Morphine Labeling

New Look

For many years now the most common concentration of oral morphine solution used in hospice has been 20 mg per mL.   Although the concentration is exactly the same, you may begin seeing different labeling.  It may now read 100 mg per 5 mL.

The Food and Drug Administration worked with Roxane, the largest manufacturer of oral morphine solution to change the labeling and the look of the product to reduce the possibility of errors.  The intent of this labeling is to help differentiate this product from another product with a concentration of 20 mg per 5 mL.

The volume of liquid is unchanged:

• 5 mg = 0.25 mL
• 10 mg = 0.5 mL
• 20 mg = 1 mL

Although the label prominently says 100 mg per 5 mL, you will also see (in smaller letters) 20 mg per mL. 

The new labeling may mean a little change in our mathematics, but remember that the concentration has not changed. 

If you have any questions about the concentration or labeling, call Pathways (1.888.755.7855) and we will be glad to double check your calculations with you. 

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

ALS: Amyotrophic Lateral Sclerosis

What is ALS?

Often called “Lou Gehrig’s Disease,” ALS is a degenerative disease of the nerve cells in the spine and brain.  As the neurons that connect the brain to muscles begin to die, the brain can no longer control muscle movement.  In later stages the patient may be totally paralyzed; for most, their minds are not affected.   

• About 5,600 cases are diagnosed annually; 60% are men, 93% are Caucasian
• Most people are between 40 and 70 years old

Early Symptoms

ALS may start with simple muscle stiffness and can differ a lot from one person to the next.  But 60% begin with muscle weakness.  A person may trip over carpet edges, have trouble lifting, or have slurred speech. They may drop things, have abnormally tired arms and legs, or even uncontrollable crying or laughing.

Later Symptoms

The rate of progression can vary, with an average survival time of 3 to 5 years, but many live 5, 10 or more years.  In a small number of people, ALS stops.  Later symptoms are:

• Muscle weakness in hands, arms, legs or muscles for speech
• Twitching and muscle cramping, especially in hands and feet
• “Thick” speech and difficulty speaking loudly
• Difficulty breathing and swallowing

End Stage ALS

Changes that may mean the death is nearing include a sense of breathlessness or the onset of a lower level of consciousness.   As respirations fail, the resident becomes less and less aware, then unconscious.   Nearly 60% of people with ALS have a sudden rapid decline and die within 24 hours.  Death also seems to happen most often at night when breathing naturally becomes slower and more shallow. 

Pain in ALS

Pain is common in later stages, probably from stiff joints, muscle cramps, or pressure on the skin and joints from immobility.  A combination of anti-inflammatory, anti-spastic and non-narcotic pain relievers may work until later stages when morphine often achieves the best pain relief.

Treating the Whole Person

Since the awareness and thinking usually remain intact, every effort should be made to continue communicating with the resident, even when he or she is too weak to speak.  This may mean using a communication board.

Knowing that death is near can lead an individual to seek resolution of “unfinished business.”  Hospice chaplains can provide spiritual support for the resident and reassure him that his family will have ongoing bereavement support.  Volunteers may supplement visits from family members.   Together we can support all the resident’s needs through the rest of his life.  Families will remember the end-of-life care you give for the rest of their lives.

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Cutting Down on Antipsychotics

Over-Prescribed

CMS, the Centers for Medicare & Medicaid, announced in May that they are embarking on a multi-year initiative to cut the use of antipsychotic drugs in skilled nursing facilities by 15% by the end of this year. CMS cited statistics showing that nearly 40% of residents with dementia were getting antipsychotics even though they did not have a diagnosis supporting their use.

Other statistics from CMS indicate that in 2010 more than 17% of SNF residents received antipsychotic doses that were over the recommended levels.

“In 2013 we will set another goal,’’ said Alice Bonner, director of the nursing home division of CMS. “At that point, we will be looking at even more significant reductions.’’

CMS plans to achieve the cuts through training state inspectors and nursing home staff on alternatives to using antipsychotics for agitation and aggressive behaviors.  Participation in the reduction program is voluntary, but SNF trade groups pledged to work with CMS.

“We believe these antipsychotics are overprescribed,’’ said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, a SNF trade group. “Many clinicians, physicians, and family members believe these medications are useful and necessary, but data show otherwise.’’

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Sundown Syndrome

Sun Sets, Confusion Rises

Sundowning is the term that refers to increased confusion and disorientation in the late afternoon and early evening.  As many as 20% of people with dementia experience sundown syndrome. 

This behavior usually is at its most severe during the middle stages of Alzheimer’s, becoming less as the disease progresses.  Some studies show that sundowning is associated with faster decline in the ability to think and with faster disease progression.

People who have sundown syndrome may have mood swings and may be suspicious, agitated, yelling, lashing out at caregivers, pacing more, and have tremors.  They may have difficulty sleeping, and wander more and “want to go home” as light fades and shadows appear.  They may also be aware of their own confusion which can frustrate them more.

