Blog – Coleen P. Kenny

As I posted last: Mom asked how (without being a nag) to get her fiance to take his medications correctly.

Medication noncompliance is a huge issue. Skipping blood pressure meds makes the doc thinks they don’t work so he increases the dose; next thing, someone’s fallen because their pressure is too low.

Or a woman skips her fluid pills some days: “I don’t want to spend all day in the ladies room.” Instead she spends a week in the hospital and six weeks in a nursing home because her heart failure got the best of her.

Noncompliance includes not taking medications; not finishing the full course; not taking the ordered frequency, such as every other day instead of daily; sharing medications with friends and neighbors; and taking over-the-counter (OTC) medications or supplements the doc or Nurse Practitioner advised avoiding.

Noncompliance in the elderly is magnified. Eyesight issues impact reading labels, and insulin needle markings are tiny so overdose is easy. Memory issues cause missed or duplicated doses. Changes in metabolism heighten side effects so someone stops their medication without telling the prescriber. Income and insurance coverage are limited so items aren’t filled. Multiple providers complicate the mix.

So how do we get folks to take their medications correctly?

1. Pill boxes are available with several time slots for a week. Family or a friend (or a hired person) can fill it once a week and check to make sure everything is used.
2. Automatic pill dispensers come with multiple options, including pulling the pill back if not taken within a certain time. Google search reveals multiple models, including http://www.epill.com/md2.html (I have no experience with nor do I endorse this model)
3. Alarms are available reminding people to take their pills, a good option if the person stays nearby and is able to hear.
4. Pre-filled insulin syringes can be requested, but insurance won’t usually cover them. Fill them ahead and tag them with day and time labels for your elder.
5. Discard expired meds and put inactive pill bottles in a plastic baggy out of sight. It’s too easy to grab the wrong bottle…
6. The elder can “brown bag” their meds for appointments (including over the counter and supplements!!) A family member or friend can keep a complete list of the medications in an electronic device such as a cell phone.
7. Be sure everyone knows everyone else who’s prescribing and make sure they’re sharing notes. Family members have handed me typed lists with all the providers and their phone numbers…very helpful!!
8. Get everything filled at the same pharmacy! People chase the $4 dream, but an alert pharmacist can catch interactions and call the prescriber before filling the script.

This is just a short list, but please let me know if you have questions or suggestions!

Okay, this heartstring, aka Golden Lasso, tethers me to Mom. Engaged this fall and getting married Valentine’s Day, she called to ask how to get her soon-to-be-spouse to take his meds without being a nag.

Turns out an astute pharmacist had called to say his refills were overdue. Almost Hubby (AH) told mom he doesn’t take his blood pressure pills everyday to save money. AH, aka Cradle Robber, is 16 years older than mom, and mom wants to keep him around a while. They have fun together. He treats her wonderfully.

He needs to take his meds.

So I asked what she’s done so far. She’s filled a pill box and put it by the coffee pot. She made a blue triangular note card reading “Take your pills!” that stands on the table when he sits to breakfast.

I told her it sounds like a great first plan.

Medication noncompliance is a huge issue in this nation, especially among the elderly and frail elderly. If one skips blood pressure meds, the doc thinks the meds don’t work and increases them; next thing you know, someone’s fallen because the pressure is too low on the new dose.

Or someone decides to take medicines some days and not others…”I don’t want to spend all day in the ladies room” is one I hear often with fluid pills. Instead she spends a week in the hospital and six weeks in a nursing home because her heart failure got the best of her.

Noncompliance includes not taking medications at all; not finishing medications (such as antibiotics) as ordered; not taking medications as ordered, like AH taking his every other day instead of daily; sharing medications with friends and neighbors; and taking over-the-counter (OTC) meds the doc or Nurse Practitioner advised avoiding.

Mom called a few days later with AH’s current lab results…his kidney function could be better…IF he would take his meds as ordered….

More on promoting compliance in the next segment, Sweet Readers!

A recent patient was a retired nurse; old school; she knew how things should be done. And as she got to feeling better, she would daily crook her index finger at me and motion me over.

“They need to wait for me to move; they shouldn’t rush me.”

“They need to tell me what these pills are for.”
She was right, and as her conditioned improved, she’d add, “I was a nurse, ya know. And that makes me a pain in the ass.” This became a daily exchange, always capped off with a devilish smile that lit her eyes.

