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Pink Puffers and Blue Bloaters – COPD
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 3- Approximate time required: 180 min.
Educational Goal:
To educate Adult Foster Care providers about Chronic Obstructive Pulmonary Disease.
Educational Objectives:
Explain what COPD is
Explain how Emphysema and Chronic Bronchitis relate to COPD
Describe to new conditions that COPD suffers have to live with
Tell about how to care for COPD patients
List and explain COPD Therapies and Medicines
Provide additional sources of information and resources for residents and caregivers
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Pink Puffers and Blue Bloaters − COPD
Pink puffers and blue bloaters; they sound like characters from a children’s cartoon, but they are something far more serious. They are actually physical descriptions of patients who suffer from emphysema and chronic bronchitis. In emphysema, the patient has lost some of their ability to breathe out regularly. They have to exert themselves harder to puff out each breath, turning pink in the process. Those who suffer from chronic bronchitis find it difficult to get oxygen in and CO2 out of their blood from clogged lungs. It can cause their skin to have a bluish tint. The lower blood oxygen level impairs the circulatory system, and fluids build up, bloating the extremities. What is really intriguing and confusing is, they are both different manifestations of the same condition—Chronic Obstructive Pulmonary Disease or COPD.
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What is COPD?
Chronic Obstructive Pulmonary Disease is a broad descriptive term. It refers to a collection of long-term conditions that permanently damage the pulmonary system. The condition leads to an impaired air flow into and out of the lungs. If the COPD conditions continue, lung function gets progressively worse over time. Compromised air flow is a serious condition that can interfere with every aspect of normal living, lead to complications in other disease states, and even cause death. COPD is the third leading cause of death in the United States and burdens the health care system with tens of billions of dollars’ worth of costs a year. There is no cure for the disease, but if you understand what is going on in the lungs, the disease can be managed, and activities of normal life can continue.
Normal Lung Conditions
The pulmonary system of the body is a series of organs designed to bring air in contact with the circulatory system. That contact allows oxygen to be taken in, and CO2 and other waste gases can be expelled. The process is called gas exchange. Getting enough gas exchanged to meet the needs of the body requires a very large thin surface area between the lungs and the blood system and a large surface area. To achieve the required surface area, the lungs branch several times, ending in many tiny air sacs. Each air sac is surrounded by a system of thin-walled blood capillaries.
Airflow through the lungs is created by intercostal muscles of the rib cage and the diaphragm muscle below. When the muscles contract, the lungs expand, creating a vacuum that pulls in air. As the muscles relax, the lungs, which are made up of a spongey elastic material, spring back into place, forcing the air out.
When you breathe in, air travels down your windpipe or trachea and branches into your lungs via two large tubes called bronchi. Inside your lungs, these tubes divide many times, like the branches of a root. The smaller tubes are called bronchioles. At that end of the bronchioles are clusters of tiny air sacs known as alveoli.
The pulmonary system has a defense system that protects the delicate structures of the lungs. It cleans the air of pollutants and irritants and removes them from the lungs. It includes:
COPD Lung Conditions
The lungs operate efficiently and automatically as long as the tissues remain healthy. If the lungs get damaged, they can repair themselves. Unfortunately, if the lungs continue to be damaged, the repair mechanisms can get overwhelmed and wear out. Over time, the damage becomes permanent, and lung function is compromised. Breathing becomes difficult. Wheezing or crackly breaths can be heard. Breathlessness and/or chest tightness is felt. It becomes harder and harder to get enough oxygen to maintain normal activity levels. Coughing happens more frequently. The body feels tired and lacks energy, and low-grade fevers are often felt.
Emphysema
Emphysema is a form of COPD where the lung tissues lose some of their elasticity. Over time, the walls of the alveoli (tiny air sac) weaken and rupture. This creates larger and larger air spaces, reducing the surface area needed for gas exchange. Also, the walls of the bronchioles weaken and are easily collapsed, trapping old air. The trapped air is of poor quality and prevents fresh air from reaching the alveoli. This further reduces the needed gas exchange, and the patient becomes weaker and weaker. The collapsed bronchioles also make it harder and harder to exhale. Those who suffer from emphysema find it easier to breathe by pursing their lips together and puffing out their breaths. This move creates more pressure in the bronchioles, keeping them open. Puffing requires more effort than normal breathing, and the strain tends to turn the skin pink. Over time, the extra exertion takes its toll, and the patient starts to lose weight. In addition, the combination of emphysema symptoms eventually causes the chest to become more barrel-shaped.
Chronic Bronchitis
Chronic Bronchitis is a form COPD where a combination of swelling and extra mucus production closes off airway passages in the lungs. In an effort to protect itself from constant exposure to irritants, the lungs produce more and more mucus. Unfortunately, at the same time, the cilia hairs that move the mucus out of the lungs become damaged by the irritants, leading to mucus build-up. The body has to rely on coughing to remove the excess mucus. The clinical hallmark of chronic bronchitis is a productive (mucus-producing) cough that lasts for at least 3 months out of the year for 2 years. Coughing is not a very efficient way to get rid of mucus. Consequently, the patient often presents with the wet sounding breaths of wheezing and crackles. As more and more bronchioles are closed off, the tissues of the body start to lose their needed oxygen supply. The skin tends to take on a bluish tint in a condition called cyanosis. The extra moist warm conditions of the lungs become a breeding ground for bacteria. Chronic bronchitis makes it easier to get lung infections and fevers.
COPD is both
In almost all incidents of Chronic Obstructive Pulmonary Disease, the patient presents with both emphysema and chronic bronchitis. It is now the common practice of doctors to refer to most cases as just COPD, except in the most severe occurrences of differentiating symptoms.
COPD is a slow, progressive disease that gradually gets worse over time. Most patients who have COPD start having symptoms in their 50s and 60s. There are times, though, when there is a sudden increase in symptoms—referred to as exacerbations. The more often exacerbations occur, the faster the disease progresses. Controlling exacerbations becomes a major focus of therapy.
What causes COPD?
COPD occurs when the lungs are constantly exposed to irritating and noxious substances over a period of decades. In most instances, that means tobacco smoke. In the U.S., 80−95% of those with COPD are current smokers or have previously smoked long-term. Additionally, second-hand smoke exposure has caused COPD in up to 20% of reported cases. Other contributing factors are the genetics of the patient and long-term exposure to workplace chemicals and dust. Women are more susceptible to the harmful effects of tobacco smoke than men.
There is a rare genetic condition called Alpha-1 Antitrypsin Deficiency. The patient is born with a defect in the protective mechanism of the lungs. Without the protein Alpha-1 Antitrypsin, white blood cells begin to break down healthy lung tissues, and COPD can develop, even without exposure to harmful chemicals.
What causes Exacerbations?
The sudden worsening of symptoms or exacerbations is usually triggered by exposure to irritation or inflammation-causing events. Infections are a major risk factor, appearing in 50 to 75% of cases. Other causative factors are poor indoor and outdoor air quality, second-hand smoke, cold weather conditions, and an increase in physical or emotional stresses.
COPD Caused Complications
COPD conditions in the lungs and circulatory systems cause extra stresses in the body of the patient. These stresses can create or contribute to the worsening of other illnesses and harmful circumstances.
New Realities of COPD
Worldwide, the incidents of COPD are increasing. In the U.S., it is estimated that 30 million people are affected by COPD symptoms. It is believed that over half of the cases do not realize that their lungs have become permanently damaged. In some cases, 50 to 70% of lung capacity is lost before symptoms become problematic. It is a common problem that COPD sufferers believe symptoms they are experiencing are just a part of getting old.
COPD is an insidious and slow-progressing disease. The early signs of increased breathlessness and frequent coughing are easily ignored. As more and more permanent damage occurs, more severe symptoms start to emerge. Wheezing and crackling breaths appear, and lung infections start to occur more frequently. Normal activities of daily living start to become more difficult to maintain.
If any of these symptomatic conditions start to manifest, it is recommended that the patient sees a doctor for a spirometry test. In a spirometry test, a breathing device is used to measure how much air is inhaled (Total Lung Capacity-TLC), how much air is exhaled (Forced Vital Capacity- FVC), and how quickly exhalation occurs (Forced Expiratory Volume in second- FEV1). The doctor can compare these measurements to a norm and determine how much lung damage has occurred.
There is no cure for COPD-damaged lungs. Once the doctor has established that a condition of COPD exists, the patient has to come to terms with a new reality dictated by how much lung function remains. The goals of COPD therapy is to stop or curb exposure to lung irritants (smoking cessation), prevent exacerbations, control symptoms to increase lung function, and learn new ways to maintain activities of normal living.
Caring for those with COPD
The possibility of caring for residents with Chronic Obstructive Pulmonary Disease in care homes stretches across the entire spectrum of the disease. Starting from the rare occurrence of a genetic defect or second-hand smoke, which caused cases in the developed mentally disabled, to the insidious stage where symptoms are just beginning to show in mental health homes where cigarette smoking is such a factor, to dealing with living with the aftermath of permanently damaged lungs in adult foster care homes. Caregivers must learn to recognize those at risk, help eliminate causative agents (stop smoking), watch for developing symptoms, and assist the resident in managing the disease once it is diagnosed. Because care home providers live with the resident 24 hours a day, 7 days a week, they can have a greater impact on COPD cases than any other medical profession.
Recognizing Symptoms and Seeking Treatment
It is impractical and cost-prohibitive to screen the general public for COPD. That is not the case in care homes, though. Care providers can review each client for risk factors and diligently watch for developing symptoms. If a caregiver has their suspicions of a developing COPD case, they can take their client to the doctor for a spirometry test.
The first caregiving step − screen each resident for the following risk factors:
The second caregiving step − watch for the signs and symptoms of COPD for those at risk:
It is essential for caregivers to remember the insidious (hidden) nature of COPD. For those residents with the greatest risk factors, a major portion of the resident’s lungs can be permanently damaged before the more obvious signs of the disease can be seen. The sooner a diagnosis can be given, the more lung function can be saved. The sooner the therapy starts, the easier it will be to maintain a normal lifestyle.
The third caregiving step − communicating your observations to the doctor:
Before sending their clients to the doctors, it is important for caregivers to document their observations and write down their concerns. Include the client’s medication in a printout and place it in the folder. Make sure the folder will accompany the patient to the doctor’s office. It is my experience that a printout in a folder is the best way to communicate with the doctor. They tend to pay attention to written documents more than verbal interactions. If family members are the ones transporting the resident to the doctor, your observations will not get lost in translation. If the caregiver is the one transporting the resident to the doctor, the file folder makes you look more professional. You get more respect and cooperation from the doctor, not only now but in the future as well. Be brief but thorough in your notes and try to include measurable facts.
For example—(you have my permission to copy this format in your own form):
Webster’s Golden Heritage Home
1234 Anywhere St, Anyplace Or -phone 503-555-7418
- Licensed Adult Foster Care Home -
Resident − Jane Smith
Age − 72
Medications − med 1 2 and 3 PRN med
Caregiver’s notes −
Doctor Jones, I am concerned about the possibility of COPD in Jane Smith. I have observed the following: Family history of breathing problems and father was a smoker. She also smoked for at least 20 years before quitting. She is cold intolerant, had a productive cough the last 3 months and tends to have crackling breaths in the morning. She has also had 3 colds in the last year. Do you think it would be wise for Jane Smith to have a spirometry test? Would you please include any follow-up caregiving instructions you have for Jane Smith in this folder and send it back with the patient?
Thank You.
Follow up instructions −
Caregiving Goals of Therapy
After a diagnosis of COPD has been made, the goals of therapy are to reduce problematic symptoms, maintain remaining lung function, and prevent exacerbations from occurring. To accomplish these goals, you as a caregiver have to help the residents understand and follow all medical orders. In addition, you have to find and take full advantage of all available therapies and resources. The emphasis of your COPD caregiving efforts falls into three categories: managing the patient, managing the therapy, and managing the environment.
Managing the Patient
The loss of lung function and the subsequent reduction of the oxygen supply to the blood forces the COPD patient to make changes in the way they live their life. The impact of those changes can be kept to a minimum if they take advantage of all the resources at their disposal. You, the caregiver, are in the best position to support these efforts to ensure the best possible outcomes are achieved.
