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Need for Individualized Plans of Care

Geriatrics would be a good deal easier if every older person suffered from just one medical condition. But most elderly people have more than one chronic disease and the older they are, the more chronic conditions they are likely to have. Since “multiple chronic conditions” is a mouthful, researchers coined the term “multimorbidity,” an only slightly less awkward way of expressing what is probably one of the most critical features of geriatric existence. It’s so critical because the best medical treatment, known as “evidence-based medicine,” is founded on studies of patients who don’t have multimorbidity at all. They are generally perfectly healthy except for the single disease being studied. So when we tell a patient that “studies show’ that blood pressure should be below 140 and that the best medication to take if the blood pressure is elevated is a diuretic, we mean that if the only problem is high blood pressure, then taking the diuretic is the best way to lower the risk of bad outcomes such as strokes and heart attacks. But if the patient also has another chronic condition, say Parkinson’s disease, which is being treated with the medication L-dopa (Sinemet), then giving that patient a diuretic to lower blood pressure could backfire—long before any heart attacks or strokes were prevented, the patient might fall down (both L-dopa and diuretics contribute to sudden falls in blood pressure when a person stands up) and break a hip. Simply assuming it makes sense to apply multiple guidelines to a patient with multiple problems can result in medication lists a mile long that cost a fortune and that cause more problems than they solve. So multimorbidity is a big deal in geriatrics. Now, for the first time, multimorbidity is getting the attention it deserves.

Image Source: Google Images

Image Source: Google Images

A couple of years ago, the American Geriatrics Society set up a task force to develop an approach to multimorbidity for physicians. This group generated a report that lays out the basic principles that should underlie care for a patient with multiple chronic conditions. And a recent symposium brought together physicians and researchers from a variety of backgrounds to come up with strategies for generating a better evidence base, for designing new guidelines, and for carrying out appropriate systematic reviews for patients with multimorbidity. The results of the symposium are published as 3 articles along with an editorial in the April issue of the Journal of General Internal Medicine.

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Obamacare cuts home healthcare for millions of seniors

According to President Obama’s mendacious political promise, “If you like your health care plan, you can keep it,” continues to cast a long and disturbing shadow of doubt and confusion over millions of Americans who have lost coverage as a result of Obamacare. As 2014 unfolds, the most vulnerable senior citizens — those who receive home health care services — are about to learn they are out of luck. Obamacare opens a trap door under them, leaving this elderly population in freefall — with many citizens losing access to home health care.

Image source: Google Images

Image source: Google Images

Add another compelling reason to reverse Obamacare. Whether by accident or intention, the “Affordable Care Act” empirically strips America’s oldest and poorest cohort, all part of the World War II generation, of this basic coverage. Here is how.

Read more here-

Enjoy $100 off the course fee! Hurry! Offer ends March 31, 2014!



Gerontological Nurse Certification Prep Course

March 19th was Certified Nurses Day but you can still get the special pricing.

Enjoy $100 off the course fee!

Hurry! Offer ends March 31, 2014!

Gero Nurse Prep is a proven online certification training program that prepares RNs to become board certified in gerontological nursing.

Why is this important to you?

  • Higher quality of care
  • Fewer adverse events
  • Higher RN job satisfaction – retention
  • Reduced turnover – lower costs
  • Happier nurses, residents, families and facility owners
  • Stronger referrals and marketing

Act Now!

Visit today to register your RNs. You can also like us on Facebook and follow us on Twitter.

Did You Know?

  • That the University of Nebraska Medical Center, College of Nursing Continuing Nursing Education (UNMC CON CNE) was awarded Accreditation with Distinction, the highest recognition awarded by the American Nurses Credentialing Center’s Commission on Accreditation.
  • We have over 700 RNs enrolled in Gero Nurse Prep and alums have a 99% pass rate on the ANCC certification exam.

More information:

Best Regards,

Anji Wittman

College of Nursing, UNMC

Have Any Questions?

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Omaha NE 68198-5330


This one is a MUST read!