One day last week though she wasn’t smiling. She stopped at the nursing station where I was charting. “Am I the only one here who can walk?”

I looked around. Indeed we had several patients in wheelchairs. I wondered if she remembered that was her starting point as well.

“You do get around better than most,” I said.

“That’s a shame. I wish there was something I could do.” Her smile was subdued and didn’t reach her eyes as she said, “See ya later, kid” and ambled on her walker to her room.

She’s still an old nurse, ya know…

“I’m so glad you’re here honey; something is wrong and I need you.”

A pull-me-down-to-bed-level hug followed these words. My 90 year old patient released me but held my arm, stroking it like she might comfort an infant. She fingered the lapel of my blue lab coat and told me how pretty it looked. She pointed to her mouth while saying, “I always loved your beautiful teeth.”

After five minutes of sitting on the edge of her bed, she told me, “I feel better now; I trust you.”

So why do I do it? Why do I take care of the frailest elderly? Isn’t it depressing, or boring?

My heart slips into my throat as I answer that question. In nursing school, the over-seventy set snagged me with a golden lasso of heartstrings that even Wonder Woman would be jealous of. When my brain says it’s time to change careers, God helps me change a life.

Whether it’s prescribing cold medicine, pain medicine, or even end-of-life medicine, I can’t imagine a different career path. I can’t imagine not being hit on the bottom by a grinning 80 year old who knew just where he was aiming that beach ball. Or not having known the silver-haired gentleman who wrote me a love poem, his words still framed on my kitchen table.
I really can’t imagine not having been there this morning when my patient thought I was someone from her past who had given her a sense of security.

I also love coaching the nurses and aides how to provide quality bedside care, and teaching the Nurse Practitioner students how to assess and safely prescribe for this frail population , and guiding families how to cope with the caregiving.

And best of all, who else out there gets told how young you look all day?

So remember, sweet Reader, I do this because I love these folks, and I’m here if you need me!
—Coleen

WOW! Gray’s Anatomy just began with a scene of two physicians debating end-of-life care… One opting for comfort care and morphine… the other accusing the first of “killing” the patient…

As a Nurse Practitioner who prescribes morphine for end of life care and the management of symptoms, I experienced a variety of feelings (responses):

Proud of “Gray’s Anatomy” for addressing a very tough issue; a very real world tough issue. Dying. and Death.

Proud of the job I do on a daily basis…educating and counseling patients and families and helping them work through these tough choices.

Proud of the nurses I work with who carry out the orders to keep the patients comfortable.

Proud of the Hospice staff who come into the nursing homes and provide “extra eyes and ears” so these folks are kept as comfortable as possible.

This is never an easy topic. And there are no easy answers. But when you, and/or your loved one, are ready to let go, I pray there will be compassionate and knowledgeable providers available to help you make those decisions.

And remember, I’m always here as well.

Speaker Training, post-lunch fatigue…Noel Gardner,MD, MDiv. from the University of Utah takes the stage. Thinning blonde hair, lanky, plain clothes; he’s left his daughter’s thirteenth birthday and his son’s championship b-ball game to speak to the speakers about Depression.

I wonder about his priorities, until he speaks with quiet passion about the disease.

Yes, Depression is a disease, a physical disease. As real as heart disease or lung disease; just as disabling but more disheartening in it’s lack of physical appearance to the outside world.

Dr. Gardner tells a half-hazy audience of a mentor who could evaluate a heart murmur with his ear instead of a stethoscope to a patient’s chest. He says as health care providers we should “learn to put our ears against the chests of our patients and listen to their hearts, to their heart stories, to the broken heart places inside.” Thinking about the 80 and 90 year old hearts I love and treat for pain and depression on a daily basis almost brought me to tears…

He points out that each patient with depression has a story that encompasses their past/present/medical/social/relational/spiritual/etc aspects. And each health care provider has a story–the chapters we bring to the patient through book learning and life experience. And even the molecules we prescribe have a backstory. Those of you who know my Storyteller side know this grabbed my attention …

He then describes the isolation of depression, quoting that we experience our joys with others but our misery tends to be solo. He explains the ripple effect of depression on every aspect of life–our appetite, activity, mood, sleep, sex drive, and our connection to God and others. And the impact is not just in the present but can run between generations.

