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Polypharmacy in Skilled-Nursing Facilities
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
Include no more than 300 words of text, three authors, and five references
Type with double-spacing
Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
As a member of a rapidly dying breed of physicians who practice general internal medicine and take care of patients in skilled-nursing facilities, I was disappointed to read that the physician freedom to practice the art of managing the many medications needed to control pain and suffering will be restricted [1].
The medications are approved by the Food and Drug Administration, and the term inappropriate is misleading. Several of the medications listed by Beers and colleagues [1] are useful in the elderly patients I treat. What do the authors consider medications that are appropriate for the indications they listed?
We physicians try to limit medications, but our backs are pushed against the wall by telephone calls from nursing staff or families of patients concerned that their relative's problems are not being treated. This can lead to polypharmacy. Many patients have multiple problems such as:
1. Degenerative disk disease requiring nonsteroidal inflammatory agents
2. Esophageal reflux requiring antacids and histamine-blocking agents
3. Chronic depression for which antidepressants are indicated
4. Sleep and mood disorders requiring medication
5. Recurrent bladder infections requiring long-term antibiotic suppression
6. Dementia leading to agitated states in the evening, which put the patients at risk and cause the nurses to request medications
7. Smoking-related pulmonary problems requiring medication to prevent bronchospasm
8. Cardiovascular problems requiring multiple medications.
It was pointed out that medications prescribed on an as-needed basis are used frequently. Nurses in most skilled-nursing facilities have more than enough to do without giving unnecessary medications.
Young doctors are not interested in primary care because they see our struggle with complex patients, confusing Medicare regulations, inappropriate expectations of care, family members who lean on the physician, and poor reimbursement. I typically see my patients in skilled-nursing facilities one time per month and receive daily phone calls from these facilities about management problems. For this I receive less than $50 per month in reimbursement. The increased liability in prescribing the medications that Beers and colleagues have listed as inappropriate is another disservice to those of us on the front line trying to provide quality care in trying times.
Philip E. Ashburn
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
Include no more than 300 words of text, three authors, and five references
Type with double-spacing
Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright 2004 by the American College of Physicians
