If you have an elderly parent or grandparent you should take time now to familiarize yourself with the causes of aspiration and its signs and symptoms. When a patient aspirates, food, drink or even saliva that should be channeled from the mouth into the stomach instead gets channeled into the lungs, causing a pneumonia in the lungs. Aspiration is usually, but not always, a life threatening situation, compromising the person’s ability to breathe on their own.

When my Dad landed in the hospital in 2002, after having a fall at home and breaking his hip, I had heard of aspiration, but that was the furthest thing from my mind. After all, how could a broken bone lead to aspiration? My Dad was aging amazingly well – he was mentally and physically intact, sharp as a tact, with normal blood pressure and no health troubles other than a bad back. My main concern was that the hip surgery go well, which it did. Without a hitch in fact.

The night before he was to be discharged from the hospital, I visited him at night after work. We were looking forward to the next day, when he would be discharged to a rehab center for physical therapy, and after that, to go home. He had already eaten dinner when I arrived at 8 pm. He had told me that earlier that day he had become confused and thought that the furniture was flying around the hospital room, and realized that it must be the pain medication. I noticed that he was wheezing off and on -- something he had never done before. Dad said that the wheezing had started just before I arrived. I asked the nurse what that meant, and she said that he “might just have a little congestion.” I asked her to ask the doctor about it and get back to me. Other than the intermittent wheezing, Dad seemed fine, so I left at 11 pm without having heard back from the doctor.

The hospital called me at 2 a.m. and said that my Dad was transferred to the ICU. I rushed to the hospital and was told that he had aspiration pneumonia -– most likely caused by aspirating his dinner the night before. That’s what that wheezing meant. When I spoke to Dad’s doctor, he said that most likely the pain medication Dad was on for the hip fracture (the Oxycontin and Vicodin) interfered with his swallow mechanism, causing the food Dad ate at dinner to go down his windpipe instead of into his stomach.

My Dad never regained consciousness, and within 48 hours he was dead from complications of the aspiration.

There are many other unlikely causes of aspiration. For example, patients who became malnourished are at risk of aspirating. Safe swallowing depends on working swallowing muscles, and drastic weight loss diminishes the swallowing muscles’ ability to function properly. A malnourished elderly patient can be at risk for aspirating simply because their swallow muscle has atrophied due to malnutrition. Because malnutrition is so prevalent in nursing home residents (for many reasons, most of which are preventable), that's one reason why nursing home residents are vulnerable to aspirating in a nursing home.

The New York Times New Old Age Blog has just posted an article on swallowing disorders, When The Meal Won't Go Down. It is an excellent introduction to swallowing issues in the elderly and will refer you to other resources on the web, such as the American Speech-Language-Hearing Association website.

Felicia Curran
www.ElderAdvocacyLaw.com

After Keith Olbermann’s (CountDown With Keith Olbermann, on MSNBC) Dad went in the hospital, Keith and his family dealt up close and personal with end of life issues. Keith is passionate about everything he cares about, and that applies to the issue of living wills a.k.a. advanced directives, legal documents which state your wishes regarding end of life care issues and which control the type and level of care you receive.

Family members who are forced to make such decisions for their loved ones in the crisis of the moment, after their loved one is in the hospital, often feel terribly conflicted –-Are they putting their loved one through unnecessary pain and suffering at the end of life, with no real chance of meaningful recovery, or Are they giving up too easily, when their loved one might be able to pull through and return to a good quality of life? Once your loved one lands in the hospital, they may not be able to tell you their wishes. By having the discussion in advance of hospitalization, you will give yourself some peace of mind that you know your loved one’s wishes, and you will be confident of making the decisions they would want for themselves.

Click on the youtube link below to hear Keith’s impassioned pitch for discussing end of life issues with your family and formulating a living will expressing your wishes.



Although most states including California recognize living wills or advanced directives, the requirements vary from state to state. To see what the options are in your state, check out this article from Findlaw:

http://estate.findlaw.com/estate-planni ... wills.html

Felicia Curran
www.ElderAdvocacyLaw.com

New York Times health columnist Jane Brody, pictured here, has done a series of articles recently that you should read if you’re concerned about preventing osteoporosis. One of Brody's articles in particular, "Exploring a Low-Acid Diet For Bone Health" is a must read, because of studies it describes showing that eating vegetables can maintain healthy bones. Bet your doctor never told you to eat vegetables to prevent osteoporosis, did they? Read on.