Getting Autonomy Right

My father will be 90 next month. He lives in a nursing home because he needs help with all the most basic tasks—eating, dressing, bathing, walking. But my father also has dementia, which has been getting worse, as dementia generally does. As a geriatrician, I know that one of the few ways to make a person with dementia better is to take away any medications that might be contributing to the cognitive impairment. So when I realized my father was still taking a small dose of the tranquilizer valium (diazepam) every day, I suggested it be stopped. I was stunned when my father’s doctor called me to say he felt stopping the valium posed an ethical dilemma.

An ethical dilemma? Valium is on the most widely recognized list of medications that are generally inappropriate for use in older people. The American Geriatrics Society recommends against prescribing valium in the elderly because the drug accumulates in the body, takes days to weeks to be eliminated from the system, and is notorious for causing confusion and lethargy, especially in people with dementia. Now guidelines and recommendations are not absolute.


Valium has not been taken off the market by the FDA. And my father is only on a low dose of the medicine. For years, he was on a far higher dose because it helped control his debilitating panic attacks. When I was growing up, he used to have panic attacks every few weeks, even with high dose valium, but the attacks were far worse without the valium. Multiple efforts to find another drug that was equally beneficial without potential side effects had failed, so my father stayed on valium. Over the last few years, his doctors have tapered the dose, but they never stopped the drug entirely. Since entering the nursing home 2.5 years ago, he has remained on valium even though he hasn’t had a single panic attack. And now he is sleepy much of the time—he can’t keep his eyes open when you try to talk to him—and is more confused than ever.

Why, then, was stopping valium ethically problematic? It might seem, by contrast, that continuing a drug that every geriatric authority deems pernicious is what is ethically problematic. But it turns out that 1.5 years ago, when my father’s mental faculties were better than they are now, though hardly normal, he told his physician that he wanted to stay on valium. So in the view of that same physician, stopping the medication now would be a violation of the all-important ethical principle of respecting autonomy.

Now I’m all for respecting a patient’s right to make medical decisions for himself. But making a medical decision assumes the patient has the capacity to weigh the risks and benefits of the treatment. And I am quite confident that my father, who is unaware that he even has cognitive impairment, can understand that valium could be worsening his cognitive impairment. I am sure that my father, who does not remember what he had for breakfast or even if he had breakfast, has no recollection of when he last had a panic attack. He is simply unable to evaluate the situation, and to rely on the opinion he had 1.5 years ago (assuming he understood the issues then, which is another matter), is absurd. “Respect for autonomy” is not equivalent to “the customer is always right.” It is not respectful of a person’s right to determine what happens to his body for a physician to mindlessly follow the dictates of the patient. When a cancer patient declines potentially life-prolonging treatment, should his oncologist accede to his wishes without first being sure the patient understood both what would happen if he got the treatment and what would happen if he didn’t?

Read more about it:

Nursing fall offs is the cause of higher patient death rates

A major study has found that nursing fall offs is the cause of higher patient death rates in hospitals.26 February, 2014 | By The Press Association


 According to the data from 300 European hospitals in nine countries  the risk of death within a month of surgery is 7% for every extra patient  added to a nurse workload. The research showed that poorly qualified  nurse has made the situation even worse. According to the researchers  the highest risk of death after surgery was found in hospitals where    nurses with lower levels of education cared for the most patients.

The Lancet journal, included figures for 30 English hospitals showing  that on average every one of their nurses looked after around nine  patients. Increase in 10% of nurses who are holding bachelor degree is  associated with 7% decrease in surgical death rates.



In some other countries the patient-to-nurse ratio was significantly smaller. Researchers considered number of factors such as nurse workload, education and patient outcomes which can impact the result. These included factors such as the age and sex of patients, types of surgical procedure, chronic conditions, and the kind of technology available in a hospital.

“This research comprehensively rebuts the myth that degree-level education for nurses is a retrograde step”   Professor Ieuan Ellis

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Using RN Continuing Education as a Weapon Against Rising Costs and Threats to Quality

The “Using RN Continuing Education as a Weapon Against Rising Costs and Threats to Quality” webinar on Tuesday, March 18, from 2-3pm EST will focus on how the current LTC environment can be improved by an intentional, comprehensive continuing education program for RNs that prepares them to achieve Board Certification.

The modest investments LTC facility administrators have made in this program have had a positive impact on the LTC RN workforce, their effectiveness on the job, and their RN turnover rate in a LTC environment characterized by rising acuity of LTC patients, tighter reimbursements, and more stringent regulations. Administrators are finding that the benefits of this program to their residents and financial bottom line far outweigh its costs.