But Dr Gardner believes, and I do also, that depression treated into remission creates its own ripple…and that if we can get folks to remission, we can impact everything in and around their lives.

There is hope. There is treatment. And it’s not all in the shape of a pill. I’m not talking about specific medications here, though they have their place, but if any of you may be suffering or know someone who is, read this blog carefully and contact your doc or Nurse Practitioner, or minister or a Social Worker… Because as Dr Gardner, the post-lunch-wake-em-all-up speaker concludes, after depression comes “a depth, a certain wisdom and power, a real compassion.”

And from newfound strength we can launch ripples of hope in all we say and do…

For more information about the symptoms of depression, check this link: http://www.webmd.com/depression/guide/detecting-depression

The FDA (Food and Drug Administration) issued a warning this past week about Maalox Total Relief… apparently people were buying it thinking it was their everyday Maalox, Turns out Maalox Total Relief contains bismuth subsalicylate (think Pepto-Bismol).

So what’s the big deal??

Well, people buying the product don’t realize it’s not their ordinary Maalox. They’re reaching for simple antacid relief but they are also getting a diarrhea med that can interact with drugs like Aspirin and increase the risk of bleeding in the stomach or intestine.

This ties closely into a Facebook friend’s post about insomnia. One of her friends suggested Benadryl.

So what’s the big deal??

Benadryl (the brand name for diphenhydramine and the “PM” in so many pain and cold medications) is an excellent medication if you have hives or a bad case of poison ivy or other type of allergic reaction. But the way it works to stop an allergy attack can also cause several side effects: dry mouth, low blood pressure, dizziness, constipation, urinary retention, and a hangover effect, to name a few.

These are bad enough if you’re young and healthy. Give them to an elderly person and you may see falls. You may see behavior issues from constipation or bladder infections. You may see what looks like depression or even dementia due to the hangover effect.

So when you’re picking something out to treat your indigestion or headache or cold symptoms, especially if you take other medications, consider running your choice by the store’s pharmacist or give the nurse in your doctor’s office or at your health insurance company a call—that’s what they’re there for!! And remember, just because you can get it without a prescription, doesn’t make it safe!

PS… What makes me an expert?? Thirteen years prescribing medications to ill and frail patients, not to mention the trouble I have, even as a Nurse Practitioner, in choosing my own cold medicine…. Be safe out there, and don’t forget to ask your doc or pharmacist, or of course, your Nurse Practitioner!!

My National Speaker’s Association meeting has fallen on Valentine’s weekend, leaving me time to reflect on the love-hate relationship of my life…

I’m talking about my on-again, off-again fling with Technology.

You see, Technology is like the BMOC (big man on campus), and I am the shy chick in the hiking club.

And Technology looks pretty good to me, especially with Valentine’s and Sadie Hawkin’s in the air, so I flirt.

I smile big on Facebook. I wiggle my brows on LinkedIn. I giggle on Twitter.

And Technology responds. Contacts increase. Events start moving.

But I get tired or bored or plain overwhelmed trying to keep up with T. I cut and paste my heart out and Technology whispers in my ear asking for more: “Wouldn’t a little Ping be fun tonight, Pumpkin?” or “How’s about you ‘n me Skype after supper tonight?”

I know that for any relationship to succeed I need to work my half of the deal, and I do try. I attend conferences to learn the latest and greatest and must haves and must do’s. Alas, Technology and I do not always see eye-to-eye… I don’t have the time to do and learn it all…

So I ask myself, What parts of this relationship am I willing to work on? What can I leave behind? and How can I make the most of the time I have to spend with Technology?

At day’s end, we stand in the doorway. I kiss Technology good night and step away.

“But can’t we blog just a little, Babe?”

Maybe tomorrow, Sweetie…

This week’s question has two parts:

Q1: My dad finally got out of trauma ICU after 13 days. He is slowly improving but can’t feed himself, eat, sit up or really anything by himself. Mom said he was talking about being released to a rehab hospital tomorrow–that sounds absurd! What can you tell me?

A: Once your dad is medically stable, the acute care hospital will move him out of as quickly as possible.

