A Dietitian’s Experience in the Nursing Home Part 2

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We Must Change the Paradigm of Health Care Delivery

President Obama pushed preventive health care with the passage of the 2009 healthcare law. But the kind of “preventive care” that he and most health professionals talk about is not preventive at all. These policy makers talk about Medicare and Medicaid coverage for tests to discover disease in its early stages, to treat disease in its later stages, and to fund pharmaceutical therapy to ease symptoms of disease—not ways to bolster health and truly prevent disease from developing in the first place.

Currently, our healthcare system not only supports disease, it rewards it. Insurance reimbursement is higher for a healthcare facility if the patient presents with more diagnoses. Pharmaceutical medications are offered at no cost to the facility or physician and, in many cases, a physician collects “perks” if even more pharmaceuticals are prescribed.

In 2003 the Medicare Prescription Drug Improvement and Modernization Act authorized CMS (Center for Medicare Services) to begin offering a comprehensive drug benefit for its elderly in January 2006 (Medicare Part D). The benefit was hugely expensive, adding more than nine hundred billion dollars to Medicare spending over the next ten years and representing an increase in total Medicare benefit outlays of twenty percent according to the 2007 U.S. Congressional Budget Office.

According to the American Association of Retired Persons (AARP), here is how the Medicare drug benefit has bled the U.S. budget for 2010:

• Pain medications: 131.2 million prescriptions;

• Cholesterol lowering drugs: 94.1 million prescriptions;

• Blood pressure medications: 87.5 million prescriptions;

• Thyroid medications: 87.4 million prescriptions;

• Proton pump inhibitor (antacid): 53.4 million prescriptions;

• Hyperglycemic agents (diabetes): 48.3 million prescriptions.

The total cost of pharmaceuticals charged to Medicare Part D in 2010 was over eighty-two billion dollars.

This drug benefit has also increased the overall cost of medical care thanks to the related increases in physician visits, prescribing and monitoring of medications (and the many ensuing adverse events), and treatment for medical complications and side effects caused by the use of so many medications at one time. According to the Agency for Healthcare Research and Quality, Americans treated in hospitals for medication-related problems surged in 2006 to almost two million.

The Census Bureau reports that the number of Americans sixty-five years old and older is expected to more than double to eighty-nine million by 2050. We may be living longer, but we are living sicker, and becoming sicker younger. Nursing homes are already admitting patients younger than sixty years of age. These are people too ill to care for themselves and must apply for Medicare’s support.

A TREND THAT MUST END

Great changes in healthcare legislation must take place in order for the system to sustain itself. I think these changes must include the reduction and/or elimination of unnecessary pharmaceutical medications and their replacement by other, safer healing modalities. Most important, we must recognize the importance of eating only whole, unadulterated foods to be and stay well.

I have worked in the healthcare system for twenty-one years as a registered dietitian in over fifty nursing homes throughout the country. I am also well educated in integrative and holistic nutrition, working as a true “nutritionist” alongside naturopathic doctors, chiropractors, acupuncturists and holistic physicians for seven years. How I was originally trained and expected to practice nutrition is very different depending on which hat I am wearing on a particular day. Because I continue to train and network in both conventional and alternative arenas, I have come to my present convictions without bias or from a hardened mindset from either position.

The outcomes exhibited by those patients who choose the path of pharmaceutically based allopathic medicine and lowfat diets recommended by the American Dietetic Association compared to those who choose a more integrative, holistic, whole-food approach to their health are undeniably dramatic. I must assume that only someone unable to recognize and understand the good health obtained from the holistic approach would choose pharmaceutical-allopathic intervention and lowfat diets. I can only assume that our government leaders who continue to support our pharmaceutically based allopathic system are either blind to the benefits of integrative/holistic therapies, blind to the ill effects caused by total reliance upon pharmaceuticals, or intentionally supportive of disease and illness because our world economy would fail without it. (The medical industrial complex is the second largest money-making industry next to the military machine.)

To illustrate these factors that allow the status quo to persist, I will share some observations from my professional experience.

OVERMEDICATION

Pharmaceutical therapy serves a purpose, but it is not one of prevention or healing. Its purpose it to cover up, suppress or reduce the symptoms of disease. Unfortunately, the industry has expanded and twisted its purpose as billions of dollars are spent on advertising and evidence-based “studies” pushed onto physicians’ desks. The industry has done a terrific job of marketing its wares to the populace at large, and introducing a culture of easy acceptance of medication for every possible ailment.

In a nursing home, as in allopathic care in general, the focus is on pharmaceutical intervention. Residents in my nursing homes take an average of nine medications each, two to three times a day. I recently witnessed twenty-three medications, dosed two to three times a day, administered to an eighty-five-year-old lady who weighed ninety-five pounds. One hundred percent of my residents are taking a cholesterol-lowering drug (statin), although mainstream research demonstrates that the risks outweigh the putative benefits in this population. The statin is never discontinued, even when a cholesterol level is very low, and it is prescribed at any age. Many residents over ninety are taking these drugs.

Statin-induced myopathy (muscle pain) is common and acetaminophen is frequently prescribed to resolve the pain. Statins are one drug that claims to be “preventative,” but after watching its effects in the elderly I find it to be quite the opposite.

I once worked at a facility that employed a new physician who had studied medicine outside of the pharmaceutical model. He did not believe in the use of statin drugs, and they were discontinued on eighty-two residents. We observed residents “waking up,” recognizing family members, no longer requiring assistance with meals, and walking for the first time in many years. The transformation in these residents was stunning. The facility staff was startled. I regret that we did not perform an evidence-based study to document this revolutionary event.

Approximately half the medications given to nursing home residents are administered to relieve the side effects of yet other medications. Adverse effects expand exponentially with the number of medications taken, partially because they indicate the presence of numerous diseases or other medical problems, but mostly because they provide opportunity for drug-borne disease and multiple drug-drug interactions.

I always foster a relationship with the consulting pharmacist when working in a nursing home, frequently asking for reviews of medication causing nutritional imbalances. A consulting pharmacist is expected to review medications and make recommendations to the medical director. Consultants I interview feel that one hundred percent of the nursing home population is overmedicated and that medication levels could be cut in half or better.

WHY OVERMEDICATION?

Why do medical directors or physicians allow over-medication?

1. They are not aware the medication is causing side effects. In most nursing homes, they visit and review their residents infrequently or not at all. Their care is typically based on a signature to a previously defined “protocol.” The rest of their care is typically responding to a nurse’s request. Most often, the nurse does not understand potential side effects and medicates the side effect, assuming it is a new disease process.

2. They are hesitant to discontinue a medication another physician has started out of respect to the physician. With many specialists, the list of medications becomes extensive.

3. They do not understand the contraindications and harmful side effects of medications. A physician receives his continued training from a pharmaceutically sponsored class or meeting with a pharmaceutical representative, whose ultimate goal is to sell drugs.

4. They may have no training in geriatric medicine, nor does the pharmaceutical representative. There are many drugs that are not well tolerated in the elderly or in an over-medicated resident with compromised liver and renal function.

5. They protect their own interests. If the resident presents with an event such as stroke and the medication for that disease process has not been prescribed or has been discontinued, the physician can be deemed liable. Therefore they prescribe the medication, even though they may not consider the therapy beneficial or believe in it.

6. They are trained only in pharmaceutical therapy or invasive procedures. When a disease presents, they want to do something to help, and pharmaceutical intervention is all they understand.

7. If they understand integrative healing therapies or suggest them, the healthcare facility would not allow it. The Medicare-Medicaid Program does not pay for this. The facility or resident would incur the cost, something most are unwilling to do.

8. They do not believe or trust in the body’s ability to heal, and assumes the resident will rely on pharmaceutical therapy forever. Why don’t medical directors or physicians suggest healing and integrative therapy? They either do not understand it, or believe they will lose income to a “competitive” therapeutic approach.

RESOLUTIONS FOR CHANGE

When a disease process presents itself, we should ask why this has occurred. Health care providers should attempt to resolve the root of the disease with a healing therapy. At the same time, if a pharmaceutical therapy to ease symptoms is implemented, this should always include plans to reduce or eliminate it as the symptoms resolve. A drug should never be used as a “cop out” in addressing the primary cause of the disease.

For example, I have a nursing home resident who is losing too much weight. As a dietitian, I am expected to order Ensure, or a pharmaceutically sponsored synthetic supplement, update food preferences, and add more fat (most often synthetic trans fat) to the food. If weight loss continues, I am expected to suggest an appetite stimulant, antidepressant, or a synthetic form of multivitamin with alcohol stimulant. If there is nausea, a medication is administered for it and the cause of nausea is not addressed. If pain is the cause of weight loss, a pain medication is administered, and the cause is not addressed.

When I challenge this current treatment paradigm, the staff is uncomfortable because I have introduced a subject about which I am more knowledgeable, and a modality with which they are unfamiliar. I am not expected or asked to spend time on a discovery as presented below in the holistic model. No one is asking why in this setting, and consequently no one is getting well.

As a holistic nutritionist I ask, “Why is this person losing weight?” I review medications that may cause anorexia or fluid loss, as well as nutritional deficiencies (such as a common anticonvulsant-induced osteomalacia). I rule out pain (often a statin-induced myopathy). I confirm that a drug is not used which is contraindicated for poor renal or liver function causing nausea. I rule out increased energy expenditure such as new diagnosis of cancer or lung disease or increased healing needs. I evaluate balance of mind, body and spirit. I analyze adequate intake and utilization of minerals, which could result in depression, sleep disturbance or poor hormone utilization. I address the root of the weight loss, which rarely simply calls for more food or supplements. Additional pharmaceuticals or “natural medicines” may be suggested. There are many natural medicines that prove clinically important, which can replace or work in conjunction with pharmaceutical therapy. Most have little or no side effects (see Jelin JM, Gregory PJ and others. Pharmacist’s Letter/Prescriber’s Letter. Natural Medicines Comprehensive Database. 12th edition. Stockton, CA: Therapeutic Research Faculty: 2009; pg 1- 2004).

In my experience, chiropractors, acupuncturists, massage therapists, naturopathic doctors, energy workers, true nutritionists (not dietitians), and so on, are trained this way. They work to support healing, not to drug or to conduct their work in support of an industry. Today you will find some physicians moving into this paradigm and away from the pharmaceutical model and some medical schools are teaching these modalities. Members of the American Dietetic Association have recently formed the group “Dietitians in Integrative and Functional Medicine,” who recognize and use these modalities, mostly in the private practice arena.

In a nursing home I find most residents do not want to take medications, complaining that medication makes them feel sick. Many will spit them out. The medication continues to be encouraged by the nursing staff, and the resident who refuses it is documented in the medical record as “noncompliant.” The medication is encouraged by a nursing staff who often feel it is making their resident sick as well, but continue to administer it because it is “physician ordered” and it is not their responsibility to question orders.

I never encounter a resident or family member who understands what the medications are that they are taking, the reasons they are taking them, their benefits or possible adverse side effects. This should all be clearly explained, allowing the resident and/or family member to choose the therapy from an educated vantage point. A choice should be offered to the resident and/or family, meeting them at their comfort level and determining a level or age at which they would like to discontinue reliance on pharmaceuticals.

Pharmaceutical use is rarely conducted responsibly. Identifying the potential side effects and contraindications as provided by the Nurse’s Guide to Medications or The Physician’s Desk Reference is rare. I frequently identify drugs prescribed when they are clearly contraindicated in a particular disease process such as renal failure, most likely causing the resident distress and certainly opening the door for potential lawsuits.

INSTITUTIONAL FOOD

Nursing homes serve institutional food, usually canned or frozen-prepared. Although the products may be more expensive than raw food, it saves in employee time (cost) and decreases the risk of a fine for improper preparation from the Department of Health, whose dictates are absurdly stringent and unrealistic.

Dietitians review calories, protein and fat content of a meal. They determine that the proper servings of the food groups as suggested in the Food Guide Pyramid are served. They do not review the quality of the food base, nor are they expected or encouraged to do this. The Food Guide Pyramid is always adopted as a guide for meals. Because of poor food quality, I find that vitamins and minerals are inadequate. The meals meet the Recommended Dietary Allowances only because the foods are synthetically fortified.

Calcium and vitamin D intakes are always inadequate and are rarely supplemented, which may be the reason for the high incidence of urinary tract infections, falls, weakness and broken bones. I often recognize this deficiency in the laboratory blood value, a value often overlooked by everyone— including the registered dietitian! If calcium is supplemented, it is most often requested by a family member and is usually in the form of the poorly absorbed calcium carbonate and unaccompanied by vitamin D. A resident is often admitted on large doses of vitamin D with poor calcium intake.

Servings of protein foods are precisely defined and measured at three to four ounces per serving to control the institution’s costs. Increasing a resident’s protein amount is allowed if increased protein needs are calculated for wound healing in decubitus or skin breakdown. Low-cholesterol diets are frequently ordered by the physician and included in the facility’s diet manuals, despite the fact that there is no research demonstrating the diet’s effectiveness. In these cases, physicians are protecting themselves in the event a cardiac insult presents and the resident was not on this diet, in which case the physician may be deemed liable.

Saturated fat intake is low. Skim or lowfat milk is used, and skin and fats are removed from most meat. Margarine is selected instead of butter because it is less expensive. In my opinion, saturated fat intake is so poor that it hinders proper absorption of fat-soluble vitamins—another reason for increased urinary tract infections, weakness and falls.

