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* Occasions of sexual abuse were discovered; Italy, Spain and Brazil. However, there is one very revealing * Incidents of physical abuse causing numerous injuries such as American study conducted over a 14-month period that evaluated fractured femur, hip, elbow, wrist and other injuries were 837 patients in a 100-bed subacute-care hospital for their nutri- reported. tional status. Only 8% of the patients were found to be well Dangerously understaffed nursing homes lead to neglect, nourished. Almost one-third (29%) were malnourished and abuse, overuse of medications and physical restraints. An almost two-thirds (63%) were at risk of malnutrition. The conse- exhaustive study of nurse-to-patient ratios in nursing homes was quences of this state of deficiency were that 25% of the malnour- mandated by Congress in 1990. The study was finally begun in ished patients required readmission to an acute-care hospital 1998 and took four years to be completed.'” compared to 11% of the well-nourished patients. The authors Commenting on the study, a spokesperson for the National concluded that malnutrition reached epidemic proportions in Citizens' Coalition for Nursing Home Reform, said: "They com- patients admitted to this sub-acute-care facility.'° piled two reports of three volumes each, thoroughly documenting Many studies conclude that physical restraints are an the number of hours of care residents must receive from nurses underreported and preventable cause of death. Whereas and nursing assistants to avoid painful, even dangerous, condi- administrators say they must use restraints to prevent falls, in fact tions such as bedsores and infections. Yet it took the Department these cause more injury and death because people naturally fight of Health and Human Services and Secretary Tommy Thompson against such imprisonment. Studies show that compared to no only four months to dismiss the report as 'insufficient'."'" restraints, the use of restraints carries a higher mortality rate and Bedsores occur three times more economic burden.'’”"'” Studies found that commonly in nursing homes than in acute physical restraints, including bedrails, are care or veterans’ hospitals.” But we know the cause of at least one in every 1,000 that bedsores can be prevented with proper nursing home deaths. '*"'? nursing care. It shouldn't take four years However, deaths caused by malnutrition, for someone to find out that proper care of dehydration and physical restraints are rarely bedsores requires proper staffing. In spite . recorded on death certificates. Several stud- of such urgent need in nursing homes where Several studies ies reveal that nearly half of the listed causes additional staff could solve s a f death on death certificates for old - ro ‘lems, we heat the familiar refrain, "Not reveal that nearly sons with chronic or multisystem disease enough research"—one that merely buys half of the listed are inaccurate.'* Even though one in five time for those in charge and relegates people dies in nursing homes, the autopsy another smouldering crisis to the causes of death on rate is only 0.8%.'* Thus, we have no way backburner. death certificates of knowing the true causes of death. Since many nursing home patients suffer from chronic, debilitating conditions, their assumed cause of death is often unquestioned by physicians. Some studies show that as many as 50% of deaths due to restraints, falls, suicide, homicide and choking in nursing homes may be covered up.'*'* It is quite possible that many nursing home deaths are attributed, instead, to heart disease, which until our report was the number one cause of death. In fact, researchers have found that heart dis- ease may be over-represented in the for older persons with chronic or multi-system disease are inaccurate. Overmedicating Seniors The CDC seems to be focusing on reducing the number of prescriptions to children, but a 2003 study found over- medication of US elderly. Dr Robert Epstein, chief medical officer of Medco Health Solutions, Inc. (a unit of Merck & Co.), conducted the study on drug trends.’? He found that seniors are going to multiple physicians and get- ting multiple prescriptions and using multiple pharmacies. Medco oversees drug benefit plans for more than 60 general population as a cause of death million Americans, including 6.3 mil- on death certificates by 7.9% to lion senior citizens who received more 24.3%. In the elderly, the over-reporting of heart disease as a than 160 million prescriptions. According to the study, the aver- cause of death is as much as twofold.'* age senior receives 25 prescriptions annually. In those 6.3 mil- When elucidating iatrogenesis in nursing homes, some critics lion seniors, a total of 7.9 million medication alerts were trig- have asked, "To what extent did these elderly people already gered—fewer than half that number, 3.4 million, were detected in have life-threatening diseases that led to their premature deaths 1999. About 2.2 million of those alerts indicated excessive anyway?" Our response is that if a loved one dies one day, one dosages unsuitable for senior citizens and about 2.4 million indi- week, one year, a decade or two decades prematurely, thanks to cated clinically inappropriate drugs for the elderly. some medical misadventure, that is still a premature, iatrogenic Reuters interviewed Kasey Thompson, director of the Center on death. In a legalistic sense perhaps more weight is placed on the Patient Safety at the American Society of Health System loss of many potential years compared to an additional few Pharmacists, who said: "There are serious and systemic problems weeks, but this attitude is not justified in an ethical or moral with poor continuity of care in the United States." He said this sense. study shows "the tip of the iceberg" of a national problem. The fact that there are very few statistics on malnutrition in According to Drug Benefit Trends, the average number of pre- acute-care hospitals and nursing homes shows the lack of con- scriptions dispensed per non-Medicare HMO member per year cern in this area. A survey of the literature turns up very few rose 5.6% from 1999 to 2000—from 7.1 to 7.5 prescriptions. American studies. Those that do appear are foreign studies in The average number dispensed for Medicare members increased reveal that nearly half of the listed multi-system disease are inaccurate. sense. The fact that there are very few statistics on malnutrition in acute-care hospitals and nursing homes shows the lack of con- cern in this area. A survey of the literature turns up very few American studies. Those that do appear are foreign studies in 28 = NEXUS Several studies causes of death on death certificates for older persons with chronic or www.nexusmagazine.com DECEMBER 2004 — JANUARY 2005