Educate
It is my firm belief that the more knowledge a patient has about their condition, the better choices they will make on their own. Their efforts will be more consistent because they ‘know’ they are working for their own good. Take the time to inform the resident of what is going on in their lungs. Give instructions on how the lungs work, what has changed that has resulted in their COPD, and what that means for their future. Reassure them that you will help them learn ways to breathe better, slow the progression of the COPD, keep them from getting sick, and find ways to live a normal life. Here are some further resources that might help you educate the patient:
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Identify self-care deficits
Living with COPD creates many new challenges for your resident to overcome. Some will be easy to cope with, while other aspects might be too difficult to handle alone. Some residents may even have developed coping habits that are actually counterproductive. You, the caregiver, should know in advance what to monitor for and know ways to help. When you identify the difficulties they are having, you can get the additional equipment, training, or therapy they need.
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Aspects of COPD that might cause difficulty:
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Lifestyle Support
Helping residents live a normal life when extra care is needed is what foster caregivers do better than any other health profession. Who else actually lives with the patient? You will see what is needed before anyone else and notice areas of need that others might miss. But this will only happen if you are actively looking. You are also in the best position to help the patient make healthy lifestyle choices and continue with needed therapy, even when it becomes difficult. You should also be prepared to battle with the powers that be to get what your residents need and to help the residents do what is necessary to live a normal life. In the end, it will make your job easier and help you retain customers longer in your home. The following are areas where you can supply support for those with COPD:
Physical support − There are a number of things that caregivers can do to increase the patient’s activity tolerance:
Exercise support − There is a natural tendency to avoid exercise when you’re breathless. This leads to muscle wasting and weakness, contributing further to activity intolerance. In a twist of irony, it’s actually better for the patient to exercise. Fit muscles use oxygen more efficiently, and the added strength increases activity levels. In care homes, general exercise conditioning is easiest to accomplish in taking walks (my personal preference because it’s therapeutic on many different levels), using stationary bikes or simple steppers. Used exercise equipment can be purchased cheaply at thrift stores like the Salvation Army or Desert Industries. Caregivers should make exercise a part of the regular daily routine.
Nutritional Support − COPD symptoms tend to create nutritional imbalances. COPD creates a loss of appetite in many people. Additionally, in the more advanced stages of COPD, caloric requirements may not be met in a regular diet. Caregivers should start measuring the patient’s weight. If it starts to drop, then diets will have to change accordingly. It is recommended in such cases that additional high-protein, high-calorie snacks be given throughout the day. High-fat and high-protein are better than high-carbohydrate snacks, likewise bodybuilder supplements or adding a raw egg to nutritional drinks like Ensure or Boost, which are easy to purchase and supply to the resident. Snack resistance may occur due to appetite loss and flavor boredom. A way to combat this tendency is to allow the resident to choose additional ingredients like adding jams or jellies to the drinks or having a deviled egg instead of a raw one. Your creativity combined with the resident’s ability to choose will go a long way in overcoming resistance.
Emotional Support − It’s frightening to be breathless, and it’s frustrating to not be able to function like you used to. It’s easy for COPD residents to slip into depression or lash out in anger when their emotions get the better of them. Caregivers can:
Quit smoking − The most potent and important COPD therapy is to stop smoking. Unfortunately, tobacco addictions are among the strongest addictions that there is. The residents will need your assistance to be successful in quitting. As a caregiver helping the smoker resident, you need to consider the following:
Managing the Therapy
COPD is an incurable disease, but its symptoms can be managed. Therapies that reduce the impact of symptoms and slow the progression of the disease can be applied. If managed properly, COPD therapies can help the patient lead a fairly normal life. Foster care providers are positioned at the focal point between the patient and the medical community at large. They can push for needed therapies and help the resident understand and accomplish each therapy as it’s prescribed. Caregivers also play a major role in monitoring the therapy for effect and help report and manage any side effect problems that may arise. It would be wise for the care provider to learn about each new therapy along with the patient and, whenever possible, be trained in delegating therapeutic tasks.
COPD Therapies:
Oxygen Therapy
Supplying extra oxygen can help reduce most ill effects of COPD. It reduces the strain on the heart and shortness of breath, helps keep the resident active and thinking clearly, and it helps them sleep and feel better. Oxygen therapy requires a prescription that will need to be presented to a durable medical equipment or a medical gas supplier.
Each prescription will include:
Ultimately, the doctor will decide on which type of oxygen equipment that will be used. In order to make an appropriate choice, the doctor should be informed about the following factors:
According to UCSF medical center, there are three types of oxygen systems currently available: compressed gas systems, portable oxygen concentrators (POCs), and liquid oxygen systems.
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Type of System |
Ambulatory Component |
Stationary Component |
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Compressed gas system |
Small, pre-filled tanks delivered to you on a weekly basis, depending on how much oxygen you are using, or tanks that fill overnight at home (aka a home-fill system) from your concentrator. These small tanks must be used in conjunction with an oxygen conserving device or regulator (OCD) that delivers the oxygen in pulses so that the oxygen supply lasts longer. |
Oxygen concentrator with 50-foot tubing |
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Liquid oxygen system |
Small, refillable tank that you fill from the reservoir as needed. |
Oxygen reservoir with 50-foot tubing |
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Portable oxygen concentrator (POC) |
A small electric device that can be worn on the back or wheeled around, runs on regular electricity or a battery, is easily recharged even in a car, and requires no tanks or filling. The maximum tubing length for proper delivery of oxygen is 7 feet. These units can be taken onto airplanes. |
Source: https://www.ucsfhealth.org/education/supplemental_oxygen/your_oxygen_equipment/
The oxygen supplier is the expert on the system they deliver. Keep asking questions of them until you and your resident are comfortable with the equipment. Here are some questions to consider: How do I clean the equipment? What is the maintenance schedule? What do I do in power outages? How can they be reached after business hours? How can I order supplies and accessories (nasal cannula, masks, humidifiers, tubing, carrying cases, etc.)?
Monitoring oxygen therapy is a matter of monitoring the activity level of the patient and appearance of low oxygen symptoms. A pulse ox is a device that measures oxygen saturation levels. It is an important caregiver’s device to monitor blood oxygen levels and a deviation from the norm-needs to be reported to the doctor.
One side effect of oxygen therapy is that it dries out nasal passages. Ask the oxygen supplier what nasal moisturizer works well with their equipment. They may supply a humidifier attachment. If they have no suggestions, I recommend a saline nasa
l gel like Ayr, Nasogel, or Rhinase. Petroleum jelly is not recommended for use with oxygen therapy. The petroleum jelly tends to dissolve nasal cannulas, and droplets of jelly are inhaled and collect in the lungs.
Medication Therapy
There are several classes of medications that can be used to relieve and/or control COPD symptoms. They are expectorants, bronchodilators, and corticosteroids. Older medications come as a pill or in liquid form and are taken orally. Most newer medications are breathed directly into the lungs from a hand-held inhaler device or in mist form from a nebulizing machine. Inhaled drugs generally require less medication and have fewer side effects than oral COPD prescriptions.
Expectorants − Expectorants thin mucus and stimulate more productive coughing. The most effective expectorant in COPD is water. It may be unusual to think of water as a drug, but in COPD, adequate hydration is a very effective therapy. Unfortunately, it is possible to get too much water, and therapy can stray into harmful fluid overload conditions. Consult with the doctor for daily amounts of therapeutic fluid intake; remember that quantity is the total from all sources.
Bronchodilators − Bronchodilators work on the nerves that relax the smooth muscle layer of the lungs. They are designed to reduce bronchospasms and open up the lung’s passageways. There are short-acting ‘rescue inhalers,’ long-acting inhalers, and brochodilating oral medications.
Long-acting bronchodilators are the mainstay of COPD therapy. They are taken once or twice a day on a regular basis. Short-acting bronchodilators have a quick onset of action (seconds to minutes) but wear off too quickly to be used as regular therapy. They are usually taken on an as-needed basis when extra breathing help is required.
Normalized breathing patterns are what to monitor for when these drugs are used. Side effects are tachycardia, anxiety, headache, insomnia, nervousness, tremors, and restlessness. When a rescue inhaler is used, these side effects may become more pronounced temporarily.
The oral bronchodilators theophylline and aminophylline are older maintenance therapies that are usually only used when costs are an issue or when other alternatives have failed. They have a more prominent side effect profile, which includes dyspepsia, nausea, vomiting, diarrhea, headache, dizziness, and tachycardia. They also can interact with other medications (including caffeine), which will interfere with therapy and cause more side effects.
Corticosteroids − Inhaled corticosteroids are used to reduce the inflammation in the lungs. They have less effect on the course of COPD symptoms, so they are usually used in combination with a bronchodilator or as an add-on therapy. Again, breathing patterns are what to monitor for. The side effects are oral candidiasis (thrush or oral fungal infection), hoarse voice, skin bruising, and pneumonia. Rinsing the mouth after each use reduces the chance of side effects. Oral corticosteroids are usually reserved for exacerbation control.
Monitoring for the long-term effect − COPD is a progressive disease that could get worse over time. The medication regime might need to be changed to compensate. Watch for long-term trends in exacerbations, PRN med use, pulse ox readings, and increases in coughing; then report your observations to the doctor.
Inhaler use
Inhalers are a very efficient method of medication delivery but only if they are used correctly. The doctor and the pharmacist are supposed to give instructions and make sure the patient understands, but that doesn’t always happen. Instructions can be forgotten or misunderstood, and often the pharmacist never even sees the patient. That leaves you, the caregiver, as the final back-up to ensure inhalers are being properly used.
Here are a few ideas that might help:
Therapeutic Breathing Techniques
Being out of breath occurs more frequently and is harder to resolve in COPD. Normal methods of ‘catching your breath’ don’t work like they used to. That naturally leads to increased anxiety. Being stressed leads to faster, more forceful breathing. The extra air pressure leads to collapsed bronchioles, which traps more bad air, contributing to more breathlessness. It’s a downward cycle that needs to be broken by more therapeutic breathing techniques. When breathlessness occurs, the caregiver can be there to coach the resident in the proper way to catch their breath and help reduce anxiety.
Pursed-Lip Breathing − “Breathe in through your nose (as if you are smelling something) for about 2 seconds. Pucker your lips like you’re getting ready to blow out candles on a birthday cake. Breathe out very slowly through pursed-lips, two to three times as long as you breathed in. Repeat” (Source: COPD foundation). The goal of pursed-lip breathing is to slow rapid breathing, prevent small airway collapse, and help get rid of more bad air from the lungs.
Here is a video example: https://www.youtube.com/watch?v=7kpJ0QlRss4
Diaphragmatic Breathing − “This technique is best used when you’re feeling rested and relaxed, and while sitting back or lying down. Relax your shoulders. Place one hand on your chest and the other on your belly. Inhale through your nose for about two seconds. As you breathe in, your belly should move outward. Your belly should move more than your chest. As you breathe out slowly through pursed-lips, gently press on your belly. This will push up on your diaphragm to help get your air out. Repeat” (Source: COPD foundation). The goal is to utilize the diaphragm more efficiently to breathe and slow the respiratory rate.
Here is a video example; https://www.youtube.com/watch?v=wai-GIYGMeo
Better breathing tips:
Managing the Environment
COPD sufferers are more sensitive to environmental changes than other residents. Caregivers will have to learn how to recognize those effects that trigger an increase in COPD symptoms and control them. Once learned, the caregiver will have to pass on their knowledge to others—like family members. To help, care home owners could change heating filters more frequently, install HEPA air filters and have their air ducts cleaned.
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Potential triggers:
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Exacerbations
Even with proper caregiving, an exacerbation can occur, which could send the patient to the hospital. An acute exacerbation is a sudden increase in COPD symptoms that lasts days to weeks. If left uncontrolled, it could cause permanent damage that would hasten the progress of the disease. It would be wise to get standing orders from doctors that instruct the caregiver on what to do at the onset of symptoms.
The signs of a COPD exacerbation are:
The most common causes of exacerbations are upper respiratory infections. The caregiver can reduce this risk by ensuring the resident’s inoculations are up to date. Consult with the doctor or pharmacist on which shots are needed and keep an up-to-date record in the patient’s file.
Advanced Therapies
There will be times when you, or the resident, get frustrated and ask, “Isn’t there anything else that we can do?” At these times, it is important to remember that the lung damage is permanent, but there are a few advanced therapies that you could ask the doctor about:
Pulmonary Rehabilitation − Pulmonary rehabilitation is a disease management program run by a multidisciplinary team of specialists. They educate the patient, provide counseling when needed, develop and supervise exercise and nutritional programs. They are designed to help the patient and their caregivers manage the disease the best way possible.
