Managing Seasonal Allergies

What We Dont Know We Dont Know in Health Care: September 24, 2024 -Oral Care, Monitored Meals, and Aspiration PneumoniaProper oral care is crucial for maintaining optimal health. Keeping the mouth clean not only helps maintain the protective properties of saliva but also reduces bacteria in the mouth which can be a source of infection in aspiration pneumonia. In addition, monitoring meals and assisting with feeding for those at high risk for aspiration is also a necessity. The process of swallowing involves dozens of muscles that start in the mouth and include the pharynx, larynx, and esophagus. These muscles can become weakened with age and from various, often age-related diseases.  The aging population is especially at risk for aspiration pneumonia due to comorbidities, frailty, and conditions that can impair swallowing.  As a result, aspiration pneumonia is one of the leading causes of death from infection in individuals over the age of 65. One study shows that 1 in 10 deaths from pneumonia in elderly nursing home residents may be prevented by improving oral hygiene (Sjogren et al., 2008). Unfortunately, proper oral care and monitoring of meals is often overlooked in the health care setting.  Perhaps the greatest reason for this is the challenge that almost every health facility faces today: adequate staffing. When I started working in acute care as an RN over 20 years ago, nursing assistants (these are the staff generally responsible for proving oral care in an acute care setting) were typically responsible for 5-7 patients. Nurses had 3-5 patients (this was on a step down cardiac unit). Between the nurse and the assistant, we were able to provide oral care at every meal and offer one-on-one assistance to any patient that was at risk for aspiration. This is no longer the case.  RNs oftentimes look after upwards of 8 patients, and there is generally either no nursing assistant on the floor or only 1 for a patient load that can exceed 20.  Consequently, proper oral care is neglected.  I have often seen patients that are aspirating during meals, but do not have adequate staffing on hand to provide them with the supervision and monitoring that they need. This presents a hazardous catch-22: the aging individual needs to eat to maintain nutritional needs yet he/she needs assistance with eating to prevent aspirating pneumonia.   How can this be remedied? If the family is present, they can provide oral care and meal monitoring. If meal monitoring is required for an at-risk individual, its recommended to touch base with the health care team to inquire as to what the specific aspiration precautions are (every individual may have a different need and/or recommendation). A care companion can also be hired to provide the needed care. I hired a companion for my father when he was in a skilled nursing facility. He was not getting his teeth brushed or flossed regularly, and I was seeing a decline in his dentition. Having this extra support provided him with much needed assistance and the care companion had the added benefit of encouraging him to eat more at every meal, something that was a bonus as he was not meeting his nutrient needs. Touching base with staff to request that oral care and meal monitoring be done can also be helpful. Having an advocate to ensure necessary care is getting done can also be very effective in the health care setting.  What is proper oral care and effective meal monitoring?  Proper oral care includes brushing the teeth for at least 1 minute after every meal. It also includes using a soft bristle brush, fluoride toothpaste, flossing daily. A final component of oral care that is often not discussed is denture care. Dentures should be cleaned at least once per day and removed at bedtime. Removing them prior to sleeping can greatly reduce the risk of pneumonia (Iinuma et al. 2014). Effective meal monitoring includes adequate supervision during mealtime for those at risk of aspiration. Such supervision includes ensuring the individual is properly positioned for a meal (head of bed as high as can be tolerated and supine position), takes small bites, eats slowly, swallows a couple times in between each bite, and intermittently takes a sip of liquid to clear the mouth of food particles. The use of straws is generally not recommended for an individual at risk for aspiration as it propels the food to the back of the throat and hence can increase risk. I recall when I was working as a Registered Nurse (RN) in acute care that I was constantly removing straws from the bedside of at risk individuals and often reminding them to eat slowly and swallow at least twice between each bite to ensure food clearance. Individuals at risk for aspiration often require a modified texture diet as it can further prevent the aspiration of food and liquids.   This is a brief summary of the attention to detail needed in addressing oral hygiene and meal monitoring amongst the aging population. Both measures can play a significant role in reducing aspiration pneumonia.  If you would like more information on understanding proper oral care or any other questions that you may have regarding aging life care, please feel free to reach out to me.    Sources:1.      Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. 2008. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc. 56:21242130. 2.      Iinuma T, Arai Y, Abe Y, Takayama M, Fukumoto M, Fukui Y, et al. 2014. Denture wearing during sleep doubles the risk of pneumonia in the very elderly. J Dent Res. doi: 10.1177/0022034514552493 3.      F Muller, 2015. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541086/#   

