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Mr. HOFFMAN. I just wanted to add that I think one of the problems is that the makeup of these teams, whether they are survey teams, inspection care teams, normally is limited to registered nurses. They are expected to some extent to pass on the care being provided by physicians. I don't think you will find many instances in which they will take exception to what the physicians are doing.

The CHAIRMAN. Dr. Grant, are the other gentlemen here supporting you or do they have independent statements to make?

Mr. Iffert, do you have anything you would like to say?
Mr. IFFERT. No, sir. I am with Dr. Grant.
The CHAIRMAN. Mr. Murphy.
Mr. MURPHY. No statement, sir.

The CHAIRMAN. Thank you all very much. This committee appreciates very much the constant support from GAO. You have helped us in so many areas. I remember one instance in respect to fire protection for the elderly. We had an occasion here when in two States within a few days of each other, 32 people died in fires and the GAO made a thorough study of that subject and found that there had never been multiple deaths in a nursing home or facility where there were sprinklers.

We don't own any stock in a sprinkler system but your organization found that if they had had sprinklers in both of those homes, those people would not have died. So we tried to get legislation through here and they promised us they were going to do it administratively in HEW.

That is the reason we didn't try to enact our proposed legislation. We proposed to lend money at long term and low interest to the institutions that needed to borrow money to put sprinkler systems in their institutions. I don't know whether HEW has ever done it or not. That is just another instance in which you helped us.

The CHAIRMAN. Ms. Oakar.
Ms. OAKAR. Thank you, Mr. Chairman.

I have made reference-I think you were here-to the fact that you talk a lot about nurses and pharmacies. I think you mentioned aides. But you really didn't make the distinction of those nurses who administer medications-even on page 4 you talk about making the information accessible to medication reviewers.

Are you using the term “nurse” to be all inclusive or not?

Dr. GRANT. No. We were confined to the requirements of the medication process and that requirement extends only to registered nurses and pharmacists. We recognize, of course, our nurse's aides have a function to perform but the review process is confined currently to pharmacists and registered nurses.

Ms. OAKAR. What about those who administer the drugs? Dr. GRANT. No question about the importance of their activity. That is not what we were looking at in this particular review.

Ms. OAKAR. I think that is all. I think it is an important study.

I would not want to give the impression that all nursing home operators operate under the kinds of dimensions we have heard. In your studies or through serendipity did you find people were often drugged; or not as often?

Were the majority of people in nursing homes overdrugged? Is this an indictment against the whole industry?

Dr. GRANT. No; I don't think so. I think it is important to point out that within a nursing home setting one would expect almost 100 percent of patients to have some kind of drug or other. It depends on what you mean by drugs or overdrugged. Almost all patients in nursing homes, bearing in mind their age and having one or more illnesses, are going to be on some kind of drug. If you are referring specifically to tranquilizers, we looked at that, as a matter of fact, and we really did not find that much that we felt we could positively point to.

But to say that patients in nursing homes will be on one or other kinds of drugs, certainly they will be. To say they are overdrugged, I guess it depends on what one means by overdrugged. If being on 23 drugs at one time, the answer would be yes, sir. But the answer depends on what are those drugs being given for. You may need to be on 10 drugs. In that case you wouldn't be overdrugged. It is not an easy question to answer is what I am trying to say.

Ms. OAKAR. Thank you.
The CHAIRMAN. Thank you very much.

Dr. Grant, and you, Mr. Hoffman, and Mr. Iffert and Mr. Murphy, we thank all of you for coming.

Now we have our last panel, Panel No. 3. Please come forward as I call your names, Dr. John Schlegel, assistant executive director, American Association of Colleges of Pharmacy. Dr. Schlegel has been involved in community pharmacy and has held teaching and administrative positions at the University of Southern California School of Pharmacy. Dr. Schlegel is accompanied by Dr. Peter Lamy, Ph. D., chairman, University of Maryland School of Pharmacy, Baltimore, Md.

Our second panel member is Dr. Richard Penna, director of professional affairs, American Pharmaceutical Association. His areas of involvement are in continuing education and credentials of pharmacists, health planning and development and implementation of policy and programs.

He is accompanied today by Mrs. Dena Cain, LL.B., director of public affairs, and Ms. Cyrelle Gerson, specialist in long-term care.