Tube feedings are implemented for residents with dysphagia. A synthetic-type formula such as Ensure or a pharmaceutically sponsored supplement is used. Tube feedings made of whole foods are discouraged because of the time required by employees to make them, the increased risk of fines from the Department of Health for improper preparation and storage, but mostly because genuine food is not paid for by Medicare but these synthetic formulas are. It is quite impossible to implement a wholefood tube feeding, unless the family or resident demands it.

REAL FOOD FOR RESIDENTS

A nursing home I recently worked in employed a cook who focused on southern-style cooking using fatback, turkey necks, liver and fresh food! The facility administrator was a “jolly” southern fellow himself and found the increased cost of serving this type of food to residents entirely appropriate. This facility had little weight loss among residents, fewer medications were prescribed, and the overall population appeared much healthier and stronger than in my other facilities.

A strong focus on nutrition and whole foods to reduce or eliminate the reliance on pharmaceutical medications in nursing home settings is imperative. If food intake is poor, or pharmaceutical therapies are depleting particular nutrients, they should be supplemented in whole-food form. Tube feeding prepared from whole foods should be used, as well as nutritional shakes made of real food to replace Ensure and pharmaceutically sponsored supplements.

Foods should be served in whole form, without their fats removed. Margarine and other synthetic trans fats should be categorically banned. Fresh foods should be highlighted, and purchased locally if the location supports this option. Organic and pastured foods should be sought out as a first priority.

THE NEW PARADIGM

Many Americans are searching for residential care offering these healing modalities, and the numbers demanding such options are increasing. After publishing my last article in the Summer 2011 Wise Traditions, “A Dietitian’s Experience in the Nursing Home,” I received close to one hundred calls and e-mails from people searching for a holistic-based residential care or nursing home.

Unfortunately, the way our healthcare system currently reimburses medical expenses makes it difficult to offer this type of nursing home, as its virtues are essentially unrecognized by Medicare and Medicaid, but if you choose to pursue this option, now there is a way. Consider the following suggestions to create the health support team you desire:

• Find a physician who is willing to recommend referral to an alternative practitioner who works in an adjunctive healing modality, and work toward decreasing medications if indicated.

• Be willing and able to pay for alternative healing therapies and insist on them. You will need a naturopath, nutritionist, acupuncturist or other healer to lead you in the process. Be aware that this avenue can be costly.

• Be patient. Real healing on a deep level takes time, but is the true goal. The quick improvement of symptoms that we have become accustomed to via pharmaceutical intervention is not true healing.

• Most important, you must be able to incur the cost and time required to purchase and prepare whole, real unprocessed food if the facility is not willing to do this. You are within your legal rights to bring in food and whole food supplements.

The Nursing Home Reform Law mandates that all services be provided to a resident when required by the resident’s comprehensive assessment and care plan, regardless of the availability of Medicare or Medicaid payment for the service.

It is time to include a naturopathic, holistic physician or true nutritionist in a nursing home who understands healing modalities. Change the type of care, forming a plan that focuses on true healing. The role of an allopathic physician should be to serve as a consultant to administer and decrease pharmaceuticals or recommend invasive procedures or supportive equipment such as oxygen.

The Centers for Disease Control say there are three ways to address the burgeoning health care crisis: a rise in payroll taxes, a reduction of benefits, or a combination of the two. Why not change the benefits our system supports to include only those that prevent disease and heal, such as whole, unadulterated food, whole-food supplements, homeopathy and herbs? Reimburse healing practitioners such as acupuncturists, chiropractors, herbologists, true nutritionists, massage therapists, energy workers, physical therapists, speech therapists, occupational therapists, consulting pharmacists, activity directors and chaplains.

The facility or physician should assume the costs of pharmaceutical interventions. If pharmaceutical interventions become necessary, this indicates the abject failure of the physician or facility to keep the resident healthy and well.

The health care delivery paradigm I envision rewards good health and encourages a facility or physician to decrease or eliminate reliance upon pharmaceuticals. The paradigm I envision heals the healthcare system and the American people.

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SIDEBAR

A HOLISTIC NURSING HOME?

Our author, Kim Rodriguez, RD, would like to assess interest in establishing a holistic-based nursing home in the United States, offering integrative medicine and a diet of whole foods. If the interest is high enough, she will then approach nursing home owners who otherwise may be forced to close based on recent sharp Medicare cuts. Such owners may be interested in shifting to private care with these priorities.
The fee for the nursing home care is expected to be around $2500 per month, not reimbursed by Medicare or Medicaid. (Typical nursing homes charge Medicare $6500 per month.) Additional costs may include nutritional supplements or other healing modalities.

If you are interested in such a facility for a loved one, contact nutrition@bellsouth.net or (803) 349-5588.

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This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Fall 2011.

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