited results. These techniques do not discredit the medical and psychotherapeutic professions, but rather serve to contribute to a holistic healing process.

To schedule a therapeutic tapping session or to better learn the technique, contact Bobbi Kolonay RN, MS, Certified Holistic Nurse at Holistic Aging.

The post What is EFT (Emotional Freedom Technique) or TAPPING appeared first on Holistic Aging.

This report was written by Senior Policy Attorney Toby S. Edelman.

Administering antipsychotic drugs to more than a quarter of a million nursing home residents meets the definition of elder abuse and, left unanswered, is a national scandal.

The Administration on Aging defines a subcategory of elder abuse – “physical abuse” – as “inflicting physical pain or injury on a senior, e.g. slapping, bruising, or restraining by physical or chemical means.”[1]

Antipsychotic Drugs Are Dangerous When Administered to People Who Do Not Need Them.

More than a decade ago, the U.S. Food and Drug Administration (FDA) gave its highest level of warning to the public about antipsychotic medications and warned that older people with dementia who were prescribed these drugs are at greater risk for death and other serious harm.[2]  Since then, recommendations of experts repeat, with increasing urgency, that antipsychotic drugs should not be given to older people.  In November 2015, the American Geriatrics Society’s evidence-based update of its Beers Criteria for “potentially inappropriate medication use in older adults” stated unequivocally that that antipsychotic medications should be avoided for older people, “except for schizophrenia, bipolar disorder, or short-term use as an antiemetic during chemotherapy.”[3]  Citing “increasing evidence of harm associated with antipsychotics and conflicting evidence on their effectiveness in delirium and dementia, the rationale to avoid was modified to ‘avoid antipsychotics for behavioral problems unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible, and the older adult is threatening substantial harm to self or others [italics in original].’”[4] Thus, there is a very limited category of people for whom the drugs could be appropriate.

Multiple ongoing studies continue to document that antipsychotic drug use is associated with increased risk for falls and fractures,[5] acute kidney injury,[6]  myocardial infarction (heart attack),[7] hospitalization,[8] and death,[9] among other poor outcomes suffered by older people who are given antipsychotic drugs.  Some of these studies focus, in particular, on older people with dementia who are administered antipsychotic drugs for reasons not approved by the FDA – so-called “off-label” uses.

Over a Quarter of a Million Nursing Home Residents Are Given Antipsychotic Drugs.

Despite the clear, consistent, and ever-growing body of evidence that antipsychotic drugs should not be prescribed for older people, hundreds of thousands of nursing home residents are given these drugs on a regular basis.  The Centers for Medicare & Medicaid Services (CMS) reports that, in the first quarter of 2016, information self-reported by nursing facilities indicates that 20.77% of 1,300,222 nursing home residents – 270,056 individuals – took antipsychotic drugs.[10]  The overwhelming majority of these residents have not been diagnosed with a psychosis that could possibly support the administration of antipsychotic drugs.  Instead, these residents have dementia or are otherwise unable to explain with words what is causing them stress or discomfort.

Why are residents chemically restrained and abused?  There are two critical reasons: inadequate staffing levels at nursing facilities and inadequate enforcement of federal standards of care.

Inadequate Nurse Staffing

Too often, nursing facilities use antipsychotic drugs to control residents when they do not have sufficient numbers of nursing staff – professional registered nurses, licensed practical nurses, and certified nursing assistants – to provide direct, hands-on care to residents.  In 2012, analyzing nationwide data that it received from the federal government about nurse staffing levels and antipsychotic drug use, the Boston Globe reported “a clear link between the rate of antipsychotic use in a nursing home and its staffing level.”[11]  The investigative journalists reported, “Homes that most often used these drugs for conditions not recommended by regulators had fewer registered nurses, who direct care, and nurses’ aides, who provide most of the hands-on care.”[12]  Simply stated, in the absence of sufficient numbers of professional and paraprofessional nursing staff, facilities inappropriately use antipsychotic drugs to quiet and control residents.