Our third panel member is Mr. Mark Abrams, director of the Society of Consultant Pharmacists. He serves as director of pharmaceutical services and is a consultant pharmacist for Retirement Living, Inc. He is accompanied by Mr. R. Tim Webster, executive director of the society, who is in charge of marketing systems of drug distribution in nursing homes and is involved in long-term care.

We are delighted to have all three of you present with us today.

Our time is growing short and I would ask you if possible to summarize your statements. Your statements will be included in their entirety in the record.

STATEMENT OF DR. JOHN SCHLEGEL, ASSISTANT EXECUTIVE DIRECTOR, AMERICAN ASSOCIATION OF COLLEGES OF PHARMACY, WASHINGTON, D.C.; ACCOMPANIED BY PETER LAMY, PH. D., CHAIRMAN, UNIVERSITY OF MARYLAND SCHOOL OF PHARMACY, BALTIMORE, MD.

Dr. SCHLEGEL. Mr. Chairman and other members of the Select Committee on Aging, I am John F. Schlegel, assistant executive director of the American Association of Colleges of Pharmacy, and on behalf of the association I would like to thank you for this opportunity to testify.

The American Association of Colleges of Pharmacy represents 5,500 full- and part-time faculty, and 30,000 students at 72 colleges-all committed to rational drug therapy. Many of our colleges have programs to train students in the drug therapy of the elderly, and many of our faculty have devoted years of their careers to the improvement of drug therapy for the elderly. Last year, AACP president, Melvin R. Gibson, appointed a task force on aging; this task force illustrates the association's ongoing commitment to the goals of rational drug therapy for the elderly.

With me today is the highly respected scholar Dr. Peter Lamy, chairman of this task force and chairman of the Department of Pharmacy Practice at the University of Maryland.

America is a drug-taking society. Between 5 and 7 percent of the U.S. health dollar goes to prescription drugs alone. Usage of drugs among the elderly is approximately double that of the general population. Utilization of an ever-growing variety of highly potent and potentially toxic drugs for a growing number of medical problems and complaints has contributed to an incidence of drug-induced disease and therapeutic misadventure that is unacceptable. Therapeutic misadventures can be caused by many factors. We will comment on three.

First, the aging process itself. Elderly patients are exposed to increased risk of the misuse of drugs primarily because they are elderly. As people age, the number of developing chronic medical conditions and disabilities increases. The aging process causes decreased or impaired kidney function, muscle activity, heart function, digestion and metabolism, psychomotor function, and weakened immune and nervous systems.

Nearly two-thirds of the residents in nursing homes have three or more chronic medical conditions, most of which are managed through the use of drugs. In general, the greater the number of chronic conditions, the greater the number of drugs.

Second, inadequate medical supervision. Residents in nursing homes seldom see physicians. Federal regulations only require physicians to see nursing home patients once a month. In most nursing homes there is minimal staffing and the more highly trained professionals pursue administrative duties, while the least trained staff are most involved in patient care. The patient is often sacrificed to drugs—a quiet patient is a good patient.

Third, irrational drug therapy. When the conditions of multiple diseases and insufficient medical supervision are combined, the result is often irrational drug therapy. Irrational drug therapy has many faces-all can be frightening; some can be fatal.

Insufficient drug regimen review represents one problem. Patients can be left months or longer taking potent drugs because there is often no formalized process to evaluate the need to continue the use of a specific drug-25 percent of all nursing homes have no automatic stop order procedures. Over one-half of the very potent psychoactive drugs are prescribed on a PRN, or as needed, basis.

What's more, up to 25 percent of the medications taken by institutionalized elderly patients may be ineffective or unneeded. This abuse and misuse of drugs clearly diminishes the quality of life for the elderly.

Drug interactions and adverse drug reactions threaten all patients, but are particularly acute in the nursing home setting, where large numbers of drugs are used. Studies have shown that nearly one-quarter of nursing home residents receive medications with a potential for interaction.

The nutritional state of the elderly patient is particularly influenced by long-term drug therapies and the taking of multiple drugs. This problem may be exacerbated because many older citizens are already suffering from subclinical nutritional deficiencies.