The typical person in their later sixties and older takes several medications for chronic conditions. These may be drugs to regulate blood sugar, thyroid, blood pressure, cholesterol, allergies, mood, or any of hundreds of other mild-to-serious conditions. Your comprehensive blood panel is your and your doctor's way of monitoring the effect of the drugs prescribed, as well as whether they're working or not or if they may be interacting with one another. And, besides, you're changing. How do we know you're changing? You're aging. Your liver and kidneys break down and eliminate drugs from your body, and your liver and kidneys are aging. You may lose muscle and gain fat, affecting how drugs work. All of this can complicate the effectiveness of meds and, especially important, create harmful side effects. So, consider these medication tips  after you see your doctor. 1. Take Medicine as Prescribed with Regular Discussions with Your Health Care Provider On that all-important visit with your doctor, be involved. The doctor or nurse should ask you if your meds have changed or if you've stopped or started either prescribed medicine or over-the-counter drugs or supplements. They all count! If you're taking something prescribed by another doctor that's not on your primary's list speak up. Take only prescription meds your health care provider has prescribed. None of this, "Here, try one of mine" from your golf partner. Taking someone else's medicine can be very dangerous. This is particularly true of pain medication, which could worsen your condition or cause addiction. You probably know opioids are highly addictive but are not the only ones. The interaction of drugs is unpredictable. Your doctor has the proper outlook on your entire series of medications. Please don't stop taking or skip prescribed medications because you think you don't need them anymore, feel they've stopped working, or think they're causing a side effect. Consult your doctor about any side effects. Take side effects seriously. In the United States, 125,000 people die annually from incorrectly taking their medications! Talk to your pharmacist or health care provider about ways to help you take the proper dosage on time every time. It's typical to forget to take your meds. But it's not okay. Many antibiotics must be taken after the infection stops or after you stop feeling the symptom. Hence the instructions to take every dose until they're gone. If you're a family member or caregiver reading this, please provide the person under your care with prefilled pillboxes and automated reminders attached to pill bottles, or subscribe to a pill packaging service that sorts, packages, and delivers by individual dose. 2. Store Your Meds Safely and Keep Current Keep all medicine up and away from children, wherever you store them. Around 10,000 children are accidentally poisoned by prescription meds every year, and a child dies every 12 days from such poisoning. If you have questions about safely storing your medicines, contact your pharmacist or health care provider.Store meds in a safe, cool, dry place. A high drawer reserved for medications in a dresser or cabinet is good. Be careful that meds that need to be cooled are stored in the fridge, but give them a shelf where children can't reach them. There will be storage instructions on the bottle. Due to fluctuating heat and humidity, a bathroom medicine cabinet may be the worst place. Even if meds are not expired, improper storage can render them ineffective or unsafe.Remember we talked about how you're changing as you age? So is your medication. If you have an old bottle of aspirin that's been haunting the top shelf of a kitchen cabinet for a couple of decades, don't use it. Some meds lose their effectiveness, but others can degrade into toxicity. Check the expiration dates. There are proper ways to dispose of unused medications. Throwing them in the trash is not one of them. Discarded drugs can end up in the water supply and may be eaten by wildlife or pets. See any disposal instructions that may be on the side of the bottle. Many pharmacies have disposal sites where you can drop the old drugs. You can search for "medication disposal sites" or see the FDA's webpage that instructs you on the options of disposing of meds.3. Be Aware of Potential Medication Interactions and Side Effects, Even Unexpected InteractionsGrapefruit juice is always good for you. Here's something you may need to learn about grapefruit juice. The grapefruit has these beneficial enzymes that naturally protect it from the effects of insects and other harmful stressors. Unfortunately, these same enzymes inhibit the breakdown of certain medications in the human stomach, making some drugs ineffective or even toxic. So, what's good for the grapefruit is only sometimes suitable for the patient. Don't let this stop you from enjoying your morning grapefruit. Ask your doctor because this has been studied, and there's a list of drugs more likely to interact. And we only bring this up to illustrate how seemingly harmless or good-for-you foods and supplements can seriously interact with your medication. Ask your doctor about any potential adverse interactions.Prescription drugs can affect each other dramatically. For example, nitroglycerin, which treats angina, should not be taken with many erectile dysfunction medications, including Viagra and Cialis, because serious interactions can occur. Your pharmacist can also advise you about potential medication interactions and side effects.You may also have a medical condition that makes a particular medication risky. Again, your healthcare provider armed with your health record, a physical exam, and blood work is the best call here. Even herbal supplements you get off the shelf at the grocery store, though you're free to take them without a prescription, can interact. It may surprise you, but 40 percent of the drugs behind the pharmacist's counter are derived from plants used as natural remedies since ancient times. Grapefruit juice is used to prevent gout attacks, for example. Go figure. So, supplements are drugs, too, and they deserve the same caution as prescription meds when mixed with others.Not surprisingly, alcohol is a common offender. The NIH warns that "mixing alcohol with certain medications can cause nausea and vomiting, headaches, drowsiness, fainting, or loss of coordination. It also can put you at risk for internal bleeding, heart problems, and difficulties in breathing." In other words, alcohol, whether it has sedative or stimulant effects on any person, should be considered a drug when taking other medication. If you're experiencing something you suspect is a medical condition, such as memory loss or difficulty, dizziness, or sleepiness, particularly for seniors, the medication may mimic the symptoms. Before you skip or stop taking the meds, consult your doctor. Ask your healthcare provider if any new health problems you are experiencing could be due to your medications at your regular physical. 