There is a solution to this form of elder abuse!  Improve staffing levels in nursing facilities.  Long-standing evidence confirms that nursing facilities employ too few nurses to meet residents’ needs.

Fifteen years ago, a comprehensive Congressionally-mandated national study documented that nursing facilities do not have sufficient nursing staff to meet residents’ needs.[13]  The study looked at staffing levels in two ways.  An empirical analysis evaluated actual practices in more than 5,000 nursing facilities in 10 states; a time-motion simulation estimated the nurse aide time needed to meet certain key care functions.

The empirical analysis found that 97% of nursing facilities failed to meet one or more nurse staffing standards and 52% failed to meet all of the nurse staffing standards.[14]  Below these staffing levels, quality of care was compromised and residents were at risk of harm.  The time-motion study estimated that 91% of facilities did not have sufficient nurse aides to meet residents’ needs in five care processes (“1) dressing/grooming independence enhancement, 2) exercise, 3) feeding assistance, 4) changing wet clothes and repositioning residents, 5) providing toileting assistance and repositioning residents”).[15]

Although residents’ needs have increased since the federal government’s staffing study was completed fifteen years ago as sicker people are cared for in SNFs, staffing has not increased sufficiently to meet these needs.

Non-Enforcement of Federal standards of care

A second key reason for the over-administration of antipsychotic drugs to nursing home residents who have dementia is the failure of federal and state government survey agencies to effectively enforce long-standing regulations limiting the use of antipsychotic drugs.

The federal Nursing Home Reform Law sets out the standards of care that nursing facilities must meet in order to participate in, and be eligible for reimbursement under, the Medicare or Medicaid programs, or both.[16]  The Law also establishes the survey protocol by which state survey agencies determine facilities’ compliance with federal standards of care[17] and the enforcement actions that may, or, in some instances, must, be imposed when facilities are determined not to be in substantial compliance with the standards.[18]  Under the federal nursing home enforcement system, enforcement sanctions are generally imposed only if a facility’s noncompliance is classified as occurring at a “harm” or “immediate jeopardy” level.[19]  “No harm” deficiencies lead to no enforcement.

Since 1992, federal regulations implementing the Reform Law have expressly prohibited the use of “unnecessary drugs.”[20] They have also explicitly required that antipsychotic drugs be administered only to treat a resident’s specific medical condition and, even then, use of the drugs is required to be reduced and, if possible, eliminated.[21]  Unfortunately, these explicit requirements are rarely enforced.

In cooperation with CMS, the Center for Medicare Advocacy and Lerner Consulting conducted a study of antipsychotic drug deficiencies in seven states.[22]  Analyzing all 295 antipsychotic drug deficiencies cited in those states in 2010 and 2011, the study found that 95% of deficiencies were cited at a “no harm” (D or E) level, regardless of the poor outcomes for residents, the total number or proportion of residents affected by deficient practices, and the number of specific federal requirements violated by the facility.

Three states cited a total of 15 harm-level deficiencies, and 11 of these deficiencies were cited by a single state.  Four states did not cite a single harm-level antipsychotic drug deficiency in the two-year period.

CMS does not describe enforcement of federal rules about antipsychotic drugs as part of its antipsychotic drug agenda.  In a June 3, 2016 report on its five-year old National Partnership to Improve Dementia Care in Nursing Homes, CMS never once mentions the imposition of sanctions as a method of reducing the inappropriate administration of antipsychotic drugs to nursing home residents.[23]  Instead, CMS focuses on training, state coalitions, partnerships, awarding a grant to the Eden Alternative for a project entitled “Creating a Culture of Person-Directed Dementia Care,” posting of resources about antipsychotic drugs on the website of Advancing Excellence, publicly reporting antipsychotic drug rates on its website Nursing Home Compare, and developing and testing of a Focused Dementia Care Survey.

