An innovative study in JAMA Internal Medicine on surrogate decision making has profound implications for how we take care of older hospitalized patients.  The study, by Lexy Torke and colleagues at Indiana University, systematically described the involvement of surrogates in decision making for hospitalized patients. Surrogate decision making refers to the phenomenon in which someone other than the patient is making or helping to make the key medical decisions.  In older ...

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Consider this scenario. You are getting older, and are concerned about the costs of nursing homes and long term care.  So, you decide to get expensive long term care insurance to protect your family from these costs.  The policy will pay some of the cost of long term care if you develop cognitive or physical disability.  All you have to do is keep making payments on the policy until you have ...

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Cancer screening is of little benefit in persons with dementia but can cause very serious harms.   Older persons with dementia have limited life expectancies which makes any benefit from cancer screening very unlikely.  This is because cancer screening works by identifying a cancer many years (generally at least 5-10 years) before it would threaten health. But cancer screening tests cause lots of burdens when given to persons with dementia.  The ...

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nursing_home_abuse Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure ...

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Many older patients fall in the hospital and these falls often lead to injury.  Hospitals are under a lot of pressure to reduce falls.   Generally, these falls happen when patients transfer such as when an older person tries to get out of bed or get up from a chair.   While hospitalized, many patients are weak, dizzy, or confused, and they can be at risk of falling when ambulating ...

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Many clinical decisions in older persons are dependent on life expectancy. For example, as life expectancy declines, cancer screening is likely to do more harm than good. Also, persons who have limited life expectancy may want to plan, discuss their values, and consider palliative care approaches of care in addition to care focused on living as long as possible. But can one actually predict life expectancy accurately in an individual patient? ...

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Quality indicators are used to measure the quality of health care delivered to patients. Quality indicators are used extensively in the VA health system, and efforts are underway in Medicare to tie reimbursement levels to performance on quality indicators. The motivations for using quality indicators are guided by the best of intentions. There are many problems with the quality of health care in the US, and quality indicators aim to improve ...

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I sometimes wonder if we spend too much time talking about professionalism. It is not that I don't think we should promote professionalism. Of course we should. But many discussions of professionalism descend into overly academic and scholarly treatises that end up obscuring rather than clarifying the values such discussions hope to promote. It may be a mistake to overly ...

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Generally, Alzheimer’s disease is diagnosed only after patients have progressed to major levels of cognitive impairment that results in substantial problems in daily functioning. But the brain changes that result in cognitive impairment start years, if not decades, before patients become symptomatic. So, wouldn’t it make sense to try to diagnose Alzheimer’s Disease in patients who have the brain changes, before they have clinical symptoms? The answer would be yes if ...

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There is a lot of focus on what elders with dementia can't do. But what about more discussion of what they can do? When you see a patient with dementia, how do you help family members maintain meaningful interactions with their loved ones? I am sad to admit that I don't do this nearly as well as I should. After all, this is not the type of thing we are taught ...

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In 1927, Francis Peabody remarked that, "The secret of the care of the patient is in caring for the patient." Medicine has made much progress since those days, but some might argue that some of the humanitarian cornerstones of caring that concerned Peabody have been lost. Of course, there are many health professionals that still embody this caring ethic. And in today's era, perhaps the group that best personifies this central ...

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Long term care is a hot topic. When people talk about long term care, they are generally talking about nursing homes. Policy makers put a lot of attention on nursing homes because they cost so much money. About half of nursing home care is paid out of public dollars. In California, in the setting of our state budget fiasco, the high cost of nursing home care to the state has ...

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