Surgical options − For very serious cases, or for younger aged individuals, lung transplantation or lung volume reduction surgery may be considered. In lung volume reduction surgeries, the most damaged parts of the lungs are removed, allowing the rest of the lung to expand and work better. Both are considered major surgeries and have their own risks and possible complications.
Conclusion
Chronic Obstructive Pulmonary Disease is a progressive lung disease where the air flow is permanently compromised. It is a serious condition that can interfere with every aspect of normal living. The patient is going to need help learning a new lifestyle and managing the disease to slow its progression. Adult Foster Care providers are in the best possible position to help with the 24/7/365 activities that will be required of the patient. For the best possible result, the caregiver should learn, along with the resident, about all aspects of the disease. Caregivers should monitor all the therapies for effect and side effect and communicate their observations to the doctor. They should also provide social and emotional support for their client and help procure any needed resource or therapy.
As always,
Good Luck with your caregiving efforts!
Mark Parkinson BS Pharm
References:
COPD (Chronic Obstructive Pulmonary Disease). Physiopedia. https://www.physio-pedia.com/COPD_(Chronic_Obstructive_Pulmonary_Disease)
Your Oxygen Equipment. University of California San Francisco Health . https://www.ucsfhealth.org/education/supplemental_oxygen/your_oxygen_equipment/
COPD. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679
Chronic Obstructive Pulmonary Disease. Wikipedia. https://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease
Emphysema (chronic obstructive pulmonary disease). Osmosis. https://www.youtube.com/watch?v=TEuSV_7gWA8
What is COPD? COPD Foundation. https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx
COPD (Chronic Obstructive Pulmonary Disease) - Topic Overview. WebMD. https://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-overview#1
Charles Patrick Davis, MD, PhD. COPD (Chronic Obstructive Pulmonary Disease) Symptoms, Causes, Stages and Life Expectancy. MedicineNet.com. https://www.medicinenet.com/copd_chronic_obstructive_pulmonary_disease/article.htm
Ana Gotter. Pursed Lip Breathing. Healthline Jul. 3, 2017. https://www.healthline.com/health/pursed-lip-breathing#benefits
Unit 6 Respitory Problems. Pg 680-684. http://www.coursewareobjects.com/objects/evolve/E2/book_pages/monahan/pdfs/NursingManagement.pdf
Marianne Belleza, RN. Chronic Obstructive Pulmonary Disease (COPD). Nurse Labs Sep. 14 2016. https://nurseslabs.com/chronic-obstructive-pulmonary-disease-copd/
Gerene S. Bauldoff, PhD, RN,. When breathing is a burden: How to help patients with COPD. American Nurse Today August 2012 Vol. 7 No. 8.https://www.americannursetoday.com/when-breathing-is-a-burden-how-to-help-patients-with-copd-2/
Lindsay A. Brust-Sisti, PharmD, Changing the Paradigm: Focus on Preventing Exacerbations in COPD. Power-Pak CE. Aug. 23 2017. http://www.powerpak.com/course/content/115436
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The Caregiver’s Roles in Managing Constipation
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 3- Approximate time required: 180 min.
Educational Goal:
To explain how to manage constipation issues in Adult Foster Care homes.
Educational Objectives:
Define the role of caregiver in managing constipation
Debunk myths that have arisen about constipation
Explain how bowels work
Discuss how chronic constipation occurs and pseudo-constipation occurences
List effective therapies and medications and their management
Provide suggestions for effect communication about constipation and its management
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
The Caregiver’s Roles in Managing Constipation
Being constipated is one of the most common complaints of residents in foster care homes. It certainly was in the homes that I was in. Some of my residents almost seemed obsessed by the idea. If they didn’t consistently have a bowel movement every day, they would start demanding a laxative. I remember buying prune juice by the case, and my medicine cabinet was crammed full of bulk laxative powders and stool softeners. The normal breakfast routine was: set the table, prepare the food, and then mix the bulk laxative drinks. I was always in a rush to try to get the laxative drinks down the resident before it turned into a thick to mush. Before I became a care provider, I did not think I would be spending so much time thinking about other people’s bowel movements. It’s funny to think of it now—so many years later, I became a bowel movement expert.
Like it or not, the reality in care homes is, caregivers have to deal with constipation. Wikipedia, the online encyclopedia, reports that “Among elderly people living in a care home the rate of constipation is 50–75 percent.” Caregivers have to be concerned about the frequency and consistency of their residents’ bowel movements. They have to dispense laxative medication and monitor it for effect and possible side effects. When there is a laxative on the PRN (take as needed) med list, the caregiver has to determine, is there actually a need for the drug?
Another reality of caregiving is that since virtually everyone has been constipated and taken a laxative at multiple times in their life, they think they are the experts when it comes to their bowel movements. In actuality, a lot of that supposed expertise is based on myth and old wives’ tales—and this has led many to suffer from a condition called pseudo-constipation, the perception of constipation where actually none exists. If the resident does not experience a bowel movement on schedule, they think they are becoming ‘irregular,’ and they reach for a laxative to become ‘regular’ again. In their minds, the lack of consistency in bowel movements equals constipation, and the result—overuse of laxatives. The more often a laxative is used where none is needed, the more likelihood that a dependency on the laxative for normal bowel movements will develop. The caregiver often finds themselves trying to dispel myths and struggling to break bad laxative use habits. If the caregiver does not have a good understanding of bowel movements themselves, their resident behavior modification efforts become so much hard to accomplish.
Mental health homes and other caregivers have to deal with the added complication of laxative abuse. The resident’s overuse of laxatives is tied to larger psychological issues. Some good examples are laxative abuse stemming from the eating disorders anorexia and bulimia.
So, let’s start by giving you the needed basic education you need to fulfill your dual roles of bowel movement expert and resident behavioral modification support specialist.
How Do Bowels Work?
We get the nutrients we need from the food we eat as it passes through the alimentary canal within our body. The alimentary canal or gastrointestinal tract (GI tract) is basically a tube within our bodies made up of several different organs. Each organ is responsible for a different step in the process of extracting what we need from what we eat.
The upper GI tract is comprised of the mouth, throat, and stomach. Their function is to mash up the food and inject liquids and digestive fluids. The digestive fluids contain enzymes and acids that further chemically break down the mashed-up food into a more easily absorbable food slurry.
The lower GI tract is made up of the accessory organs, the small intestine, large intestine, and rectum. The main accessory organs are the liver, gallbladder, and pancreas. They aid in the further breakdown of the flood slurry. The small intestine is a long, folded and coiled tube (about 10 feet in adults). It receives the food slurry and absorbs about 90% of the nutrients we need from it. What is leftover is indigestible and is passed to the large intestine as waste. The large intestine reabsorbs the water from the slurry waste, turning it into a paste. The more time the waste stays in the large intestine, the more water is reabsorbed. The paste becomes more and more solid, making it easier to expel. The solid waste is pushed into the rectum. As the rectum expands, stretch receptor nerves send signals to the brain that it’s time to go to the bathroom.
How Does Constipation Occur?
Food travels through the GI tract and is moved by three main factors: gravity, regular body movements, and peristalsis. 
Peristalsis is defined as “successive waves of involuntary contraction passing along the walls of a hollow muscular structure (such as the esophagus or intestine) and forcing the contents onward” (source: Merriam-Webster). While gravity and peristalsis are, for the most part, constant forces, food passage caused by body movement is dependent on how active the body is. Under normal conditions, material passes through the GI tract automatically and without difficulty.
Constipation occurs when something interferes with the three main forces involved in bowel movements. The result is, fecal matter stays in the large intestine for longer periods of time. The more time spent in the large intestine, the more water is reabsorbed. The fecal matter collects and becomes more and more solid, resulting in constipation. The same results happen when the urge to defecate is ignored. Constipation can also be caused by disturbances in the underlining physiology of the GI tract. An easier way to comprehend that is, there is something broken in the machinery that runs the plumbing in the bowels. Some of the parts just don’t work right.
Chronic Constipation
Occasional constipation is quite common. Random events conspired to cause a temporary bout of constipation. The events are usually self-limiting. The body can make the required adjustments that will take care of the problem by itself. The caregiver doesn’t have to worry about such events. Chronic or frequently-occurring constipation is a different matter; it becomes a problem when it does not go away by itself. It can make your resident very miserable and create several complications. Along with the discomfort in the lower GI, the resident could also experience bloating, flatulence, nausea, loss of appetite, headaches, frustration, and irritability.
Other complications caused by chronic constipation are:
The seriousness of constipation was shown to me in a very real and tragic way. When I was a pharmacist practicing in Coos Bay, we had a bathroom next to the pharmacy that both the staff and the public used. One day, there was a customer that would just not leave the bathroom stall. Eventually, his wife came looking for him. I went into the bathroom to check on him. I didn’t want to cause embarrassment, so I just took a peek under the stall door. I saw an arm, which had turned blue clear up to his elbow, dangling near his feet. He supposedly had a heart attack while straining and died right there on the public toilet. What a way to go, and how sad it was for the worried wife!
Causes of Chronic Constipation
Chronic constipation is not a disease unto itself. It is a symptom of other issues. Frequent or long bouts of constipation are a red flag warning the caregiver that something is going wrong, or a condition is getting worse. A savvy caregiver can use this to their advantage and nip potential problems in the bud. In regards to constipation, these are the things that caregivers should be thinking about:
|
Demographic |
Daily recommended amount of water (from drinks) |
|
children 4–8 years old |
5 cups, or 40 total ounces |
|
children 9–13 years old |
7–8 cups, or 56–64 total ounces |
|
children 14–18 years old |
8–11 cups, or 64–88 total ounces |
|
men, 19 years and older |
13 cups, or 104 total ounces |
|
women, 19 years and older |
9 cups, or 72 total ounces |
|
pregnant women |
10 cups, or 80 total ounces |
|
breastfeeding women |
13 cups, or 104 total ounces |
Source: https://www.healthline.com/health/how-much-water-should-I-drink#recommendations2
Opioid/Narcotic Drugs that Cause Constipation:
Some of the major medication culprits are:
Antidepressants − amitriptyline, imipramine
Anticonvulsants − phenytoin, carbamazepine
Mineral supplements − iron and calcium
Antacids that contain aluminum and calcium
Antipsychotics − clozapine, thioridazine, chlorpromazine
Calcium channel blockers − verapamil, diltiazem, nifedipine
Parkinson’s disease medication − levodopa
The Roles of the Caregiver in Constipation Care
Having a basic knowledge of the working of the bowels and constipation is only the beginning. In order to be a good caregiver, you have to be able to apply that knowledge for the betterment of your residents. The proper application of knowledge is what I will call ‘being a savvy caregiver.’ Let’s see if I can help turn you into that savvy caregiver!
The bottom line (excuse the pun) of constipation care is to recognize it as a symptom that has resulted from a number of possibilities, not as a disease that needs a cure. When constipation occurs, the first thoughts of a truly efficient and effective caregiver are: “What has gone wrong, and how can I control it?” If you reach for the laxative first without this first step, you might have doomed the resident to further constipation once the laxative wears off. In plain terms, you resolve constipation, not cure it.
The savvy caregiver will realize that this change in emphasis has added several layers of complexity to their job. They are going to have to become a researcher, monitor, patient advocate, and symptom manager. But the savvy caregiver will also realize that if they get those roles right, their job will actually get easier. Bouts of constipation will become fewer and be more easily managed. Let’s talk about these different caregiver roles that will be required of you:
Being a Researcher
The primary goal of bowel care in foster care is maintaining bowel regularity. That first involves knowing what ‘regular’ means for each resident. Unpleasant as it sounds, you will be required to pay attention to when the resident goes to the bathroom and research what goes on in there. I know it might be an embarrassing and uncomfortable thought. Take comfort in knowing that this is the role the resident expects from you. It will be a natural occurrence for you to ask questions about their bowel movements. Being pleasant, confident, consistent and professional takes the edge off of the task.
Here are a few other ideas that I think will help:
Being a Monitor
Once you get a handle on what being regular means for each resident, it’s time to switch roles to that of a monitor. Monitoring involves always being aware of what is going on in the lives of your residents. Savvy caregivers are always on the lookout for the signs that something has changed.