[1] Administration on Aging, “What is elder abuse?” http://www.aoa.gov/AoA_programs/Elder_Rights/EA_Prevention/whatIsEA.aspx/
[2] In April 2005, the FDA issued “black box” warnings against prescribing atypical antipsychotic drugs for patients with dementia, cautioning that the drugs increased dementia patients’ mortality. FDA, “Public Health Advisory: Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances” (April 11, 2005), http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm05317 In June 2008, the FDA extended its warning to all categories of antipsychotic drugs, conventional as well as atypical, and directly and unequivocally advised health care professionals, “Antipsychotics are not indicated for the treatment of dementia-related psychosis.” FDA, “Information for Healthcare Professionals: Conventional Antipsychotics,” FDA Alert (June 16, 2008), http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm.
[3] The American Geriatrics Society 2015 Beers Criteria Update Expert Panel, “American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,” Journal of the American Geriatrics Society, Vol. 63, No. 11, page 2233, Table 2 (Nov. 2015), http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/pdf
[4] Id. 2242.
[5] Lisa-Ann Fraser, Kuan Liu, Kyla L. Naylor, Y. Joseph Hwang, Stephanie N. Dixon, Salimah Z. Shariff, Amit X. Garg, “Falls and Fractures With Atypical Antipsychotic Medication Use: A Population-Based Cohort Study,” JAMA Intern Med. 2015;175(3):450-452,  http://archinte.jamanetwork.com/article.aspx?articleid=2089230.
[6]  Y. Joseph Hwang, Stephanie N. Dixon, Jeffrey P. Reiss, Ron Wald, Chirag R. Parikh, Sonja Gandhi, Salimah Z. Shariff, Neesh Pannu, Danielle M. Nash, Faisal Rehman, Amit X. Garg, “Atypical Antipsychotic Drugs and the Risk for Acute Kidney Injury and Othr Adverse Outcomes in Older Adults: A Population-Based Cohort Study,” Ann Intern Med. 2014; 161(4):242-248, http://archinte.jamanetwork.com/article.aspx?articleid=2089230; http://annals.org/article.aspx?articleid=1897100.
[7]  Zheng-he Yu, Hai-yin Jiang, Li Shao, Yuan-yue Zhou, Hai-yan Shi, Bing Ruan, “Use of Antipsychotics and Risk of Myocardial Infarction: A Systematic Review and Meta-analysis,”  British Journal of Clinical Pharmacology (accepted for publication), http://onlinelibrary.wiley.com/doi/10.1111/bcp.12985/pdf.
[8]  Rajender R. Aparasu, Satabdi Chatterjee, Hua Chen, “Risk of Hospitalization and Use of First- Versus Second-Generation Antipsychotics Among Nursing Home Residents,”    Psychiatric Services, Vol. 65, Issue No. 6, 781-788 (June 2014), http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201300093
[9] Donovan T. Maust, Hyungjin Myra Kim, Lisa S. Seyfried, Claire Chiang, Janet Kavanagh, Lori S. Schneider, Helen C. Kales, “Antipsychotics, Other Psychotropics, and the Risk of Death in Patients With Dementia; Number Needed to Harm,” JAMA Psychiatry. 2015; 72(5): 438-445, http://archpsyc.jamanetwork.com/article.aspx?articleid=2203833.
[10]https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-
Reports/Minimum-Data-Set-3-0-frequency-report.html [site visited May 19, 2016].
[11] Kay Lazar and Matt Carroll, “A rampant prescription, a hidden peril,” Boston Globe (April 29, 2012), http://archive.boston.com/news/local/massachusetts/articles/2012/04
/29/nursing_home_residents_with_dementia_often_given_antipsychotics_despite_health_warnings/?page=full.
[12] Id.
[13] CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase 1, Vol. I (Winter 2001), http://phinational.org/sites/phinational.org/files/clearinghouse/Phase_I_VOL_I.pdf; Vol II, http://phinational.org/legislation-regulations/report-congress-appropriateness-minimum-nurse-staffing-ratios-nursing-
home-1; Vol. III, http://phinational.org/sites/phinational.org/files/clearinghouse/Phase_I_VOL_III.pdf.  CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II, Vol. I (March 2002), http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIofIII.pdf; Vol. II, http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIIofIII.pdf; Vol. III, http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIIIofIII.pdf.
[14] CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II, Vol. II, pages 3-16 and 3-17, http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIIofIII.pdf.
[15] Id. 3-19.
[16] 42 U.S.C. §§13958-3(b)-(d), 1396r(b)-(d), Medicare and Medicaid, respectively.
[17] 42 U.S.C. §§1395i-3(g), 1396r(g).
[18] 42 U.S.C. §§1395i-3(h, 1396r(h).
[19] CMS, Nursing Home Enforcement Reports Through December 31, 2014, page 5, attached to CMS, “Public Release of Nursing Home Enforcement Information Announcement,” S&C: 16-27-NH (June 3, 2016) (Memorandum from David R. Wright, Director, Survey and Certification Group, to State Survey Agency Directors), (CMS confirming that “most enforcement actions are taken in response to deficiency findings at the actual harm and immediate jeopardy levels”),  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-27.pdf.
([20] 42 C.F.R. §483.25(l)(1), Unnecessary drugs, provides:
(l) Unnecessary drugs—
1) General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i) In excessive dose (including duplicate drug therapy); or
(ii) For excessive duration; or
(iii) Without adequate monitoring; or
(iv) Without adequate indications for its use; or
(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(vi) Any combinations of the reasons above
[21] 42 C.F.R. §483.25(l)(2) provides:
(2) Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that—
(i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and
(ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
[22] “CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities,”  http://www.medicareadvocacy.org/cma-report-examining-inappropriate-use-of-antipsychotic-drugs-in-nursing-facilities/#.
[23] CMS, “Update Report on the National Partnership to Improve Dementia Care in Nursing Homes,” S&C: 16-28-NH (June 3, 2016) (Memorandum from David R. Wright, Director, Survey and Certification Group, to State Survey Agency Directors), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-28.pdf.