Causes

Although the causes of sundown syndrome are not proven, many experts believe that in Alzheimer’s the changes to the brain affect the part that regulates our bodies’ rhythms of sleep and wakefulness—the cluster of nerve cells that keeps the body on a 24-hour clock. Other possible causes include:

• Mental and physical fatigue, making the resident less able to cope with stress
• Low lighting, increased shadows
• Discomfort due to pain, urinary tract infection, fecal impaction, etc.
• Medications
• Hunger
• Noisy sleeping environment
• Lack of organized evening activities
• Too much sleep during the day
• Change of shift activity with many people coming and going

Management

This is especially the time to apply basic techniques for dealing with people who have dementia:

• Reassure the resident in a calm way; tell them they will be all right and that they are in a safe place.
• Don’t argue with the resident or ask why they are confused.
• Try to find out if they have a need; are they cold, hungry, wet, in pain?
• Remove the resident to a calmer place, such as outside or his room—somewhere with fewer people and noises.
• Change caregivers if there is a chance that this is upsetting the resident.
• Reminisce with the resident about bedtime activities they followed with their children when they were young parents.

Consider alternative techniques such as: aromatherapy, a pet, calming sounds (bubbling brook, birds, wind in the trees), soothing food or warm milk, singing a favorite song or hymn, reading a familiar poem or children’s book, gently brushing hair, putting on a favorite movie, or massaging shoulders (only with the resident’s permission and in a common area). 

Prevention

Preventing problems is the best form of managing them.  These suggestions won’t work for every person, but persistence pays off if you keep trying:

• Maintain a consistent sleep schedule and daily routines; limit daytime sleep to short naps.
• Increase activity during the day including some physical activity such as walking or dancing.
• Monitor diet; avoid caffeine, or serve only in the morning.  Offer a light, bedtime snack.
• Let residents choose where they are most comfortable sleeping. 
• Consider the use of melatonin to promote sleep.
• Keep a dim light on at night and the room uncluttered.
• Have the resident occupied during shift change if this seems related to the sundowning.
• If sundowning occurs at a certain time every evening, plan for it.  Have the resident involved in an activity during this time.

Seek medical advice if other measures don’t work.  There may be medical conditions contributing to the sundowning.  The physician can also review the resident’s medications to check for drugs that can be eliminated.

Always keep in mind that this behavior is not done on purpose—the resident may be as baffled by it as you are.  But good planning can help prevent and manage sundown syndrome.

References: Mayo Clinic online; Web MD; Alzheimer’s Association, Care & Compliance Group.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

A Twist on Cultural Diversity

In the Bay Area, where diversity is the norm, caregivers often represent cultures from all over the world, while the residents they care for may be mostly white, Anglo-Americans whose only language is English.  Perhaps a look at Anglo-American culture will reveal ways to improve interactions between caregivers and residents.

In an ideal world, two people trying to communicate would each reach out to understand the other’s culture.  Realistically, residents may not be capable of learning about the caregiver’s culture to meet the caregiver halfway.  It defaults to the caregiver to bridge the gap.

Generalizations

Although no statement about someone in a particular culture holds true for all members of that culture, we can make useful generalizations that steer us in the right direction.  For example, Anglo-Americans tend to be:

• Time oriented and more rigid about times: 10:45 means exactly 10:45.
• Direct, with less socializing before getting down to business.
• Less formal, speaking and acting casually.
• In general, Anglo-Americans want to be pain-free and may not be as stoic as some other cultures.  They may ask for pain medication where a person from another culture might “tough it out.” 

Comfort zones

Anglo-Americans may be more open about discussing personal matters, illness, and dying than others. 

If a resident wants to talk about a subject that makes you uncomfortable, you may want to find someone else who might be able to interact with him more directly—perhaps someone from social services, a chaplain, or another caregiver.

Researchers have demonstrated that Anglo-Americans generally require a larger personal space around them—in other words, they don’t stand as close when talking as people of other cultures do.*  For instance, they may become uncomfortable and step back if they feel another person is standing too close.

Independence

Anglo-Americans as a whole tend to be more individually oriented and like control. They leave less to fate and want to direct their own lives. American law requiring informed consent is based on the principle of autonomy—freedom of choice for the individual.  In other cultures the family or physician may make decisions for a patient, whereas in the US the individual is considered more important to decision-making than the family. 

Many Anglo-Americans see themselves as having a pioneer spirit and prefer not to be dependent on their children for care or support, while in other cultures it is expected that older people will live with their adult children. 

Best practices

Whenever cultures differ there is plenty of room for misunderstandings.  Usually neither is right or wrong—just different.  The best practice for communicating smoothly is to ASK.  Ask family members or the resident about how things are done in their family.   People are usually grateful that you are asking and appreciate that you are trying to learn about how they like to do things.

*The New York Times, “In Certain Circles, Two Is a Crowd,” Nov. 16, 2006.

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.