The signs of constipation include:
A major portion of the information you gather while monitoring will come from communications with the resident. A savvy caregiver knows monitoring does not end there. You are going to have to interpret what the resident is saying and compare it to what you are observing. Most often you will believe what they are reporting to you, though that is not always the case. Sometimes, what you see in your monitoring will be more important than what the resident tells you when you question them. The following are some of the special cases that I have observed in my caregiving and pharmacy careers:
Over Reporting
Very few of your residents will have had any medical training. When you question them about constipation, their answers will be tainted by what they think they know—what they know about the bowels they picked up from who knows where. Some of their perceptions are correct, some are correct but described wrong, and some are a just flat-out myth. You won’t be able to do your job right until you get accurate information from them. That will happen only after you get rid of their misconceptions.
Misconceptions are driven by fear and myth. The truth will cut through misconception but only if it is given with empathy, patient explanation, and good communication techniques. In other words, your residents will not listen until they know you care and sympathize with them. Talk to your residents in ways they understand and give them enough time to assimilate the information—that is done by a consistent, proper follow-up.
“What does all that fluff and stuff mean?”, you ask. The first couple of times you ask them about their bowels, what they tell you will most likely be wrong or inaccurate. You will have to verify and clarify their answers with your own observations. For those bits of info you find wrong, you’ll have to properly educate them on what is actually going on. This is one of those tricks that turn caregivers into savvy caregivers.
Constipation Truth and Myth
One of the most common resident misconceptions about constipation is what is called pseudo constipation. It’s one of those “correct but described wrong” events. What they call constipation is actually a lack of consistency in bowel movements. The myth is, if you don’t have a bowel movement every day, you’re getting constipated. Some residents get fixated on daily consistency and try to achieve it through the misuse of laxatives. The misuse leads to laxative dependency, and the body loses its ability to regulate itself.
The truth is, being irregular is not the same as constipation. Bowel movements are variable and are dependent on what we have eaten and how active we’ve been. The truth is, if nothing has collected in the rectum, you don’t need a bowel movement. Modern medicine has observed that among healthy people, bowel movements can vary between three times a day and three times a week. Using this as a guideline, true constipation in healthy adults would only start to occur after about three days.
As a caregiver, if the resident reports that they are constipated, you have to ask yourself, “Is this a matter of consistency or constipation?” To find out, you’ll have to ask follow-up questions: “When was your last bowel movement?” “How active have you been?” Are there any contributing factors to consider? How healthy are they, or can the resident’s body take care of the problem itself? How psychologically stressed do they get if they don’t get a laxative? How solid is the stool when they do go? That’s a lot of questions. Over time, and with practice, you’ll get good at finding the true answers. At first, I recommend erring on the side of resident comfort. If there is pseudo constipation going on, it will take time to ease the resident out of it.
Constipation is an illness that needs a cure (laxative). That is a flat-out myth. The truth is, constipation is not a disease that one catches like a cold. It is a symptom, which is to say that it is a natural consequence that is the result of other processes. The correct way to understand constipation as a symptom is, it is either a primary or secondary result of other events. Primary constipation is caused by natural body processes like not eating enough fiber. Secondary constipation is the result of separate disease processes like Irritable Bowel Syndrome or Chron’s disease. Sometimes, constipation is described as idiopathic, or the cause is just unknown.
It may seem like I am splitting hairs here, but this is actually a very important point to drive home to the resident. It means that instead of reaching for a laxative to ‘cure’ constipation, you work on correcting the underlining causes, and constipation goes away by itself. It’s a matter of trusting the body to take care of itself. Enforcing proper daily habits and good caregiving techniques will be your most powerful tools in fighting this myth. If there is a strong fear of constipation as a disease in the resident, reassure them that constipation only causes harm if it gets out of control. Tell them that you won’t let that happen.
Toxins in the stool is a fear myth. It leads the resident to believe that constipation causes toxins to build up in the bowels, and they will cause harm. As a pharmacist, this myth kind of makes me mad. You’ll notice that the persons pushing this myth the hardest are the ones trying to sell you something. They are trying to make money by whipping up a fear that constipation is causing the patient to poison themselves. What a bunch of hogwash! There have been pseudo scientists pushing this quackery for well over a century. They even went as far as creating clinics that administered coffee enemas and high colonics. If you take a closer look, you won’t find much credible scientific evidence to back up their claims. If you find yourself having to deal with this myth, start by telling them that a pharmacist told you that the main ingredients of these ‘de-toxifying’ products are just plain laxatives. Then ask them how many ‘local’ doctors do they personally know who actually prescribe detoxifiers, or how many pharmacists recommend their purchase. The answer is, “None do.”
Underreporting
There are times when constipation issues keep reoccurring without any apparent medical reason. Full-blown bowel problems just seem to appear out of nowhere. In my experiences, I discovered three possible root causes of these mysterious occurrences:
Modesty is a powerful social consideration. At its core is the expectation of privacy. You just don’t let others see you in the bathroom with your pants down. Also, you don’t talk about what goes on in the bathroom. Some of your residents would rather suffer physically than suffer embarrassment. This leads to residents downplaying their symptoms and underreporting problems associated with their bowels.
Privacy concerns can lead your residents to fear going to the bathroom in public or unfamiliar places. As a result, residents ignore their bowel urges, causing constipation issues in normally regular clients. This is a particular concern in certain mental health and dementia cases and when the developmentally disabled are required to go into unfamiliar settings.
Emotional stress in mentally venerable populations can cause constipation. It’s part of the ‘flight or fight’ hormonal response to stress. Talking about it just adds to the stress, so they avoid the subject.
In these cases, monitoring for constipation can be problematic. The resident’s silence, emotions, and fear put up a wall that’s hard to see through. The solution to this problem is found in the realization that there are two exceptions to the modesty, privacy, and stress concerns. It is allowed and even expected to talk about bathroom concerns with your mother and medical professionals. Fortunately, adult foster care providers are naturally a little of both. The savvy caregiver can handle underreporting problems by:
Being a Patient Advocate
Your caregiving role in constipation will be, for the most part, monitoring the patient and following doctors’ orders. There are times, though, when you have to take on the additional role of patient advocate. Constipation is a common occurrence and is easily solved through the use of laxatives. It is easy to lose sight of the fact that constipation is a symptom, and its chronic occurrence might be a sign of more serious concerns. Doctors are taught to actively look for critical concerns, but they are hampered by two problems:
Savvy caregivers know that it’s up to them to report serious concerns when they arise. They also know that they might have to become a bit of a thorn in the doctor’s foot. Sometimes, you’ll have to push a little bit to get the problem looked at seriously.
Communications with the Doctor
When interacting with other medical professions, it’s very important to be crystal clear in your communications. Just saying “My resident is constipated” is not going to be good enough to get the doctor’s attention. You are going to have to give facts and quantifiable details. Timeframes, the frequency of occurrences, numerical level of pain and discomfort on a 1−10 scale, and other related symptoms like nausea and vomiting should be in your communications and paperwork.
Blood in the stools or on underpants is an automatic trip to the doctor. The blood is going to be bright red or pink if it is from a surface cut or a major bleed internally. If it is a minor or moderate bleed internally, it will be mixed with the fecal material, giving it a distinctive order and texture. Look for black tarry stools or stools that look like coffee grounds.
In your communications, you will not be telling the doctor what the diagnosis is, but you can ask all the questions you want. It’s a polite way of being a pushy patient advocate. Put the question in writing, with a place for a written response. For example, “Could the increase in constipation be related to the new iron supplements you ordered? If so, what changes will you want me to follow-up on?” or “There has been a threefold increase in this month’s PRN laxative use. Could this be an indication that the increased stress behavior (or insert any other possible concern) needs to be looked at? Yes ___ No ____.” Don’t be afraid to use medical terminology. If you know it, use it. That will get the doctor’s attention faster.
Another important factor in communicating with doctors is: telling them what has changed. This will give the doctor important clues that will help them make a proper diagnosis. In order to know what is different, it is very important to know your resident inside and out. When thinking about the bowels, that ‘inside out’ statement takes on a whole new literal meaning.
Savvy caregivers will know which questions to periodically ask which resident. They will know that paying close attention to the PRN medicine logs makes it easier to see subtle changes in their residents. They will notice changes in behaviors and will not ignore an increase in a resident’s complaints. They will take note of a resident’s difficulty in accomplishing normal activities of daily living. They will also be on the lookout to see physical changes in the resident.
To help you recognize changes in stools and give a clearer report to the doctor, I recommend using the Bristol Stool Form Scale:
Being a Symptom Manager
There are two considerations in being a symptom manager in a care home. The first is: managing the lifestyle of the resident to prevent the problem. The second is: to manage the medical therapy ordered by the doctor to resolve the issue. But you already knew that it’s what the average adult foster caregiver does every day. I don’t want you to be average. My goal is to tell you what the savvy caregiver does to excel at what they do.
Prevention
To excel in bowel care, savvy caregivers should take the time to understand how the bowels work and set up their homes to maximize the body’s own bowel regulating processes. While there is no way to ensure never experiencing constipation, setting up your home routines using the following guidelines should help prevent constipation:
* A special note about the use of prunes as a therapy:
If you intend to add prunes or prune juice to resolve a case of constipation, you have come dangerously close to crossing the forbidden ‘choosing a therapy’ line. Keep yourself out of trouble by communicating with the doctor. The doctor should also know if you intend to add prune products as a regular daily menu item.
* A special note on habits as a caregiving tool:
Good habits are the caregiver’s best friend. Don’t underestimate the power of habit in the lives of your residents. Savvy caregivers actively work at setting routines and consistently enforce them.
Medical Therapy
You might think that your role in medical therapy is to just follow doctors’ orders. The savvy caregiver knows that this is only part of their role. Following orders is not a robotic event. It’s not good enough to just blindly follow orders. You have to understand what the doctor is trying to do, ensure resident compliance, monitor for effect, and report your observations back to the doctor. In effect, the savvy caregiver turns themselves into the doctor’s advocate with the resident.
Understanding what the doctor is trying to do
The therapeutic choices made by the doctor are determined by what they think is needed to be done to resolve the underlying issues. Sometimes, the doctor’s rationale is not readily apparent. Caregivers should research and ask questions until they have a good handle on what the doctor is trying to do. It will help determine what to monitor for and how to educate the patient.
Here are few general things I have noticed that influence a doctor’s decision about constipation (it will help you in doing your research):
Ensuring Resident’s Compliance
As the doctor’s advocate in the home, it is your job to help the patient cooperate with the doctor’s orders. Cooperation is a lot easier to obtain if the resident knows what is actually going wrong and has a realistic expectation of what the doctor can do about it. Translate what you know into a language the resident understands and dispel any myths you encounter.
For example, it is unrealistic to expect instant relief of constipation. Let the patient know that most laxatives take a day or two to start working. It is unlikely the resident will be harmed if they have to wait for relief. If that is not fast enough for the resident, and they start to demand an enema, teach the resident about item number 3 above. Knowing the facts helps the resident to have less anxiety and increases the resident’s confidence in the doctor’s recommendations.
Monitoring For Effect
As the doctor’s advocate, you are their eyes and ears. You have to watch to see if the choices they have made are actually doing what the doctor intended. You also have to watch for any unwanted side effects.
The acute resolution of constipation is easy enough to monitor, but what about chronic therapy? That’s where PRN logs come in handy. Watching the pattern of PRN med use can help you understand what is normal for your resident. If the PRN log entries start to show changes, it is a red-flag signal. Start looking closer at what is causing the change. It’s the old “a stitch in time save nine” thing.
There is one more thing I would like to note before getting into the actual constipation medication: Doctors don’t have crystal balls; they are always in the dark about what goes on with your resident. They can’t see your PRN logs. They will assume that everything is all right until somebody has a complaint. So, if things aren’t going right, let the doctor know. The more information you can provide to them, the better doctors they will be to your residents.
Medications
Most of the medications used for constipation are available ‘over the counter’ (OTC). That does not make them automatically a milder form of therapy. Some are very strong and carry with them dangers of misuse and dependency. Fortunately, selecting the appropriate drug is the doctor’s worry; your job is to monitor for effect and watch for unwanted side effects.
OTC Constipation Medications by Drug Effect
Lubricant/Emollient
Docusate (Colace, Surfak) softens the stools by adding fats and pulling in water. It does not have a laxative effect and is used mainly to help prevent straining. It is very well tolerated with little side effects and may take 1−3 days for effects to be seen.