Brody’s article starts off from 2 surprising facts: 1) Osteoporotic fractures are rare in Asian countries such as Japan, even though the Japanese eat almost no calcium-rich dairy products and 2) Countries such as the U.S. which consume the most dairy products have the highest rates of osteoporotic fractures. The Japanese, it turns out, have better bone health than we do, eating little dairy products. How could that be?

As Brody explains it, it has to do with the fact that the large amounts of meat we typically eat in the United Staes actually deplete the calcium reserves in our bones. She explains that our bones are the “storage tank" for calcium compounds that regulate the acid-[alkaline] balance of the blood. When the blood becomes even slightly too acid, alkaline calcium compounds are leached from our bones to reduce the acidity of the blood. Some foods speed up the leaching process because they metabolize in the stomach to acid by-products in the blood. Other types of foods metabolize to alkaline by-products, which protect bone health. Thus if we eat too much acid-forming foods, and not enough alkaline-forming foods, our body will withdraw calcium from our bones to restore the correct acid-alkaline balance in our blood.

Acid-forming foods include meat, fish, eggs, and most legumes (beans and peas, except lentils, which are alkaline-forming). Sugar, coffee, alcohol, and most grains are also acid-forming. Alkaline-forming foods include virtually all vegetables and fruits, many nuts and seeds.

With a few exceptions, such as hard-cheeses, most dairy foods “are metabolized to compounds that are essentially neutral” even though they contain calcium. Because dairy-eating countries such as the United States tend to eat lots of meat also, experts have concluded that countries that consume the most dairy products have higher rates of osteoporotic fractures because they also consume the most meat, poultry, and fish, which are calcium-depleting.

What about calcium supplements? Should you take them? Brody cites a review of scientific literature published in the Journal of Clinical Endocrinology and Metabolism, which says that most clinical trials show that milk, dairy foods and calcium supplements do not prevent fractures.

Bottom line: Replacing some of your meat and even fish with fruits and vegetables may be more effective than taking calcium supplements. Aim for at least 9 servings of fruit and vegetables a day. Before discontinuing calcium supplements, talk to your doctor (and bring a copy of Brody’s article -- many doctors will be unfamiliar with the low-acid diet but it will make sense to them if they read about it).

Brody has done 2 other articles about osteoporosis -"As Bones Age, Who's At Risk for Fracture" (on how to tell whether you’re at risk for osteoporosis) and http://www.nytimes.com/2010/01/05/health/05brod.html ]"Options for Bone Loss, But No Magic Pill[/url](a review of osteoporosis medications).

To read the Brody article on eating vegetables to prevent osteoporosis, http://www.nytimes.com/2009/11/24/health/24brod.html]click here.[/url]
To read the Brody article on “As Bones Age ...”,click here.
To read the Brody article on “Options for Bone Loss ..." http://www.nytimes.com/2010/01/05/health/05brod.html ]click here.[/url]

Felicia Curran
www.ElderAdvocacyLaw.com

The New York Times ran an article on Monday describing an innovative type of training for medical students thinking of specializing in geriatric medicine – spend a week or two in a nursing home. The article profiles how a medical student, Kristin Murphy, pictured here, spent two weeks at a nursing home in New York. She was given the mock diagnosis of “mild stroke that affected her right side, difficulty swallowing and chronic lung disease,“ and had to act the part. She said that the experience gave her an even greater desire to practice geriatrics.

The idea is to sensitize the medical students to the experiences of their elderly patients who are sick enough to be in a nursing home, and to make prospective geriatric doctors familiar with the types of places that their sickest patients may find themselves living. The attention that the training program is drawing to need for geriatric doctors is great, but most medical students who will agree to live in a nursing home in the first place are probably already highly sensitive, and the medical students who need sensitization the most probably won’t participate in this program to begin with.

A cardiologist doesn't need to have had a heart attack herself in order to know how to diagnose and treat heart problems. So why should a geriatrician need to know about the quality of life issues that confront residents of nursing homes?