He will need strong rehab to get used to simply being upright again; are they getting him out of bed sitting in a chair? Even so, standing will make the blood pressure drop and make the person feel lousy until they readjust. Is the staff moving his limbs for him so they don’t tighten up? Is he in pain?

Will your mom get to look at places before they transfer him? If he’s going to a Sheltering Arms type hospital, that’s encouraging because it means they think he can tolerate therapy.

Q2: Pain-yes. And he is not sitting in a chair or his bed, nor is he standing. They are moving his limbs. The hospital hasn’t spoken with my mom about what rehab hospital to send him to…they are talking to dad, which for many reasons, is not a good idea. Mom is calling the hospital to get some answers- I told her to keep talking to people until she gets some answers.
Thanks Coleen, i really appreciate it

A2:
1. The staff must manage his pain or he’s not going to move

2. They need to start sitting him on the side of the bed to let his legs dangle… our bodies “forget” how to respond to gravity and the blood rushes to our legs instead of our brains and we fall over. It’s tougher on older folks because the sensors in the blood vessels are less sensitive and react more slowly. So they feel worse and are more likely to fall, but the only “cure” is advancing time upright.

3. Your mom and dad can ask the staff to put a note on the chart to make sure she’s present when they discuss the plan of care… (whether at the hospital or rehab hospital); providers sometimes move too fast and talk to the patient who may be with it enough to talk in the here and now, but not remember it later or make good decisions without help. And that’s not just older folks, that’s any of us.

4. Kudos to you and your mom for advocating and caring for him… I know this isn’t easy… available anytime if you need me!!

—Coleen

My soapbox led me to post on Facebook, “If you could ask a geriatric expert a healthcare question about your aging parent or grandparent, what would it be?”

This is the first question and answer in what I hope becomes a blog series useful to all those struggling…

Q: How do you get patients motivated to get up and move around without getting them upset?

My mom is having this problem with my grandma. When my mom tries to get her out of bed, my grandma gets upset with my mom and then it’s hurt feelings all around.

My grandma is 87 and used to doing everything herself so i am certain she has got to be struggling with having to depend on someone to take care of her. Her broken arm is healing well, but I’m sure she is stiff and achey just from being 87!

The staff at the rehab hospital don’t have any ideas, and they are going to discharge her in the next week or two, so this information is going to help my mom when she brings grandma home… and me when my parents need care!

Some ideas to make it less stressful for everyone would be great!

A: My answer is threefold for this complex and not unusual situation.

1. Is her pain managed?

You hit the nail on the head when you mentioned “stiff and achey just from being 87.” Her arm may be healing well, but generalized pain is often overlooked. The frail elder may be comfortable lying still in the bed, but try to move those stiff old muscles and bones, and it hurts. In the hospital, nursing home, or at home, we need to assess pain during movement and not just at rest!! Then one key is timing the pain medication 45-60 minutes before therapy or getting up for the day.
Pain management in the frail elderly is a complex topic, and I will discuss it in a future blog.

2.Depression must be treated!

Anyone in a hospital or rehab loses both function and control; add pain into the mix, and your grandma has every right to, and every likelihood of, a clinical depression.

This depression is not something you or your mom or the staff can pep talk her out of or hug away or tell her to get over, or as one of my patient’s sons did today tell her, “There are people a lot worse off than you.” (I almost kicked him in the shin!)

There are new excellent anti-depressants with fewer side effects than ever before available; I have three medications of choice with my LOLs (little old ladies) depending on other factors such as appetite and pain. Again, in the interest of blogging brevity, depression in the frail elderly is another day’s topic, but please note I do not use fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) in my frail elder patients.

3 Medical issues must be considered.

Is she uncomfortable due to constipation? Does she have a bladder infection? Is she dizzy when she gets up? Dizziness can be due to several issues but blood pressure should be checked lying, sitting, and standing (if standing is tolerated) and reported to the doc or Nurse Practitioner.

And finally, and yes, fourth-fold, sometimes the family member has to stop pushing. A dignity/control issue may develop with a “Who is the parent?” scenario. I acknowledge this becomes more difficult if your mom will be taking her home.

My thoughts and prayers are with my friend who sent this question, and with each of you reading this blog. Please pass it along if you find it useful, and be sure to comment and send me your questions!

—Coleen