4. Keep a Medication List There are many good reasons to keep a list of your current medications besides remembering which ones you're taking. Making a list is an excellent excuse to go through your cabinet or drawer and collect all your medicines. You can check duplicates and expired prescriptions (Don't mix expired medications with new ones!), find out if you need to take one you've forgotten about, and add any non-prescription medicine or supplements (including vitamins) you need to update your doctor on.Keep the list with you. And keep it current. Give a copy to a friend or relative for sure your emergency medical contact person in case of emergency and when you're traveling. Note any medicines you're allergic to or have had bad reactions to. Wear a medical alert bracelet for severe medicine needs (like insulin) or allergies. Store your medication list on your cell phone in a notepad app. If you're fortunate enough to have a healthcare provider who has your prescription record online, this can save you a lot of headaches when filling out medical forms even at the dentist. These forms almost always ask for the dosage, too, so those should be included. A medication list should include the following:Your prescription medicine's brand name or generic name.Over-the-counter medication, herbal preparations, and supplements that you take regularly or on occasion.Condition you're treating with the medication.The dosage (for instance, 300 mg).How often do you take it?Anything you're allergic or reactive to.The phone number of your pharmacy.Most people see more than one provider. Even if they don't ask, share your list with each provider and ensure it's updated at each visit. It's okay to suggest it to your provider, and it's essential, and it would be worth scheduling an annual review of medications with your primary care physician.Some meds are expensive, and sometimes there are generic alternatives. It also matters which insurance you use and where the pharmacy might get the medicine. These days, a good pharmacy can check the price of drugs from one provider or another. Using prescription discount cards (they're free) also can get you a surprising discount sometimes. Ask your healthcare provider if there is a less expensive, effective alternative.Also, tell your doctor if the medication doesn't work. If you're taking pain medication, it should lessen the pain. It could be a simple fix. New drugs are being developed all the time. Your primary physician is the one to ask. They may say it's safe to try it. Before you try a new brand-name pharmaceutical, you know the price. A drug that costs two dollars in its generic form may be $600 in its brand version.

   If you are satisfied with the clinicians at your primary care office, cherish those relationships.  For many reasons, it is getting more difficult to find primary care clinicians who go the extra mile for you and your loved ones.  If you are not content with your primary care team, I offer the following suggestions.    First, find a clinician (physician, nurse practitioner, or physician assistant) who enjoys listening to you and your stories.  The art of medicine is mostly about the art of listening.and believing what you share.  Listening and understanding build trust, essential for any good relationship.  Every city and small town in our country has such clinicians.     Second, appreciate that young nurse practitioners and physician assistants can listen to you and help sort out your problems every bit as well as a seasoned physician who is overworked and/or approaching retirement.  In my 40 + year career, Ive had the opportunity to train hundreds of NPs and PAs.  They gain the knowledge, expertise, and confidence to become great providers within 9-12 months of graduating from professional schools.  Often, they have more technical skills than older physicians.  This works to your advantage in the following ways.  Assume you have an unusual combination of symptoms.  They know how to explore the Internet and rely on specialists to find the best plan of care for you.  Now assume you need a steroid injection in a joint.  Many NPs and PAs can provide procedures that overworked physicians never learned.     Third, see the entire practice as your primary care provider.  A good practice has all members working together as a team.  The members include front office staff who greet you for in-person visits, medical assistants and nurses who answer your phone calls, and the clinicians who care for you in person or with tele-health visits.  If you find that any team member isnt respectful, you should feel free to discuss this with the office manager.  All good practices should welcome feedback.      Fourth, if you have the means and value extra attention, consider a concierge practice.  Unfortunately, concierge physicians are beyond the reach of the vast majority of seniors in our country.  Further, we are seeing a shortage of these physicians just as we are seeing a shortage of all primary care physicians.  This brings us back to my key message: you can find trust and comfort with a dedicated NP or PA.  When we consider the evolution of geriatric practice over the last 4 decades, we understand that it is NPs and PAs providing the vast majority of visits in nursing homes, assisted living facilities, and in-home visits.Finally, it is important to understand the pressure and demands on your primary care office.  The advent of the electronic health records in the 1990s added a massive burden to all practices.  The hope (and the myth) was that EHRs would lead to higher quality medical care.  The reality is that EHRs havent improved true quality.  EHRs are the main reason so many good clinicians are feeling burned out.  The clinicians feel they have to pay more attention to the EHR (and quality metrics) than to the patient in front of them.  When you express your understanding of this dilemma to your clinical team, they greatly appreciate this.  Again, building understanding and trust leads to the best quality of care and beneficial outcomes. The article was written by Dr. Don Murphy, Geriatrician and Hospice Physician who plans to run for Governor of Colorado, on behalf of. He can be reached at murphdoc@comcast.net, his cell, 720-490-6757, or his main YouTube channel, TheCrazyMurphys5560.