A recent article by Jane Brody on what is special about geriatric doctors sheds some light on this issue. Jane Brody interviewed, R. Sean Morrison M.D., pictured here,
a geriatric specialist at Mount Sinai Medical Center in New York. Jane Brody asked Dr. Morrison how he would approach a new patient who is 85 years of age. Dr. Morrison said he would start with a series of questions: ''Tell me about yourself. What do you like to do? What are the things you would like to do that you cannot do anymore? What is your medical history? What medications do you currently take? What brings you here today?''

If you are elderly, Dr. Morrison explained, “You want a doctor who asks more than just about your medical conditions. . . . The doctor should ask about the effect of medical conditions on quality of life, and then should explore what improvements are possible. ‘The focus of care should be on quality of life. . . .Too often, doctors lose sight of this goal when the focus is on treating specific diseases.'’ Dr. Morrison gives the example of “ if a patient has serious arthritis and hypertension and cannot go to places without a readily accessible bathroom on the first floor because she takes a diuretic for high blood pressure, perhaps the blood pressure medication should be changed. The patient may prefer a different drug that carries a slightly greater risk of stroke if it means a better quality of life.“

So if quality of life is part of what the geriatrician needs to address, they need to educate themselves on the diminishments of quality of life that can come with old age, and nursing homes, unfortunately, will present many instances of diminished quality of life for the medical student to draw on.

The Brody article also has an excellent discussion of what questions you should make sure your parents’ doctor is asking at their doctors' appointment.

To read Jane Brody’s article, click here.

To read about Kristen Murphy's experience in the nursing home, click here.

Kudos again to Kristen Murphy and others for their efforts to walk a mile in another person's shoes.

Felicia Curran
www.ElderAdvocacyLaw.com

The San Francisco Chronicle is running a series of articles under the caption "Dead by Mistake" that is an extremely interesting look at the needless deaths and injuries caused by preventable medical errors. Yesterday's article, "Secrecy Shields Medical Mishaps From Public View" discusses how little progress has been made since a 1999 federal study called "To Err Is Human" outlined steps the medical profession can take to cut the number of deaths by medical errors in half. It shows how the secrecy surrounding hospitals, the lack of compulsory reporting of mistakes, and the financial incentives given to hospitals, all combine to perpetuate if not encourage medical errors.

The article states that "A national investigation by Hearst Newspapers, including The Chronicle, found that the hospital industry, the federal government and most states have failed to take the effective steps outlined in the report a decade ago. Consequently, over that period, as many as 2 million Americans have died needlessly of preventable medical mistakes." The idea is that hospitals can prevent medical errors by setting up protocols, systems, and procedures that provide safety checks and balances to keep patient's safe, much the way that years ago car manufacturers began to design cars with safety features (such as ignitions that won't start unless the car is in park) that can prevent accidents from happening.

Why wouldn't a hospital want to save lives and prevent accidents by minimizing the number of mistakes they make? According the the Chronicle's report, "Hospitals can actually lose money by providing safer care. For example, when Utah's Intermountain Healthcare hospital chain improved its system for prescribing heart patients the proper medications on discharge, rehospitalizations were reduced by 900 beds a year. As a result, the hospital lost $3.5 million in revenue. 'To my hospital administrators, there was actually a certain amount of whining about this,' said Intermountain executive Dr. Brent James, another "To Err Is Human" co-author."

Medicare has recently taken the approach of denying payment to hospitals for "Never Events" -- viz.,illnesses and injuries patients pick up in the hospital that are entirely preventable if proper procedures are followed. Included in the list of Never Events are pressures ulcers or bed sores, and post-surgical infections. The idea is that if hospitals know they will not be able to bill the patient's Medicare for illnesses caused by the hospital's negligence, the hospital will stop negligent practices that cause injury.

New reporting laws, such as a 2007 California law that require hospitals to report errors to the the California Department of Public Health, and which requires the Department to investigate the error within 48 hours, also can make a difference.


A companion article, Lost, Stolen, or Never Existed profiles patients who have been the victim of medical mistakes. By reading the stories of the victims of medical mistakes you can hopefully learn something that might might protect you or your family next time you are in the hospital.

To read the Chronicle's article, Click here.

The Chronicle has also set up a website that has lots of information on medical errors, www.deadbymistake.com.

Felicia Curran
www.ElderAdvocacyLaw.com