Mineral Oil also has a softening effect but is mainly used as a lubricant. It can be taken orally, though it is most often used as an enema. It can be swallowed into the lungs (aspiration), where it will cause problems. It also tends to block absorption of vitamins in the bowels, so it is not for long-term use. If used as an enema, it can take up to 6−8 hours to work.
Bulk-forming
Psyllium (Metamucil, Konsyl), calcium polycarbophil (FiberCon), methylcellulose (Citrucel) are fiber supplement laxatives that work by pulling in water and adding bulk to the stools. The added bulk triggers the stretch receptor nerves that stimulate peristalsis and increases the urge ‘to go.’ They may take several days to start to work. In my experience, they are mainly used as a preventative. There is a danger that they could contribute to fecal impactions. They will also tend to create a bloated feeling and produce more gas.
Osmotic laxatives
Magnesium hydroxide (Milk of Magnesia), magnesium citrate (Citroma), polyethylene glycol (Miralax), sodium phosphate (Fleet Saline Enema), glycerin (Fleet Suppository) are stronger saline laxatives. They work by retaining water in the stool and pulling in more from the intestines. Their actions can be seen in as little as 30 minutes up to overnight. Be warned: they can cause cramping and add to dehydration problems. In some people, osmotic laxatives stop working if used continuously, so monitor for effect, even if they have been on it for a while.
Stimulant laxatives
Bisacodyl (Dulcolax Correctal), senna/sennoside (Senokot) stimulate the muscles of the intestines to contract, pushing the stools through faster. They take 6−8 hours to start working. Obviously, cramping may be an issue. There is also a strong possibility of tolerance and dependence developing with long-term use.
Some final notes:
Prescription Medications
Anti-constipation prescription drugs are usually used only when first-line therapy fails, or there is a specific need. If you are struggling with your current OTC therapy, they can be used as an alternative or as an add-on therapy. Before starting that conversation with the doctor, there are a few thoughts to keep in mind. Prescription drugs will cost more than OTC meds. In my opinion, they are not a more powerful alternative; most are a more specifically targeted therapy. Some are relatively new drugs, so the doctor might not have much experience with them.
Sugar syrups
Lactulose and Maltose are chemicals similar to sucrose (table sugar). They have a sweet taste, but we have a hard time digesting them. Most of it goes straight through to the bowels, where it pulls in extra fluids by osmosis. They can be used as sugar substitutes, but when taken in larger quantities, they have a laxative effect. Unfortunately, the bacteria in our gut have no problem digesting the chemical sugars, so there might be the extra side effects of gas, bloating, and cramps. As a prescription, they come in a thick maple syrup-like liquid. Adding active cultured yogurt to the diet might help control the gas.
Naclotide (Linzess)
Linzess mimics some of the body’s own mechanisms to draw water into the bowels. It has been approved for use in IBS and Idiopathic constipation. It should be taken 30 minutes before breakfast. It can cause severe dehydration in children, so it is not approved for children under 6. The side effects are diarrhea, gas, stomach pain, and headache. Linzess should not be crushed or chewed, but it can be taken apart and sprinkled over food or given via the NG tube.
Lubiprostone (Amitiza)
Amitiza works on the chloride channels of the gut, drawing in more fluid. It is used in a variety of conditions, including opioid-induced constipation. Common side effects may include nausea, stomach pain, diarrhea, gas, bloating, or a headache. Taking Amitiza with food can help control nausea if it becomes a problem.
Plecanatide (Trulance)
Trulance also mimics some of the body’s mechanisms to draw water into the bowels. Plecanatide is a new drug approved for chronic idiopathic constipation, with more disease therapy approvals likely to follow. It can be crushed and taken with or without food. The most common side effect is diarrhea.
Conclusion
We’ve covered a lot of material fairly extensively. You will notice that the skills required for resolving constipation problems will help improve the rest of your caregiving efforts. Those who master managing constipation therapy become better all-around caregivers.
It requires you to:
Hopefully, I have done my job and given you the potential to become a savvy caregiver. Now, it’s up to you to become one.
As always,
Good Luck with your caregiving efforts!
Mark Parkinson BS Pharm
References:
Dr Ananya Mandal, MD. Drugs that Cause Constipation. News Medical Life Sciences . Aug 3, 2017 https://www.news-medical.net/health/Drugs-that-Cause-Constipation.aspx
How the bowel works. Coloplast Stoma Care. Apr 5, 2013.https://www.youtube.com/watch?v=6CoIDScAzog
Tim Taylor,. Digestive System. Innerbody. http://www.innerbody.com/image/digeov.html
Constipation. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253
Gil Wayne, RN. Constipation. Nursing Labs. Aug 9 2012. https://nurseslabs.com/constipation/
Understanding Constipation. AGA Institute. brochure 375-057IND_12-1. http://www.gastro.org/patient-center/Understanding_Constipation_Brochure_Jan_2013.pdf
Jeannette Y. Wick, RPh,. Finding Effective Relief for Constipation. Pharmacy Times. Jun. 24, 2013. http://www.pharmacytimes.com/publications/otc/2013/otcguide-2013/finding-effective-relief-for-constipation
Jay W. Marks, MD. Constipation (Relief, Home Remedies, Treatment Medications). MedicineNet.com. https://www.medicinenet.com/constipation/article.htm
Over-the-Counter and Prescription Constipation Medications. Healthline. https://www.healthline.com/health/constipation-medication#otc-medications2
Medicines to Treat Constipation. WebMD. https://www.webmd.com/digestive-disorders/prescription-medications-to-treat-constipation#1
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The Myth of the Almighty Antibiotic
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To give Adult Foster Care providers the proper perspective about antibiotic therapy.
Educational Objectives:
To dispel myths that has risen around antibiotics
List the types and classes of antibiotic drugs
Define empiric therapy vs definitive therapy vs Prophylaxis Therapy
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
The Myth of the Almighty Antibiotic
Since the 1940s, Antibiotics have been the wonder drug that has transformed the landscape of modern medicine. Entire diseases have been virtually eradicated from the face of North America. They have worked so well that the myth “The Almighty Antibiotic” has arisen in the public’s mind. For those that believe in the myth, every time a child has an earache, or an elderly mother develops a cough, an antibiotic is demanded by well-meaning caregivers. Belief in the myth is so strong that if antibiotics are prescribed, they are taken only until the symptoms go away, then the leftovers are saved for future illnesses. The truth is, the use of antibiotics is not so clear-cut. Like all therapies, they need to be applied with skill to only those that need it. As with all drugs, antibiotics need to be monitored for effect and side effect, and there is always the risk of allergic reactions developing. In the home, caregivers play a key role in ensuring that antibiotics are utilized appropriately.
Antibiotics (more accurately called antibacterials) are drugs used to treat infections and or prevent bacteria from growing in the first place. They work by either killing outright or inhibiting bacterial growth. Once the growth is slowed, the body’s own immune system can take over and eradicate what’s left of the infection.
Antibiotics were first discovered in 1928 by Dr. Alexander Fleming, who noticed dead zones in a bacterial culture he was growing. He learned that mold had contaminated the culture and had secreted what he called ‘mold juice’ that killed the surrounding bacteria. That discovery led to the development of Penicillin. Since then, hundreds of other antibiotics drugs have been developed. The most commonly used are generally grouped into 10 drug classes:
How are antibiotics selected by the doctor?
The primary consideration in antibiotic selection is the effectiveness of the drug at controlling or preventing a bacterial infection. Generally speaking, antibiotics’ effectiveness is determined in three different ways: definitive therapy, empiric therapy, and prophylaxis therapy. Secondary considerations are: the cost of the drug, its side effect profile, its interaction with other drugs or disease states, and the duration of therapy.
Definitive Therapy
In definitive therapy, the responsible microorganism is already known. A pathogenic diagnosis is reached by determining the site of infection, defining the host (e.g., immunocompromised, diabetic, advanced age), and when possible, a microbiological culture diagnosis.
A microbiological culture diagnosis is determined most often in a lab. A sample is grown so that the bacteria can be examined under a microscope. Some bacteria need to be stained with chemicals so that they can be seen and identified easier. The process was first invented by Hans Christian Gram, a Danish bacteriologist. The way the bacteria take the stain helps determine what kind of bacteria they are, generally known as gram positive or gram negative.
Once the bacterium is known, the narrow-spectrum antibiotic can be chosen. Choosing an antibiotic with a narrower scope of effect helps make the therapy more effective. It reduces side effects, the duration of therapy, and its cost. Unfortunately, growing the culture can be difficult and ironically adds additional costs and time. Often the costs are even higher than the benefits gained from the narrower spectrum drug, making definitive therapy prohibitive.
Empiric Therapy
Waiting for a definitive bacterial identification is frequently impractical. Patients are not very patient and usually want therapy now. There are also those who are in such a critical state that waiting would be unethical. Often the doctor can rely on their experience to identify the ‘most likely’ bacterial pathogen. Therapy based on an educated guess is called empiric therapy. In such cases, a broader spectrum antibiotic, which covers a wider range of bacterial possibilities, is chosen.
Prophylaxis Therapy
The third antibiotic therapeutic choice is prophylaxis or applying antibiotics to prevent the ‘possibility’ of an infection. Again, the specific bacterial target is unknown. The antibiotic is chosen based on the ‘most likely’ microorganism that could cause an infection. They are usually shorter, more targeted courses of therapy, sometimes even a single dose. Prophylaxis is usually seen in surgeries, used in dental procedures and to prevent the spread of a known pathogen in a susceptible population.
Problems with antibiotic use
The potency of antibiotics and their ease of administration have spread the use of these drugs throughout the world. In popular culture, there has developed a general anticipation that if you get sick for any reason, you ask for an antibiotic, and things will get better. Antibiotics are asked for even when the patient knows there are no bacteria involved. They think, Let me take them just in case they will help; there will be no harm. The reality is that these drugs are not without side effects, and their popular use has created the potentially dangerous consequence of antibiotic resistance.
Side Effects
It is almost impossible to control where an antibiotic goes once it has been ingested. This creates the potential for unwanted effects. The drug may affect other body processes, interfere with other medications, or kill off the beneficial bacteria that the body relies upon. Each prescription comes with a listing of potential side effects that have occurred in other patients while taking the drug. These side effects may or may not occur in every patient. Even if they do occur, their effect may or may not prove to be significant.
Intestinal Flora Imbalance
In the gut of each person resides a whole world of microbes. It’s a flora of good bacteria (which we rely on), bad bacteria (which could multiply and cause harm), and other microbes like yeasts and molds. We can function normally because this flora is in balance. The good microbes help to keep the bad microbes in check. All antibiotics are designed to eradicate bacteria, even the good bacteria that is helping to maintain the balance in our flora. As a result, every course of antibiotic use has the potential of causing other infections to grow and cause problems. This is a particular concern in patients with compromised immune systems.
Some of the more common antibiotic-caused infections are:
Antibiotic Resistance and Superinfections
By far, the most serious problem in antibiotic use is the emergence of antibiotic resistance, which has caused the rise of superinfections. No two living things are exactly the same. As with all things, there are tiny differences between each bacterium. Some of these variations give the bacteria a survival advantage over others, causing them to grow and reproduce. It’s the natural evolution of the species. The same evolutionary process occurs when antibiotics are taken. The medication does not kill off all of the target bacteria. Those bacteria that have survived and multiplied are now resistant to the antibiotic. If an infection arises from that new resistant strain, other means will have to be used to stop the infection. Eventually, antibiotic-driven evolution creates bacteria that are very hard, if not impossible, to stop. They are commonly called superbugs or superinfections. A superinfection you might have heard about is MRSA (Methicillin-resistant Staphylococcus aureus). It is a very serious infection that has claimed the lives of many victims.
The same resistance evolutionary progression can occur in the cleaning and sterilization processes. In hospitals and other medical facilities where cleaning and sterilization occur regularly, new tougher strains of bacteria have arisen. Infections that are acquired in hospital stays are generally harder to get rid of than those infections acquired in the community at large. Hospital-acquired infections are also called nonsocial infections.
Antibiotic misuse
With appropriate use, followed up by skillful caregiving, antibiotic resistance can be limited. Unfortunately, there are several factors that continue to contribute to the rise of further antibiotic-resistant bacteria:
What is the Caregiver’s role in antibiotics?