This report was written by Senior Policy Attorney Toby S. Edelman.

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Geriatric medical organizations have long warned against over-prescribing to older people, who are more susceptible to common side effects of psychotropic drugs, such as dizziness and confusion.  These symptoms lead to further decline in cognition, falls, and increased anxiety.These neuroleptics and antidepressants frequently make people look and act apathetic, zombie-like as if they’ve been lobotomized — even at moderate or low doses.

What’s really going on?

For more than 20 years, the American Geriatrics Society has published “Beers Criteria” which lists dozens of potentially inappropriate drugs and their mutual interactions. Unfortunately, inappropriate prescribing in older people is even more common than previously thought according to a recent study.

Prescription rates of drugs like antidepressants, sleeping pills and painkillers nonetheless generally increased in older people, previous studies have found. The new report captures one important fact; the rise in so-called poly-pharmacy — three drugs or more — is happening in primary care.

“I was stunned to see this, that despite all the talk about how poly-pharmacy is bad for older people, this rate has doubled,” said Dr. Dilip Jeste, a professor of psychiatry and neurosciences at the University of California, San Diego.

The research team, led by Dr. Donovan T. Maust of the University of Michigan and Dr. Mark Olfson of Columbia University, analyzed data from annual government surveys of office-based doctors. The team focused on office visits by people 65 or older that resulted in the prescribing of at least three of a list of psychiatric, sleep and pain medications like Risperidone, Valium, Prozac, OxyContin and Ambien. It found that the overall number of such visits increased to 3.68 million in 2013 from 1.5 million in 2004 — nearly a 150 percent increase, partly because the population is aging but mostly because of an increased percentage of prescribing multiple medications.

So what is the answer? It is very important an older adult have an advocate who is well versed in the dangers of poly-pharmacology and is aware of alternatives that are safer and effective. The RN Life Care Managers of Holistic Aging fit this profile and provide this service to any interested client.

Natural Ways to Treat Depression

There are a number of safe and effective ways to address anxiety and depression that do not involve drugs. Let’s take a look at a few natural methods to consider before reaching for and taking another pill.

1. Diet

Eat real organic food, as close to its original source as possible. Avoid all processed foods, sugar (particularly fructose), grains and genetically modified organisms (GMOs). Try eating a Gluten free diet as gluten has been directly linked to symptoms of depression. When you consume foods high in carbohydrates and sugars this leads to excessive insulin release. This starts a hypoglycemic cycle that can lend to agitation, anxiety, depression and panic attacks.

Reducing gut inflammation is imperative when addressing mental health issues. Increase consumption of traditionally fermented and cultured foods which can reduce gut inflammation, promote a healthy gut flora, and add healthy probiotics. Consume food such as sauerkraut, kefir, kimchi, and miso soup. New research from Lund University in Sweden has shown that certain types of intestinal bacteria can accelerate the development of Alzheimer’s disease. 

2. Get adequate Vitamin B12

Vitamin B-12 and other B vitamins play a role in producing brain chemicals that affect mood and other brain functions. Low levels of B-12 and other B vitamins such as vitamin B-6 and folate may be linked to depression.

When you get older, the lining of your stomach gradually loses its ability to produce hydrochloric acid. This acid releases vitamin B12 from your food. If you’re over 50, it’s safe to assume you are not absorbing vitamin B12 at an optimal level.

With the long term usage of Proton Pump inhibitors and other antacids 3/5^th of the population over the age of 50 is B12 deficient.

3. Optimize your Vitamin D levels

Vitamin D is very important for your mood. Your body actually makes most of its vitamin D from sunshine; vitamin D levels have been shown to be the lowest during the month of February for American’s. According to one recent study, seniors who have low vitamin D levels may double their risk of dementia and Alzheimer’s disease and were 11 times more prone to depression.

Check your Vitamin D level at least once a year.  You’ll want to be within the therapeutic range of 40 to 60 ng/mL (100 to 150 nmol/L) year-round. If you cannot get sufficient sun exposure to maintain this level, taking an oral vitamin D3 supplement would be advisable. Also increase your vitamin K2 and magnesium when taking oral vitamin D.

4. Mindfulness Meditation

We can’t control our emotions, and the more that we try to stop anxiety, or sadness, or fear from coming up, the more it comes up. Mindfulness is paying precise, nonjudgmental attention to the details of our experience as it arises and subsides, doesn’t reject anything. Instead of struggling to get away from experiences we find difficult, we practice being able to be with them. We begin to realize that our thoughts and emotions are not who we are, and from this observing stance, we begin to create space for these difficult experiences to be as they are, where they already are. The amazing thing is that often, once a person stops spending all their energy on fighting how they feel, and get clear on what they really want their life to stand for, they become free to do things that really matter to them.

5. Get adequate daily exercise

Most people agree there is strong correlation between mood and exercise. However, did you know that, exercise might be an acceptable substitute for antidepressants? See this study in Health Harvard .

Exercising creates new GABA-producing neurons that help induce a natural state of calm. It also boosts your levels of serotonin, dopamine and norepinephrine, which help buffer the effects of stress.

6. Get enough sleep

Evidence suggests that people with insomnia have a ten-fold risk of developing depression compared with those who sleep well. When you don’t get the 7-9 hours of quality sleep you need, it can heavily influence your outlook on life, energy level, motivation, and emotions. Here are some recommendations on getting a good night’s sleep.

7. Emotional Freedom Techniques (sometimes called Tapping)

Recent research has shown EFT significantly increases positive emotions, such as hope and enjoyment, and decreases negative emotional states. The basic premise is that the cause of all negative emotions is a disruption in the body’s energy system, which is the centerpiece of eastern medicine.  When the energy in our body is flowing normally, we feel great; when it becomes stagnant or obstructed, this causes disruptions along the energy meridians. That damage leads to negative or damaging emotions which can develop into physical symptoms.  Tapping with your fingers on meridian points corrects these imbalances. At the same time, tapping tunes into the underlying issue. When done properly, the emotional factors that contribute to the problem are typically released along with the energy blocks.

EFT is particularly powerful for treating stress and anxiety because it specifically targets your amygdala and hippocampus, parts of your brain that help you decide whether or not something is a threat.

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