The elderly often have an altered response to medications. Usual dosages of such drugs as the diuretics, antihypertensives, and the psychoactives, are frequently inappropriate for the elderly. Druginduced symptoms are often interpreted as common conditions of the aging process—such as confusion, incontinence, dizziness, and anorexia-and these symptoms are frequently treated with other drugs.

Irrational drug therapy has many faces-an overmedicated patient, a patient who is not receiving the drug needed to combat a disease, more frequent hospitalization and longer hospital stays, increased cost, and generally lower quality of life.

There is no solution to the problem without pharmacy whether that means employing the third largest health profession, the Nation's 130,000 pharmacists, or retraining physicians and other providers to have pharmacy skills. Contrary to the belief of some, pharmacy education has changed from emphasizing drug products to emphasizing the application of drug and disease knowledge to patient care.

Four contemporary pharmacy concepts play a critical role in reducing the problems of drug use in the elderly: drug utilization review, increased patient monitoring, patient education, and direct consumer education.

If we wish to reduce the number of drug interactions, drug duplication, medication errors, and costs, we need drug utilization review by pharmacists.

Increased ongoing patient monitoring by pharmacists allows detection of adverse drug reactions, unnecessary or unwarranted medications, drug-induced symptoms, over or underutilization of medications, excessive duration of drug therapy, or withholding of an appropriate drug of choice for therapy.

Patients have a right and responsibility to understand and be involved in their care. Pharmacists are uniquely qualified to counsel patients about their own therapies, nonprescription drugs, prescription drugs, home remedies, alternatives or supplements to drug use, diet-drug interactions, and the do's and don'ts of drug use. Increasingly, pharmacists are being trained to communicate with the elderly, who may have impaired hearing and vision, a confused state of mind, and reluctance to report symptoms.

An increasing number of pharmacists are participating in direct consumer education about the wise use of drugs at eating together places, churches, senior citizen apartments, and similar places.

We have described some problems and have demonstrated the ability to respond. The responsibility now rests with the Congress to create legislation to implement the solutions we have outlined. Given the authority and incentives, pharmacy will respond. In the design of future legislation, we urge the Congress to consider the following legislative objectives:

One, mandate review and monitoring procedures to address the many drug-related problems the elderly encounter, and provide the economic and professional incentives for implementation.

Two, provide adequate funds for research to increase the body of scientific knowledge related to drug use in the elderly.

Three, support educational programs to bring this new knowledge to the Nation's health students and practitioners, and to consumers.

This concludes my portion of the testimony, Mr. Chairman.

Dr. Lamy, a respected researcher and author in the field of geriatrics, will now present case histories that I think the committee will find most interesting.

The CHAIRMAN. Very good.
Dr. Lamy.

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STATEMENT OF DR. PETER LAMY Dr. LAmy. The first is about a 72-year-old woman, suffering from Parkinsonism. She was treated with L-dopa, one of the few drugs available for this disease. However, the drug has certain side effects, which occurred in this patient. The side effects were treated with another drug, which also has a side effect, called an anticholinergic effect. The patient was restless and suffered from sleep interruptions, which were treated with still another drug. Unfortunately, this drug, too, had an anticholinergic effect.

To make matters worse, a cold was treated with a non-prescription drug, having the same side effect as the other three. A crisis stage was reached-and the patient developed a drug-induced psychosis. Anybody familiar with the side effects could have predicted this or recognized this. In this particular case, the psychosis was considered a new disease, and was treated with an antipsychotic drug. In fact, the previous drugs should have been withdrawn. A pharmacist's intervention would have prevented this unnecessary Occurrence.

The second case deals with digoxin, one of the most frequently used drugs for the elderly. It is used for congestive heart failure, to increase and strengthen the pumping action of the heart, and it is also used to treat irregular heartbeats.

It is a very difficult drug to use, and 20 to 30 percent of the elderly receiving it suffer from digoxin toxicity. Yet the literature points out that 60 to 80 percent of the elderly receiving digoxin probably do not need to continue taking it. A case in point is a 78year-old, white female with congestive heart failure and reduced kidney function. Suffering from congestive heart failure, she was treated with digoxin and a diuretic. She then developed irregular heartbeat, which is a side effect of digoxin, and to treat this, the prescriber increased the dose of digoxin.

What the prescriber did not recognize is that the irregular heartbeat came from an overdose of digoxin. Therefore, the digoxin

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