As with all therapies, adult foster care providers play several key roles in antibiotic use in their homes. Caregivers are patient advocates ensuring the residents get the therapies and resources they need. They are also the doctor’s advocate with the patient, ensuring instructions are followed. They are patient monitors, looking for effects and side effects. Finally, they are communicators, educating the resident and informing the doctor about important follow-up information. But besides these obvious roles, the caregiver has several important aspects to be aware of regarding antibiotics and the spread of bacterial infections:
Conclusion
The myths of antibiotic use have arisen in popular culture since they were discovered in the 1940s. There is a common belief that there is a pill for every illness and that antibiotics work for every case. Such myths are far from the truth. Patient, doctor, and caregiver actions based on these myths have contributed to the rise in antibiotic resistance and the creation of superinfections. Caregivers play key roles in the proper use of antibiotics and the handling of infections in their residents.
References:
Antibiotics. Wikipedia.com. https://en.wikipedia.org/wiki/Antibiotics
Antibiotics Guide. Drugs.com https://www.drugs.com/article/antibiotics.html
Christian Nordqvist. Antibiotics: All You Need To Know. Medical News Today. Mon 2 January 2017.https://www.medicalnewstoday.com/articles/10278.php
Antibiotics: An overview. Khan Academy. https://www.khanacademy.org/science/health-and-medicine/current-issues-in-health-and-medicine/antibiotics-and-antibiotic-resistance/a/antibiotics-an-overview
Iris Dawn Tabangcora, RN . Antibiotics. Nurse Lanbs.com. Jan 9, 2017.https://nurseslabs.com/antibiotics/
Yvette C. Terrie, BSPharm, RPh. A Patient's Guide to Proper Antibiotic Usage. Pharmacy Times. Dec 1 2014.http://www.pharmacytimes.com/publications/issue/2004/2004-12/2004-12-4835
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Putting the Mouth Back Into the Body
Improving Preventative Oral Care
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To put emphasis on more effective oral care in adult foster care homes
Educational Objectives:
Explain about the disconnect between medical care and oral conditions in the mouth
List the medical conditions affected by neglected oral care
Explain about oral care factors in adult foster care
Provide a list of oral care products available today
Provide a list of helpful hints
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Putting the Mouth Back Into the Body
Improving Preventative Oral Care
It may sound funny, but there is a major new health initiative to put the mouth back into the body. Let me explain; in the past, there has been a huge disconnect in oral medical care. Conditions in the mouth were shunted off to an almost separate health system called dentistry. Non-dentistry medical practitioners ignored conditions in the mouth. They, for the most part, relied on the patient to seek out dental care by themselves. Unfortunately, no one likes going to or paying for dentists, including insurance companies. The result—for a large portion of the population, medical problems in the mouth were ignored. This disconnect occurred even when there were clear links between what goes on in the mouth and the health of the rest of the body. The result was a downward spiral in health for these patients. Their medical conditions contributed to poor oral health and hygiene. Inflammations, infections, and tissue destruction resulted in the mouth. This led to pain, discomfort, and bad breath, leading to alteration in behaviors in the patient. Untreated infections continued to grow, destroying dental tissues and negatively altering normal facial looks. This led to further social isolation and negative behaviors. The continued pain led to altering diets, becoming poorer in quality. The downward spiral continued as general health declined. Infections spread to areas outside of the mouth. Depression and irritated attitudes grew, creating further social isolation, leading to even more depressions. Poor diets and infections contributed to a weakened body, which made other disease states even worse.
Medical conditions directly affected by the conditions of the mouth
It is hard to say which came first—the systemic disease or poor oral health—but the following conditions have a proven link to dental health:
Diabetes − When there are infections, the body increases the blood glucose to fight off the infection, including infections in the mouth. Poorer diets that result from painful teeth contribute to loss of glycemic control. Chronic infections lead to chronic inflammation which weakens the body. This can contribute to the development or the worsening of diabetic symptoms.
Respiratory disease − The more bacteria in the mouth, the greater the chance that bacteria will be inhaled into the lungs. Pneumonia can result. Lung infections can also worsen the symptoms of asthma and chronic obstructive pulmonary disorder (COPD).
Cardiovascular disorders − Bacteria from oral infections can enter the bloodstream and infect the heart. More often, though, it’s the chronic inflammatory factors that negatively affect the cardiovascular system.
Mental Health − The chronic pain that results from oral infections and the loss of teeth negatively affect mental health conditions. Social interactions involving food decrease, leading to isolation. The degradation in the appearance of the teeth and the associated increase in bad breath contribute to a negative self-image. The loss of social interaction and a negative self-image worsen mental health disorders.
Failure to Thrive − In the elderly and the infirm, all of the above can have a significant negative effect on the body as a whole. Poor oral health contributes to the patient just giving up on living.
Cancer − Chronic oral infections have been linked to an increase in periodontal cancers.
The growing body of evidence is irrefutable. Cavities and periodontal disease have a major negative impact on the health of patients. Despite this growing awareness, there still seems to be a wall between oral health concerns and the rest of the body. I am just as guilty as anyone else. I remember several cases where I just did not connect the decrease in oral health and the worsening of the overall health of my residents.
I remember a little old lady who we could just not keep healthy. Despite all of our effects, there was a general decline in health. I remember the doctor just about gave up and labeled the condition ‘failure to thrive.’ Finally, she landed in the hospital, and she never returned to our home. I was shocked when I heard that the reason for the hospital admittance was a dental infection.
I also remember several cases where ill-fitting dentures caused us lots of problems. It was only after we addressed the denture problems that the residents returned to their normal behaviors. I wonder how much effort we could have saved if we had only worked on the dental problem first.
Now that I am thinking about it, I even ashamedly remember a few cases where the resident had such bad breath that nobody wanted to get near them. How bad is that? Social isolation in a care home!
Adult Foster Care Residents and Dental Health
We have to admit that adult foster care providers are just as guilty as any other health provider at not connecting dental health with the health of the rest of the body. That is really sad too because the elderly clientele that comes into our homes generally have greater incidences of poor oral health. That also is true for mental health and developmentally disabled homes.
Risk factors for poor oral health found in care home populations:
The more caregivers think about the subject, the more obvious the problem becomes. Periodontal disease and tooth decay are major problems for our residents. The dental health of our residents needs to become more of a greater priority in our caregiving efforts. If personal dental hygiene is difficult for our residents, we need to encourage and assist them. As patient advocates, if there is a wall between dental health and mainstream medicine, we need to push through it or even knock it down.
Good Dental Hygiene
The real tragedy of dental disease is that it’s so easily preventable. All it takes are a few simple dental cleaning procedures consistently applied daily. The American Dental Association (ADA) states that we should brush our teeth for two minutes twice a day and floss our teeth either before or after brushing. They also recommend seeing a dentist on a regular basis. That’s it! No big multistep procedures involving multiple people; just plain and simple stuff.
To make good dental hygiene even easier and more effective, the ADA has approved a full line of dental products. They include fluoride toothpaste and mouthwashes, dry mouth relieving products, and oral hygiene devices. The full list can be viewed on their website.
To explain why such simple procedures can be so effective, let’s take a look at how oral infections and dental cavities occur. The mouth is a cavity that is the gateway to our insides. We cram all sorts of stuff into it, from delicious cookies to rusty nails and dirty fingers. We also suck in whatever happens to be floating in the air we breathe. In the moist warm environment of the mouth, all sorts of microorganisms settle in and start to grow. Every time we feed ourselves, its dinner time for our mouth garden too.
Combating the Problem in Care Homes
In my opinion, care home caregivers can have a greater impact on improving dental health than any other healthcare provider—even dentists. Who else lives with the patient and can ensure proper oral hygiene 24/7? As patient advocates and caregivers, there is no other care provider better suited to putting the mouth back into the body than care home providers.
Helpful Hints
The following are a few thoughts I think can help you with your dental care efforts. This is by no means an exhaustive list. If you have a dental problem that’s kind of tough to deal with or have further questions, ask the dental professionals.
Conclusion
Because of fears, cost, and medical apathy, the mouth was taken out of the body by mainstream medicine. It not only caused a lot of suffering in the mouth but also compounded troubles throughout the body and in other disease states. Those patients that end up in care homes seemed to be particularly at risk. Eldercare, Developmentally Disabled, and Mental Healthcare home providers are in the best position to do something about the problem. Through proper screening, monitoring, support, and providing dental hygiene equipment and supplies, caregivers reduce dental issues and greatly contribute to the health of the rest of the body.
As always, good luck with your caregiving efforts!
Mark Parkinson
References:
Gingivitis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/gingivitis/symptoms-causes/syc-20354453
Dental Health and Cavities. WebMD.com https://www.webmd.com/oral-health/guide/dental-health-cavities#1Michael Posey, BSPharm. Improving Preventive Oral Care to Enhance Overall Health: The Pharmacist's Role. Power-Pak CE. Jun. 30, 2017https://www.powerpak.com/course/content/115111
Elizabeth Southern Puette, RDH. Providing Daily Oral Care for Seniors as a Caregiver. Tooth Wisdom. Oral Health for Older Adults. https://www.toothwisdom.org/a-z/article/providing-daily-mouth-care-for-loved-ones/
Miriam Davidson. Keeping It Clean: Toothbrushing Tips. MDA/ALS News Magazine Jan. 1 2011. http://alsn.mda.org/article/keeping-it-clean-toothbrushing-tips
Amy L. Cooper, RDH. Alternatives to Flossing. Tooth Wisdom. Oral Health for Older Adults. https://www.toothwisdom.org/a-z/article/when-flossing-is-a-challenge/
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Bringing Your Residents to Tears –
Remedying Dry Eyes
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 2- Approximate time required: 120 min.
Educational Goal:
To teach about the dry eye condition and tell how to relieve it.
Educational Objectives:
Define the chronic dry eye condition.
Tell about the anatomy and physiology of the eye and tears
List Foster care issue in regards to dry eye relief
Tell about the therapies for dry eye relief
List and explain the drugs designed for dry eye relief
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Bringing Your Residents to Tears –
Remedying Dry Eyes
How often do you think about the moisture covering your eyes? If you’re like me, that would be never. That is until there is not enough moisture, and my eyes become dry. It’s then hard not to think of anything else but my dry eyes. If the condition continues, the problem becomes distractingly irritating. That is how some of your residents feel when they are afflicted with chronic dry eyes, sometimes referred to as dry eye syndrome. The goal of this CE course is to help you, the care provider, deal with dry eye syndrome whenever it occurs.
What is going on in dry eyes?
At its simplest, dry eyes are the sensations we feel in our eyes when there is an inadequate amount of tears to lubricate and nourish the surface of the eye. It is caused by either an insufficient quantity of moisture in the eyes or the tears are of such poor quality that they fail to meet the needs of the eye.
A more in-depth look at chronic dry eye presents a much more complex picture. Let’s start with the official name of the condition. Chronic dry eyes are medically known as dry eye disease, dry eye syndrome, keratoconjunctivitis sicca, dry eye disorder, ocular surface disease, and dysfunctional tear syndrome. Why are there so many names for the same thing? The reason is, there is not a single definition of dry eye disease that has been accepted by all medical practitioners. A general characterization was set forth by the International Dry Eye WorkShop which states, "Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface." In plainer language, it says that it is a condition that results in discomfort and vision problems that could be caused by serval different factors. Let’s take a look at the eye to see what they mean.
Anatomy and Physiology of the Tears
The eyes, as they are commonly referred to, are actually a complex combination of bodily structures. They are comprised of the eye organ itself, eyelids, lashes, tear glands, muscles, blood vessels, and nerves. The structures associated with tears are the lacrimal gland, Meibomian gland, and goblet cells of the conjunctiva (inside portion of the eyelid).
Just as with the eyes, the substance commonly referred to as tears are also very complex, containing fatty oils, water, mucus, and more than 1,500 different proteins.
The moisture covering the eye is called the tear film. It serves to hydrate and lubricate the eye surface. It also provides a protective barrier and makes a smooth ocular surface that helps our sight, similar to a lens. It inhibits microbial growth, supplies nutrients to those portions of the eye surface that have no blood supply, and supports wound healing.
The tear film is generally composed of three layers:
The outermost layer is derived from meibomian glands in the eyelid margins. It contains lipids like cholesterol, fatty acids, and triglycerides. The meibum slows down evaporation of the water tear layer and provides barrier protection against foreign matter like dust and microbes.
The middle layer is called the aqueous layer. It is produced by the lacrimal glands. It makes up most of the tear film (approximately 98%) and contains water-soluble substances such as electrolytes, proteins, nutrients, and immunoglobulins.
The innermost mucin layer is composed of a mucus-like substance produced by specialized skin cells called goblet cells. It provides a cushiony surface that lubricates the eye and helps evenly secure the water layer to the eye surface.
The tear film is not a static thing. It is constantly being replenished with every blink. It is estimated that a majority of the tear film is replaced with every two blinks. The tears normally drain into the ducts linked to the nasal cavity.
Wow! Who knew that tears were so complicated? It is no wonder that there is no consensus in properly naming chronic dry eye problems. With thousands of components in tears and tear production, accurately naming all the things that could go wrong is quite the daunting task. Add to that complexity, the small size of the structures and quantities involved, and the difficulties in taking samples, doctors are forced into dealing with generalities rather than specifics when treating dry eye problems.
Pathophysiology of Tears (what has gone wrong)
In writing this CE course, I, like the doctors, have been forced into writing in generalities rather than specifics. If you desire specifics, then I suggest you consult with your local eye care professional. So, in general terms, dry eye problems can be caused by the low quantity and or low quality of tears. The disturbance of the base tear film leads to hyperosmotic conditions (the concentration of solids in the water increases). This causes cell damage, which triggers the inflammation process. Inflammation usually results in red, irritated eyes. Increased tissue swelling can squeeze off tear duct openings, further reducing the tear volume in the eye. If conditions continue to spiral down, then the compensation mechanisms of the eye can get overwhelmed, and a significant eye tissue damage can result. What brought about these conditions in the first place could have been triggered by a single problem or multiple factors.
Severity
Care providers should take every case of eye problems seriously, though some are more critical than others. There is always the possibility that chronic dry eyes can lead to permanent vision impairment.
Possible Contributing Factors
Hopefully, by now, if I have done my educating job right, you can appreciate the complexity of dry eye problems. I can easily make a list of contributing factors, but for a person to point at one and say “That is the root of the problem” is not so easy. Doctors and caregivers should be open to the possibility of multiple triggers.
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Table 1. Medications Involved in the Etiology of Dry Eye Disease (DED) |
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Medications/therapies/conditions |
Target and/or effect |
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Drugs with antimuscarinic effects · Antihistamines · Antipsychotics · Anticholinergics (e.g., oxybutin) · Tricyclic antidepressants · Selective serotonin reuptake inhibitors |
Inhibition of cholinergic receptors to lacrimal glands, leading to hyposecretion (reflex motor block) |
|
Beta adrenergic blockers |
Reflex sensory block, leading to tear hyposecretion |
|
Topical anesthetics · Proparacaine drops |
Reflex sensory block, leading to reduction in blink rate and tear hyposecretion |
|
Androgen deficiency, anti-androgen therapy |
Dysfunction of meibomian and lacrimal glands, leading to DED |
|
Elevated estrogen levels, estrogen replacement therapy |
Associated with DED; exact mechanism not clear |
|
Retinoid therapy |
Structural and functional damage to meibomian glands, leading to evaporative losses and increased tear viscosity |
|
Diuretics |
Associated with DED; exact mechanism not clear |
|
Vitamin A deficiency |
Unstable tear film and lacrimal hyposecretion |
|
Oral corticosteroids |
Clinical observation: increased risk of DED |
Source: Stop the Rub: The Treatment of Dry Eyes Catherine A. Opere, Karen K. O'Brien
Prevalence (especially in care homes)
I hope that the course has been interesting so far, but I want to move beyond interesting. The rest of the course is where the rubber meets the road, or, in other words, why you should care about dry eyes as a care home care provider.
It has been estimated that 1/3 of the population will experience some form of dry eye in their lifetime. The prevalence of dry eye is 11% for men and 17% for women. Those figures in and of themselves indicate that the condition is a significant health concern in the general population. But your residents aren’t the general population, are they? They are the weak and infirm. Just compare the list of contributing risk factors and the general condition of your typical elderly resident. It doesn’t take a genius to figure that you’re almost 100% guaranteed to have to deal with multiple cases of dry eyes in your caregiving career. That holds true for Developed Disabled and Mental Health homes as well.
Foster Care Issues
For foster care providers, it’s not a matter of ‘if’ you’ll have to deal with dry eyes; it’s more a matter of ‘when’ it’s going to happen. In my book, it’s always better to be prepared before it happens rather than reacting after the fact.
Monitoring − Be on the lookout for the symptoms of dry eye, especially in those residents with multiple risk factors.
Watch for:
Therapy − Unlike other disease states, the goal of therapy is not to cure or manage the underlining physiological events, which is quite difficult as mentioned before. The goal is to make the patient comfortable. In care homes, achieving that goal presents some grey areas in caregiving. The lines blur between what is considered basic caregiving, activities for daily living, and therapy. In eye care, what is considered basic caregiving, delegated nursing duty, and medical treatment? For example, is it considered therapy to wash the goop out of crusty eyelids in the morning for residents who sleep with their eyes open? Do you have to get a nurse to delegate putting in over-the-counter eye drops in a resident’s eyes if it’s only done occasionally? In my opinion, it’s a matter of several factors: how often the activity happens, if there is a diagnosis of dry eye disease in the resident’s record, and how severe the condition is. For mild occasional cases, err on the side of good caregiving. For moderate to severe cases, err on the side of medical treatment. As always, when in doubt, err on the side that won’t get you in trouble with county licensors and doctors (better safe than sorry).
If the dry eye symptoms are occurring on a regular basis, get your resident to an eye care professional. Be sure to get clear instructions on what to do back from the doctor and get them into the resident's file and MARS. If they don’t readily cooperate, I suggest the trick of writing what you think is needed and faxing it to the doctor with just a yes or no checkbox attached.
For example,
Instill over-the-counter eye drops as per manufacturer’s instructions PRN in Mary Smith’s eye. ____ Yes, _____ No
Prescriber’s signature _____________________.
Medications
There are very few prescription medications for the treatment of dry eye disease. They mainly stimulate tear production or are anti-inflammatory drugs.
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Anti-inflammatory or immune system modulators |
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Generic name |
Brand name |
Dose |
Side effects caregivers should watch for |
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Cyclosporine |
Restasis |
1 drop in affected |
Relatively well tolerated; the most common side effect is ocular burning (17%); less common are, redness, discharge, watery eyes, eye pain, foreign body sensation, itching, stinging, and blurred vision |
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Lifitegrast |
Xiidra |
1 drop in affected eye(s) twice daily |
Most common effects (5% - 25%) are instillation site irritation, dysgeusia, and decreased vision effects. |
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Caregiver administration notes: Contact lenses should be removed prior to application of drops and reinserted no sooner than 15 minutes after administration of drug. Individual dose vial contents should be applied into the eye(s) immediately after opening and remaining contents should be discarded. Side effects most likely will be temporary and manageable but if they interfere with activities of daily living notify the prescriber. |
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Tear stimulators (used mainly in severe cases due to side effects) |
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Generic name |
Brand name |
Dose |
Side effects caregivers should watch for |
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Cevimeline |
Evoxac |
30 mg by mouth 3 times daily; total daily dose should not exceed 90 mg |
Possible side effects include sweating, flushing, increase urination and nausea; side effects occur less frequently with cevimeline than with pilocarpine |
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Pilocarpine |
Salagen |
5 mg by mouth 4 times daily; total dose should not exceed 10 mg/dose and 30 mg/day |
Common side effects include sweating, increase urination, flushing, headache, and nausea |
You may also see prescribers use ointments occasionally. The ointments prescribed most often are purified petrolatum, or a saline gel. They are commonly used in geriatrics when the resident sleeps with their eyes open or they have severely sagging eyelids. The caregiver concerns that you should watch for are a temporary blurred vision that can lead to falls and interference with other medicated eye drops. It’s just a matter of timing of applications and monitoring the resident after use. Caregivers should instill eye drops before ointments and wait for at least 10 minutes before applying the salve.
Over-the-Counter Artificial Tears
By far, the most common therapy for dry eyes is tear supplementation with over-the-counter artificial tears. We all have used or are very familiar with OTC eye drops. It’s a $2 billion-a-year global industry. One of the caregiving issues with such a prevalent drug product is that some of your residents will be used to applying the product themselves. They are certainly allowed to continue the practice if they want to, but you have to get all the necessary medical permissions and documentation that are required of care homes. Don’t let this one slip by you, or it could come back to haunt you at inspection time.
Another issue that caregivers might have to deal with is product selection. On the off chance the prescriber just writes OTC eye drops PRN, or the resident self-medicates and wants you to buy the eye drops for them, you might have to choose which artificial tear product to purchase. In doing so, there are a couple of factors you need to be familiar with:
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Preservatives Used in Artificial Tear Substitutes |
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Preservative |
Comments |
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Benzalkonium chloride (BAK) |
Can cause cytotoxic effects in eye tissues and disrupt tear film. Try to avoid BAK if possible. |
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Edetate disodium (EDTA) |
Stimulates allergic and inflammatory responses in ocular tissues; most often combined with other preservatives. If the eye turns red after use look for this in the ingredients |
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Sodium chlorite |
Considered relatively safe to ocular tissues |
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Polyquaternium-1 |
Polymeric quaternary ammonium compounds are less toxic than BAK |
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Sodium perborate |
Considered relatively safe and it eventually breaks down to water and oxygen when it contacts the tears |
When artificial tears are not enough
There is a drug option for the doctor to choose when the use of artificial tears isn’t doing enough to bring comfort to the patient. It’s an insert that looks like a tiny grain of sand called Lacrisert (hydroxypropyl cellulose). It is placed in the eye once a day. As it slowly dissolves, it releases chemicals that can lubricate the eye. If artificial tear therapy is failing, you could ask the doctor if Lacrisert is an option. There are also surgical options: plugs that block the tear ducts from flowing into the nasal cavity and making tear supplements from the patient’s own blood. All of the above are expensive and quite involved, so they are reserved for very serious cases.
Non-drug Therapies
The environment the resident lives in has a huge impact on dry eyes. It is the area the caregiver has the most control over. Dry Eye Disease can be minimized by paying attention to the environment immediately around the patient. Here is a checklist of caregiving activities for you to go through periodically:
Caregivers should pay attention to eyelid hygiene. Wash the eyelids regularly with a mild soap. It removes the eye goop that can interfere with tear production. No-tears baby shampoo is great for this task. Massage gently the eye with a warm soft cloth or towel to stimulate the meibum gland flow. Of course the resident could do this by themselves, but I recommend the caregiver at least supervise the activity. The task becomes easier if you stick a clean cloth in the resident's shirt pocket. Then it becomes more convenient to massage the eye several times a day.
Medication Administration Techniques
There are right and wrong ways to instill eye medications. Regardless of how you or the resident has used eye products in the past, the following are the tried and true medication administration techniques that should be used. They will ensure the medication gets to where it is needed with the fewest concerns.
The patient:
The medication container:
Eye Drops:
Gels and Ointments:
Conclusion
The eyes are complex bodily structures that are lubricated and maintained by equally complex solutions we call tears. When there are not enough tears, or the tears are of poor quality, dry eye conditions manifest themselves. If the condition becomes chronic or severe, permanent damage can occur to the eye. Due to multiple risk factors, residents in care homes are at greater risk of suffering from dry eyes. Caregivers in care homes should be able to recognize those who are at greater risk and monitor for dry eyes. Caregivers should also help maintain good eye care hygiene. Most often dry eyes are treated by altering environmental conditions and the use of artificial tears.
The caregiver should be able to keep their residents comfortable by understanding what affects their resident’s eyes to make them dry. Also, they should know how to select and use artificial tears and eye ointments and monitor for side effects. I hope this CE course has helped you in your eye care efforts.
As always, good luck with your caregiving!
Mark Parkinson BS Pharm
References:
Catherine A. Opere, B Pharm, Karen K. O'Brien, PharmD. Stop the Rub: The Treatment of Dry Eyes. Power-Pak.CE.com. Dec.16, 2016. https://www.powerpak.com/course/content/113825
Markk B. Abelson, MD,. 3, 500 Years of Artificial Tears. Review of Ophthalmolog. Dec. 8 2014. https://www.reviewofophthalmology.com/article/3500-years-of-artificial-tears
Dry Eye. American Optometric Association. https://nei.nih.gov/health/dryeye/dryeye
Dry Eys. Mayo Clinic http://www.mayoclinic.org/diseases-conditions/dry-eyes/basics/definition/con-20024129
Dan Alalouff. Dry Eye Syndrome. Nursing In Practice Feb 3 2012 https://www.nursinginpractice.com/article/dry-eye-syndrome
Gail P. Mooney, MSc,. Eye Care. Nursing Times. Jun 21 2007https://www.nursingtimes.net/clinical-archive/assessment-skills/eye-care/199389.article
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3 Alternative ‘Paths’ in Medicine
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To explain the medical practices of Homeopathy, Osteopathy and Naturopathy .
Educational Objectives:
Define Homeopathy, Osteopathy and Naturopathy
Explore the aspects of managing alternative medical therapies in an Adult Foster Care setting
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
3 Alternative ‘Paths’ in Medicine
Our world is filled with amazing advances in science and medicine. But for some, the more advanced our society becomes, the more unnatural it seems to them. They long for a simpler approach to life, one based on organic, not artificial, elements. There are also others who cannot afford the cost of more advanced medical choices and have to turn to ‘old fashion,’ less expensive alternatives. Then there are others who never saw the need to change to more advanced methods and remained with what worked best for them.
Regardless of the reason, there are many who have chosen an alternative approach to medical care. An approach that contains unconventional choices or complementary elements to mainstream medicine. As a caregiver, you may be faced with having to understand and manage these alternative therapies. This course is designed to help you learn about three of those choices: Naturopathy, Homeopathy, and Osteopathy—three alternative ‘paths’ in medicine.
The first step—define alternative medicine.
According to the National Institute of Health (NIH) of the US Department of Health and Human Services:
Many Americans—more than 30 percent of adults and about 12 percent of children—use health care approaches developed outside of mainstream Western, or conventional, medicine. When describing these approaches, people often use “alternative” and “complementary” interchangeably, but the two terms refer to different concepts: If a non-mainstream practice is used together with conventional medicine, it’s considered “complementary.” If a non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.” True alternative medicine is uncommon. Most people who use non-mainstream approaches use them along with conventional treatments.
For the purposes of this article, I will be describing the three ‘paths’ as alternative medicine, but in adult foster care reality, you will only see elements of these approaches as complementary to mainstream medicine.
Alternative vs. Mainstream
The difference between mainstream medicine and alternative medicine is in how they approach the problem of healing the patient. Mainstream is also called Western medicine, allopathic, biomedicine, or scientific medicine. At its core is an evidence-based approach to solving health problems. In essence, when a health problem arises, a theory is put forth on how to solve it. The theory is tested until it is more or less proven effective at solving the problem according to government standards. It is then approved for general use by licensed practitioners. The strengths of this approach are its proven effectiveness and repeatability. Its weakness is, it tends to have a very narrow focus on a problem, ignoring the individual as a whole. Also, the medicines are artificial and may have side effects.
Alternative medicine, which includes naturopathy, homeopathy, osteopathy, chiropractic, and the eastern medicines of India and China, is known for its holistic approach to solving medical problems. Generally, it looks at the whole body and tries to determine what is out of harmony. Bringing the whole body back into sync enables the body to heal itself. When medicine is used, herbs are a preferred choice. There is also an emphasis on eliminating toxins from the diet and environment. The strengths of the holistic approach are the promotion of healthy living and feeling good. Its weakness is the lack of clinical evidence of efficacy in solving health issues.
One could say that with evidence-based medicine, you are cured, but you might feel worse, and with holistic medicine, you might not get cured, but you feel better about it. All joking aside, I am not making a judgment statement about any form of medicine in this article. This article is intended for educational purposes only. As with most health professionals, I am trained in evidence-based medicine, but I personally use herbal and homeopathic supplements from time to time.
Naturopathy
According to the American Association of Naturopathic Physicians:
Naturopathic medicine is a distinct primary health care profession, emphasizing prevention, treatment, and optimal health through the use of therapeutic methods and substances that encourage individuals’ inherent self-healing process. The practice of naturopathic medicine includes modern and traditional, scientific, and empirical methods.
The association also states that the goals of naturopathic therapy are:
Currently, there are six colleges that give a doctoral degree in the United States. Though there is a doctoral degree issued, the medical training is not as rigorous as traditional medical degrees. Colligate candidates do not have to take the Medical College Admissions Test (MCAT) or Graduate Record Examination (GRE) for entrance, and postgraduate residencies are optional. According to the American Academy of Family Physicians, the number of training hours’ difference between a family physician and a naturopath is between 15,195–15,215 total hours. There are colleges in Washington, Oregon, and California. Sixteen states license naturopathic doctors, including Oregon, Washington, and California. Naturopaths are not licensed to perform major surgeries. There are unlicensed naturopaths that practice medicine, but only licensed practitioners have the designation ‘ND’ after their name.
A typical visit to a naturopath would include a lengthy first visit (1−2 hours) that would be followed by briefer follow-up visits. The state of the patient would be determined through questioning and multiple diagnostic tests. Therapies would be prescribed, which may or may not include medicines, and which may or may not be based on clinically-proven studies. NDs are trained to utilize prescription drugs, although the emphasis of naturopathic medicine is on the use of natural healing agents such as herbal or homeopathic supplements. Clinically unproven folk remedies may also be utilized. Most herbal supplements are not regulated by the Food and Drug Administration (FDA) of the United States.
Homeopathy
Homeopathy is a system of medicine based on the principle: “like cures like.” In practice, a patient suffering from a disease is given extremely small amounts of substances that produce the same symptoms as the disease. In theory, the body’s own defense and homeostatic mechanisms are then stimulated to work harder at ridding itself of the original disease. In essence, homeopathy is trying to make the body heal itself. Like naturopathy, homeopathy tends to focus on the whole individual (holistic), with an emphasis on maintaining a healthy lifestyle.
At the core of homeopathic medicine are the homeopathic preparations. These are powerful, often toxic, substances that are diluted down to extremely small quantities. Often the quantities measure in just molecules of the active substance. If there are no molecules of the active ingredient, the profession claims that the water retains a memory of the substance that still retains its effectiveness. In the United States, homeopathic drugs are regulated by the FDA.
According to the American Institute of Homeopathy:
Homeopathic medicines are included in the Food, Drug and Cosmetic Act of 1938 (see SEC. 201. (g)(1) of the Act 21 U.S.C. §321), and therefore fall within the regulatory authority of the FDA, which recognizes the Homeopathic Pharmacopoeia of the United States (HPUS) as their official compendium. The HPUS is also recognized in the Controlled Substances Act (21 U.S.C. § 802). Approximately 98% of homeopathic medicines are classified as non-prescription drugs. Our members are duly licensed to prescribe medicines contained in the USP and HPUS, in accordance with our respective DEA licenses.
Currently, there are three homeopathic colleges in the U.S. In addition, other health profession colleges teach courses in homeopathy. No state issues licenses for homeopathic doctors. There are medical boards that issue board-certified specialty certificates upon completion of a board exam. For example, the American Board of Homeotherapeutics issues Diplomates Specialty Certification to licensed medical and osteopathic doctors. Passing the board exams grants the specialty status of D.Ht.
Osteopathy
Osteopathy is a system of medicine that is based on the holistic theory that diseases and maladies are caused by the loss of structural integrity of the body. Normal body integrity can be restored by manipulation of body parts and by additional therapeutic measures such as surgery and the use of prescription drugs.
According to the American Osteopathic Association:
Doctors of Osteopathic Medicine (DOs) are fully licensed physicians who practice in every medical specialty. They provide a full range of services, from prescribing drugs to performing surgery, and they use the latest medical tools. But DOs offer something special—their unique approach to patient care. Osteopathic physicians are trained to:
In the U.S., there are 34 accredited osteopathic colleges in 32 states. Collegiate candidates must fulfill premed school requirements and take the MCAT exam. Students get basically the same medical education as traditional doctors, with emphasis on the holistic approach and about 200 class hours of OMT training. Graduates leave school with a Doctorate of Osteopathic medicine degree or DO. DOs can continue their medical education by participation in medical residency programs. Doctors of Osteopathy are licensed in all 50 states. They have been given full prescriptive authority and can legally perform major surgeries.
Integrated Medical Practice
The NIH states: There are many definitions of “integrative” health care, but all involve bringing conventional and complementary approaches together in a coordinated way. The use of integrative approaches to health and wellness has grown within care settings across the United States. Researchers are currently exploring the potential benefits of integrative health in a variety of situations, including pain management for military personnel and veterans, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors.
Integration of mainstream medicine and alternative medicine can be seen in regular doctors, pharmacists, and nurses getting specialty degrees and certificates in alternative medicine. Also, clinics and hospitals are hiring licensed alternative medical staff.
Adult Foster Care and Alternative Medicine
There are many licensed and unlicensed alternative medical practitioners in the U.S. today. Popular culture and the internet have made it easier for patients to seek out different medical options. Of course your residents have the right to choose any legal medical treatment that they want. But what does that mean to you, the caregiver? As a licensed medical professional, you have some government mandated responsibilities to consider: 1) Follow medical orders; 2) Refer choosing which therapies to use to the doctor; 3) Monitor the health of your resident.
If one of your residents is choosing to participate in alternative medical therapies, you have a legal duty to notify the resident’s primary medical doctor. If the primary medical doctor approves of the alternative therapy, or if the therapist is licensed by the state you live in, you now have to manage that alternative therapy. Herbal and Homeopathic supplements will have to be charted in the MARs and PRN logs. Dietary orders will have to be followed. Herbal supplements and Homeopathic remedies will not come with med info sheets from the pharmacy. You have to ask if there are any concerns to monitor for. You can ask the doctor, pharmacist, or licensed therapist. If the therapist is not licensed, it would be wise to confirm what is said with someone who is licensed. One more final thing to understand about this subject is: if you do not report the alternative therapy to the doctor, in essence, you are approving the therapy instead of the doctor, which will only get you in trouble.
Conclusion
An increasing number of residents in adult foster care homes are choosing health care approaches developed outside of mainstream Western or conventional medicine. In addition, more and more medical professionals are integrating holistic medicine into their practices. Caregivers in adult family, mental health, and developmentally disabled homes are being required to manage these therapies. That means asking question and researching until they are comfortable with their understanding. Be careful to notify the doctor and verify all claims with licensed professionals.
As always,
Good Luck with your caregiving efforts!
Mark Parkinson BS Pharm
References:
Definition of Naturopathic Medicine. The American Association of Naturopathic Physicians. http://www.naturopathic.org/content.asp?contentid=59
About Naturopathic Medicine. Bastyr University. http://bastyr.edu/academics/naturopathic-medicine/about-naturopathic-medicine
Greg Martin. Family Physicians versus Naturopaths. American Academy of Family Physicians .https://www.aafp.org/dam/AAFP/documents/advocacy/workforce/gme/ES-FPvsNaturopaths-110810.pdf
Russel Faust MD. Alternative Medicine Labels: Homeopathy, Naturopathy, Osteopathy, Chiropractic, Ayurveda. …Ask the Boogordoctor. http://www.boogordoctor.com/definitions-homeopathy-naturopathy-osteopathy-chiropractic-ayurveda/
What’s The Difference Between Osteopathic And Homeopathic Medicine?. Home Remedy Network. http://home-remedy-network.com/alternative-medicine/whats-the-difference-between-osteopathic-and-homeopathic-medicine
Naturopathic Diet
Cathleen Calkins. Naturopathic Diet. Livestrong.com. Oct. 3,2017.https://www.livestrong.com/article/130374-naturopathic-diet/
Lora Bennett. MD. Alternative vs Traditional Medicine Providers. Advance Family Health PPLC. http://advancedfamilyhealth.org/alternative-vs-traditional-medicine-providers/
Complementary, Alternative, or Integrative Health: What’s In a Name?. U.S. Department of Health & Human Services, National Institutes of Health,https://nccih.nih.gov/health/integrative-health
The American Institute of Homeopathy. http://homeopathyusa.org/
Currently Accredited Homeopathic Schools . Accreditation Commission of Homeopathic Education in North America. http://www.achena.org/Schools.htm
Osteopathic medicine in the United States. Wikipedia. https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_United_States
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