Learning Objectives:

  1. Correlate the attainment of RN board certification with standards of clinical excellence
  2. Explore the relationships between comprehensive education,  RN retention, and overall quality of care outcomes
  3. Provide data supporting the business case of comprehensive RN education and professional development investment


Heidi Keeler
Assistant Professor
University of Nebraska Medical Center

Catherine Bevil
University of Nebraska Medical Center

Its a complimentary webinar with no registration fees required. Register here..

Issues in Long Term Care

In 2010, 40 million Americans were age 65 or older. By 2050 that number is expected to jump to 88 million. Among these older citizens, only three in 10 will never receive long-term care services. The majority will get such care—though not necessarily in a nursing home or assisted living facility. The current definition of long-term care includes services provided in the home by family members or paid caregivers. Adult day-care is also considered a form of long-term care.

The cost will be huge. In addition to the increase in the number of people over 65, the number of people 85 and older is also predicted to jump dramatically. This is the “frail elderly” group most likely to need long-term care. In 2010 there were 5.5 million of these older people, but by 2050 there will likely be 19 million.


These demographic shifts raise two questions. How will the nation decide to pay for that care? Will it be given in different ways and settings?

66% of people 65 and older can’t pay for even a year in a nursing home.

The demand for long-term care services will explode as the population ages and more people live longer with chronic conditions. Who will pay for these services and how will they be delivered?

Read more here….



ANCC Board Certified Nurses get $200 off on registration rates. It gives you opportunity to connect with your peers, participate in expert-led, hands-on sessions and learn about the newest nursing standards and best practices in health care. You can also choose your educational track. Don’t miss this exceptionally precious offer. Register now and  and get your $600 special registration rate!



A New Role For Skilled Nursing in Long Term Care

When I was a medical resident at Boston City Hospital, a large, public, inner city hospital, I began wondering whether hospitals sometimes caused as many problems as they cured. Over and over, I saw older patients admitted with one disease such as pneumonia or a heart attack, who ended up falling and breaking a bone or getting a blood clot from being confined to bed. So I did a study in which I measured how often older people became confused, stopped eating, developed incontinence, or fell while they were in the hospital. I tried to separate out those cases in which the new symptom could be plausibly related to the admitting diagnosis: for example, someone who was hospitalized with a stomach ulcer would normally stop eating during the initial treatment, and someone with a stroke might well be confused. Then I compared the rates at which people over 70 developed these unexpected complications with the rates at which younger people developed them. Finally, I speculated that each of these problems might trigger a cascade of adverse events: a patient who became incontinent might have a catheter placed in his bladder, which in turn might cause a urinary tract infection; a patient who got confused might be physically restrained and his immobility might lead to a blood clot.


What I found was that among the 502 patients I examined, a startling 41% of those over 70 developed 1 or more of the 4 problems I was interested in compared to only 9% of the younger group—and these were all problems that could not clearly be related to the acute illness for which the patient was being treated. It made me question whether hospitals were a safe place for older patients.

Read more here


Murriel Gillick, “Barking Up the Wrong Tree”,

Sedentary Lifestyle Increases Risk for Heart Failure

We are all aware of the risks of heart disease: diet, exercise, smoking, lipid levels, stress, genetics, etc. Now, research is showing us more specifically to what these lifestyle risks relate. A recent study published in the Journal Circulation: Heart Failure, found that a high sedentary lifestyle increased the chance of having heart failure, as much as 1.34 times that of a low sedentary lifestyle.

Heart Failure

Picture Source:

Similarly, the study found that lower levels of physical activity were also related to heart failure, as much as 1.52 times as likely to get heart failure that those with high levels of physical activity. It is crucial to stress the importance of healthy, active lifestyle for all, to the individual’s highest ability, to protect the heart from disease. This evidence can be used as a motivator to discourage sedentary behaviors.

Young DR, Reynolds K, Sidell M, Brar S, Ghai NR, Sternfeld B, et al. Effects of physical activity and sedentary time on the risk of heart failure. Circ Heart Fail. 2014 Jan 1;7(1):21-7.

For more on this study, see: