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An Unintended Effect

Side Effects of Mental Health Drugs

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An Unintended Effect

Side Effects of Mental Health Drugs

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An Unintended Effect

Side Effects of Mental Health Drugs

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 2.5- Approximate time required: 180 min. 

Educational Goal: 

Instruct about the side effects of common mental health drugs and how to manage them.

Educational Objectives:

1. Instruct how the body functions in regards to drugs

2. Explain where side effects come from

3. Explain about the complexity of mental health issues

4. Teach about the different classes of mental health drug

5. Tell how to manage common drug side effects

6. List precautions for special populations

Procedure:           

1. 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.

Unintended Effects:

Side Effects of Mental Health Drugs

Clueless

     When I was a 20-something year old, new caregiver in the relative new field of adult foster care, I have to admit I was pretty clueless. Back then, there were no basic training requirements and no continuing education lessons to take.   If it sounds like it was easier way back when- let me tell you, it wasn’t. Learning as you go, on the job training in health care definitely has its drawbacks. I didn’t even realize how clueless I was until after I started pharmacy school.  As I learned more and more about healthcare and medication effects, I kept telling myself I wish had known that when I started out as a caregiver.  I thought over and over again, “So that is why so and so acted so annoyingly. They couldn’t help it. It was a side effect of their medication. Maybe if I had known, I could have told the doctor and done something about it.”

  Of particular interest to me were mental health drugs. The very prescriptions I depended on to help my residents live normally actually caused some of the abnormalities. Because I was uninformed, my residents suffered, but you don’t have to be. Together, we can help you recognize the annoying side effects of medication in your residents sooner and, with their doctor’s help, do something about them.  

The Basics on the Body’s Behavior

     The human body and the way it behaves are controlled by a complex system of chemicals, hormones, and bodily functions. Our bodies take in food and drink and convert them into the basic chemicals we need to function. We utilize some of those basic elements to run the mechanics of our systems, like sodium and chlorine (salt) and glucose (simple sugars).  Other elements our bodies convert to more complex chemicals called hormones.  They are made to regulate more complex functioning that is not possible to produce from the basic materials we consume. Both of these types of chemicals float around in our bodies where ever our bodily fluid currents take them.  When a certain chemical floats passed an area that utilizes that particular material, it is taken in and produces the desired effect. 

     If it all sounds kind of random and based on luck, it isn’t. Our bodies are designed to take advantage of the shapes and properties of each chemical to produce the desired effect in the place it is needed. This is easier to understand if you think of this concept as a lock and a key. The key floats along until it reaches a certain keyhole that it fits in. When the key is inserted, the door is opened or the function is turned on or off. Only that certain chemical key shape will fit into that keyhole to produce that effect.  So if the body requires a certain function, it will produce that key until the desired effect is produced. When the function is produced, new keys are made that will fit into another certain keyhole that will turn off the production of the original chemical key. This is called the negative feedback effect. The variety of functions needed by the body are produced and controlled by this very, very complex system of chemical keys and key holes.

     Medical science has learned that it can manipulate bodily functions by producing chemicals (drugs) that are similar in shape to the chemical keys utilized by our bodies. The problem is we can’t copy the whole key/keyhole system exactly. It’s far too complicated. There is always some minute detail that we can’t replicate, don’t understand, or even know about.

     For example, we can make a chemical key (drug), but we can’t control where it goes after it gets into the body.  Let’s say we want to help a patient who is in pain. We produce an artificial chemical key that fits into the keyhole that turns on the pain-killing function of the brain. Unfortunately, that same chemical key also fits into the sleep-inducing keyhole and the nausea-producing keyhole of the brain. After the patient takes the pain killer drug, the pain is reduced but sleepiness and nausea are also experienced. That’s why drugs produce unintended effects known as adverse reactions or simply side effects.  

Mental Health Drugs and Effects

     The brain is by far the most complex organ / function system in our body. Millions of cells with trillions of connections are covered with a whole host of chemical receptors surrounded by a chemical soup of neurotransmitters. Add to that the complex interaction between individuals and our environment. It’s a marvel that we can accomplish anything with such a complex system.  It is no wonder that things go haywire for some people resulting in mental illness. Sometimes there’s a problem with how the body is put together or how it functions (genetic). Sometimes it’s how we interact with our surroundings or what we take into our bodies (environmental). The end result is that those individuals can’t mentally function normally.

     The medical community recognizes the need for help, and we try to manipulate the mental functions of the patient with drugs and other therapies to bring that person back to normal functioning. Medications that are used for this purpose are generally called psychiatric, psychotropic, or psychotherapeutic drugs. They are not intended to cure the patient but are designed to treat the symptoms of the mental illness so the patient can feel better and continue with their lives. With these treatments, there is always the chance of unintended effects. It can’t be helped.  Caregivers must learn to look for and help the patient manage the side effects that may arise.   

Information leaflet

    Medical science, drug companies, the government, and caregivers have put a lot of effort into producing predictable results while minimizing the side effects that can occur with any therapy. Only a small percentage of drugs are approved for human use. Those that are approved are extensively studied. All possible effects of each drug have been dutifully recorded. That information is required by law to be given to the consumer whenever that drug is dispensed. The information is supposed to help patients and caregivers anticipate the drug’s what is supposed to happen. It is also helps you be better prepared for what actually does happen, intended and unintended. A caregiver should always read a new drug information leaflet. 

Classes of Psychiatric Drugs

     Everyone is different, so it is easy to see that medication works differently for different people. The prescriber usually has a variety of prescription choices to try to alleviate a specific set of symptoms. If one medication either doesn’t work, doesn’t work well enough, stops working, or has side effects that are too bothersome, the doctor can use another drug for the same purpose. We generally group medications with similar effects into different classes

Antipsychotic /Schizophrenia Drugs

     Psychosis is a symptom of mental illness where the patient has an impairment of their perception of reality. It can radically change their personality and cause difficulty in living normally. Symptoms’ severity can range from a mild case of dementia or visual hallucinations to a major case of schizophrenia that requires hospitalization.

     Older medications used for psychosis are called “Typical” antipsychotic drugs. Some of the more commonly used are:

·        Chlorpromazine (Thorazine)

·        Haloperidol (Haldol)

·        Trifluoperzine (Stelazine)

·        Thioridazine (Mellaril)

·        Perphenazine

·        Fluphenazine

     Newer antipsychotic medications are called “atypical” antipsychotic drugs. Some of the more commonly used are:

·        Risperidone (Risperdal)

·        Olanzapine (Zyprexa)

·        Quetiapine (Seroquel)

·        Ziprasidone (Geodon)

·        Aripiprazole (Abilify)

·        Paliperidone (Invega)

·        Clozapine (Clozaril)

Extrapyramidal Side Effects

     A major side effect concern with “typical” antipsychotics, especially in long-term use, are the extrapyramidal side effects. The extrapyramidal system (EPS) is a part of our nervous system that controls voluntary movement. “Typical” antipsychotics can interfere with dopamine, a major neurotransmitter chemical of this system. The EPS side effects are usually reversible. If nothing is done, though, the unintended effects may become permanent.  If any of the following side effects occur, notify the doctor immediately. EPS side effects include:

·        Acute Dystonia: Sustained muscle spasms frequently in the neck and head. It can cause twisting and repetitive movements or abnormal posture. It nearly always develops after the first few weeks of therapy or after a significant change of therapy. It can be painful and life threatening if it interferes with breathing.

·        Hypokenesia:  Reduced muscle movements. It can cause an expressionless face, short shuffling steps, and difficulty in starting to walk. Signs usually develop within three months.

·        Diskenesia: Involuntary muscle movements. It can cause repetitive grimacing, tongue rolling/thrusting, chewing, lip smacking, puckering, rapid eye movement, twitching, and rocking back and forth.

·        Tarive Dyskinesia: If left unresolved, dyskinesia effects become permanent and are then called tardive dyskinesia (TD). Elderly women and diabetics seem to be at the greatest risk. About 5 percent of patients who chronically take typical antipsychotics develop TD.

·        Rigidity: The patient has troubles moving their limbs.

·        Paraesthesias: A sensation of numbness or tingling that can lead to seizures.

·        Neuroleptic Malignant Syndrome: A rare and potentially fatal condition that can happen shortly after taking a drug. Watch for fever, rigidity, rapid breathing, sweating, and confusion. If left unchecked, comma, seizure, and death can occur.

Agranulocytosis/ Weight Gain-Diabetes

     The second generation of antipsychotics is called “atypical.” They have a greatly reduced chance of EPS side effects but have their own unintended effects to be aware of.

·        Agranulocytosis: Loss of white blood cells. Without white blood cells, the body is susceptible to life-threatening infections. Clozapine causes this to occur the most and requires a blood test every one to two weeks.

·        Weight Gain: Changes in a person’s metabolism can lead to major weight gains. Weight gain can lead to other health concerns.

·        Diabetes: “Atypicals” cause trouble with glucose and lipid processing that can lead to diabetes.  Olanzapine and Clozapine seem to have the highest occurrence. Risperidone and Quetiapine have only moderate occurrence.

Less serious side effects

     Patients who take either “Typical” or “Atypical” antipsychotics can experience less serious side effects. Most go away by themselves after a few days or are easily managed. Driving or operating machinery would be unwise until the patient figures out how the new medication affects them. If a patient is already unsteady on their feet, they should receive extra monitoring and assistance when starting or changing any antipsychotic.  The side effects are:

·        Drowsiness

·        Dizziness when standing or changing positions (Hypotension)

·        Blurred vision

·        Rapid heartbeat

·        Sensitivity to the sun

·        Skin rashes

·        Menstrual problems

·        Dry mouth (reduction in saliva production, not an increase in thirst)

·        Constipation

·        Nausea

     A special note that can be quite problematic for elderly care workers: The FDA issued a Public Health Advisory for atypical antipsychotic medications. They determined that death rates are higher for elderly people with dementia when taking this medication. A review of data has found a risk with conventional antipsychotics as well. Antipsychotic medications are not FDA-approved for the treatment of behavioral disorders in patients with dementia. If a patient starts to develop signs of dementia by hallucinating or having delusions, the doctor may be reluctant to prescribe antipsychotic medications for treatment.
 

Antidepressant Drugs

     Depression is defined by being in a state of sadness, unhappiness, or hopelessness. Many things can cause or contribute to depression, including, medications, experiencing loss, old age, and emotional and economic problems.  A major contributing factor to clinical depression is an imbalance of neurotransmitters, which can be treated with medication.

     There is a wide variety of antidepressant drugs. The most commonly used classes are:

 1. Selective serotonin reuptake inhibitors (SSRI)

·        Fluoxetine (Prozac)

·        Citalopram (Celexa)

·        Sertraline (Zoloft)

·        Paroxetine (Paxil)

·        Escitalopram (Lexapro)

2. Serotonin and norepinephrine reuptake inhibitors (SNRIs).

 ·        Venlafaxine (Effexor)

 ·        Duloxetine (Cymbalta)

     Each medication has its own set of side effects, and individual reactions can vary significantly from patient to patient with any drug. Looked at collectively, users of SSRI and SNRIs have reported insomnia (trouble sleeping or change of sleeping patterns), agitation, or feeling jittery, headaches, and nausea.

The tricyclic antidepressants are an older class of medications and include:

·        Amitrptyline (Elavil)

·        Imipramine (Tofranil)

·        Nortriptyline (Pamelor)

·        Clomipramine

·        Doxepin

     The side effects in this class of medication are sedation, dry mouth, constipation, blurred vision, and bladder retention problems. Older men with prostate problems may have more problems with urination.

Other noteworthy antidepressants are:

·        Trazadone - a tetracyclic antidepressant. It has a significant drowsiness effect. Many doctors take advantage of this effect and use it as a sleeping aid. Users have also reported blurred vision, confusion, and dizziness.

·        Mirtazapine (Remeron) - a tetracyclic antidepressant. More common side effects are constipation, dizziness, dry mouth, increased appetite that leads to weight gain.  It might be wise for care providers to monitor the patient’s weight.

·        Bupropion (Wellbutrin/ Zyban) - an antidepressant that can also be helpful for smoking cessation. The more common side effects are dry mouth, agitation and trouble sleeping.

Antidepressant concerns

     All antidepressants have a slow onset of action. Weeks may pass before any effects are noticed. There will not be any sensation of euphoria, just a gradual feeling of being normal. Unfortunately, side effects can be seen as early as the first dose. They are usually mild and go away by themselves.

     Many antidepressants carry a suicide warning, especially for teens and children. Caregivers should take seriously and act upon any suicide indications, even when it comes up in casual conversations or joking.

     Alcohol is a drug that causes extra problems. Other drugs can also interact with antidepressants. A potentially life-threatening interaction called serotonin syndrome may develop.

      Symptoms usually occur rapidly. Mild to moderate reactions include increased heart rate, shivering, sweating, dilated pupils, twitching or tremors, agitation, blood pressure changes, and fever.  Life-threatening signs are fever above 106 degrees Fahrenheit and seizures. Drugs to watch for are tramadol (Ultram), ADHD stimulants, migraine “tryptans,” the herbals 5HTP and St John’s Wort, lithium, and many others.  

Herbal remedies

     St John’s Wort and 5HTP have both been used for mild to moderate depression. There is not much scientific evidence that either work very well, but some patients insist on using them. There are several unintended drug interactions that can occur with other medications, so work closely with the doctor and pharmacist if these remedies are consumed.

Mood stabilizers

     Bipolar disorder or manic depression is classified as a mood disorder. The patient experiences uncontrolled swings from very high moods of mania to low periods of depression. Often mood-stabilizing drug are used first. Other medications are then added as needed to control other symptoms that may arise. For example, antidepressants used for low periods and antipsychotics used for hallucinations during periods of uncontrolled mania. 

     Lithium was the first mood stabilizer approved by the FDA in the 1970s. It is still extensively used today.  Lithium is a basic element. Not only can it be used to stabilize mood, but it can also interfere with the function of other basic elements like sodium and potassium. Some of these and other side effects can get quite serious. They are:

·        Loss of coordination

·        Excessive thirst

·        Frequent urination

·        Blackouts

·        Seizures

·        Slurred speech

·        Fast, slow, irregular, or pounding heartbeat

·        Hallucinations (seeing things or hearing voices that do not exist)

·        Changes in vision

·        Itching, rash

·        Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

     Medication therapy will most likely be long term. Those basic elements that can be affected by lithium can also affect its long-term use.  If one of your residents is on lithium, they should have their blood levels checked regularly by their doctor. The doctor should make sure the kidneys and the thyroid are working normally.

     Anti-seizure medications are designed to inhibit nerves from firing. As such, they also can be used for stabilizing moods. Seizure medications used for bipolar disorder are:

·        Divalproex sodium (Depakote)

·        Carbamazepine (Tegretol)

·        Lamotrigine (Lamictal)

·        Oxcarbazepine (Trileptal).

 The side effects of divalproex sodium or its precursor drug valproic acid are:

·        Changes in weight

·        Nausea

·        Stomach pain

·        Vomiting

·        Anorexia

·        Loss of appetite.

     Young girls and women on valproic acid may have their testosterone levels affected and may develop polycystic ovarian syndrome. If a resident’s menstrual cycle becomes irregular, you should notify the doctor.  Long-term use of valproic acid can damage the liver or pancreas so they should be checked periodically. The FDA has also issued suicide warnings for anticonvulsant medications. 

     It is very rare but lamotrigine (Lamictal) can cause a very serious and potentially lethal skin condition called Stevens Johnson Syndrome (SJS). SJS is a severe inflammatory eruption of the skin and mucus membranes that can permanently scar and even kill.  What caregivers should watch for is an initial flu-like period of fever, headache, and sore throat followed by skin lesions. If skin eruptions appear, notify the doctor right away.  

Anti-anxiety medications

     Anxiety is defined as an unpleasant state of inner turmoil and nervousness. In an increasingly difficult world and under changing circumstances, a high level of anxiety can often be felt. There are also mental illnesses where feelings of anxiety are not under the control of the patient. Anti-anxiety medication (anxiolytic) use is more prevalent in care homes than in the general population, because of their cliental and general environment of change. 

     The most commonly used anti-anxiety medications are the benzodiazepines. They include:

·        Clonazepam (Klonopin)

·        Lorazepam (Ativan)

·        Alprazolam (Xanax)

·        Chlordiapoxide (Librium)

·        Clorazepate (Tranxene)

     Benzodiazepines work by quickly reducing certain brain activities producing a temporary relaxing, calming effect. Their side effects are also related to the reduction of function of the central nervous system. They are:

·        Drowsiness

·        Dizziness

·        Blurred vision

·        Headache

·        Confusion

·        Grogginess

·        Nightmares.

     Unintended effects of benzodiazepines can be addiction, emotional blunting, and depression with long-term use. They are considered drugs of abuse.  Alcohol and other drugs of abuse are a major concern with benzodiazepines.

     Other anxiolytic medications are:

·        Buspirone (Buspar) who’s side effects are:

                    ·         Dizziness

                    ·         Headaches

                    ·         Nausea

                    ·         Nervousness

                    ·         Lightheadedness

                     ·         Excitement

                     ·         Trouble sleeping

·         Beta Blockers, which include propranolol (Inderal) and atenolol (tenormin). They are commonly used for high blood pressure. Their side effects are:

                     ·          Fatigue

                      ·         Cold hands

                      ·         Weakness

                      ·         Dizziness upon standing

·         Low blood pressure

     There are other concerns with anti-anxiety medication therapy. For most patients, therapy is supposed to be only temporary. Patients can become habituated to anti-anxiety medications. They lose the ability to adjust to life’s demands without their chemical-coping mechanisms. This can be an issue when new residents who are on tranquillizers move into your homes. After they get used to the change, they have a hard time giving up the medication. It is hard to tell the habituation effect from a true addiction.

      Long-term use also makes it easier for the drug to build up in the resident creating over-sedation.  They look and act drugged out and drunk. Falls and lack of responsiveness become a greater issue.  Long-term use in the elderly (who have a greater sensitivity to sedation) can cause confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia. Over sedation and pseudo-dementia are serious problems for care homes

         Many well-meaning caregivers discontinue the medication too quickly creating withdrawal. Caregivers should look for extreme depression and fatigue, irritability, anxiety, flu-like symptoms, and insomnia. These symptoms will eventually go away by themselves. If they become an issue, counsel with the doctor about your observations.

Stimulants Used in ADHD

     Attention Deficit Hyperactive Disorder (ADHD) and the closely related Attention Deficit Disorder (ADD) are conditions where some of the control centers of the brain are not as active as they should be for proper functioning.  There are medications that can stimulate the brain so that its control center can function properly, helping sufferers lead more normal lives.

These stimulate medication are:

• Methylphenidate (Ritalin, Metadate, Concerta, Daytrana)
• Amphetamine Salts (Adderall)
• Dextroamphetamine (Dexedrine, Dextrostat)
• Lisdexamfetamine dimesylate (Vyvanse)

 Their side effects are:

·        Decreased appetite

·        Sleep problems

·        Jitteriness

·        Tics (sudden repetitive movements)

     Stimulant medication has been known to cause sudden cardiac death. Extra screening should be done if there is a history of heart problems, especially at the beginning of therapy.

     Psychiatric problems can be aggravated when stimulants are taken. Medication use can trigger or make the symptoms worse. Caregivers should watch for signs of hostility, aggression, anxiety, depression, and paranoia. Residents with prior mental health issues, especially mania or bipolar disorder, are at a particularly high risk. Caregivers should carefully monitor their mental health patients taking these prescriptions.

     Stimulants are drugs of abuse, but taken as directed long -term studies show virtually no problems of drug addiction. Controlled release versions of these medications should not be crushed or chewed. Too much drug will be released at one time, increasing the potential of overdose or abuse for the purposes of “getting a buzz” from the medication. 

     There have been some reports of patients trying to lose weight on the medication because of its effect on appetite. There is no evidence to support the sustained weight loss claims.

     Caregivers should remember that ADHD patients have a problem with remembering to take all the doses because of their increased distractibility. Long-acting medication can help reduce this problem by reducing the amount of times the medication needs to be taken. Abuse potential should be taken into consideration when considering switching to the long-acting forms of their prescription. 

     With some patients, stimulant drug use is a concern if they have been ineffective. There are a few non-stimulant alternative treatments for ADHD. They are:

·        Atomoxetine (Straterra) whose common side effects are:

·        Changes in menstrual cycles

·        Changes in urination

·        Dry mouth

·        Palpations, increased heart rate

·        Kidney problems (contact doctor if skin or eyes turn yellow)

·        Constipation

·        Insomnia

·        Abnormal dreams

·        Increased aggression

·        Teen suicide warning

·        Alpha blockers, which include clonidine (Catapres) and gaufacine (Intuiv). These can also be used for high blood pressure. Notable side effects are:

·         Dry mouth

·        Sleepiness

·        Weakness  and or dizziness (check for low blood pressure)

·        Headache

·        Constipation

·        Abnormal dreams

Caregiver Notes

     It is useful to be informed of potential medication side effects, but if they appear, what are you going to do about it. The following information might help in your caregiving efforts.

Medication management steps

As a pharmacist, I recommend the following steps:

Step 1- Read the literature that comes with the medication. It may seem daunting at first, but you’ll soon notice patterns in the material and it will become easier and quicker the more you read.

Step 2- Observe and record. Monitor the patient and pay attention to what changes. Listen to complaints and see if they are consistent with any side effects. Don’t emphasize the printed side effects to the patient. You might accidently encourage the patient to develop side effects that don’t really exist.

     Record significant events then watch if the intensity reduces over time. Many bothersome side effects will go away by themselves as the patient’s body gets used to the new medication. Ask questions of others who are with the patient, like family members, teachers, job supervisors, and other caregivers.

Step 3- Report. Tell the prescriber about the side effects that occur. They want to know what is happening with their patient. They can’t be with the patient all the time but you can.  If the doctor hears nothing, they assume everything is going OK. Sometimes even if you report annoying side effects, the doctor will do nothing about it. If that occurs, the doctor might have decided that the desired effect outweighs the unintended effect.  If the side effect starts to be a problem for your caregiving efforts, it will be up to you to communicate effectively with the doctor. Make them understand the impact those annoying side effects are having upon you and your other residents.  Be professional not just a whiner, reputations are earned –both good and bad.

Managing Common Side Effects

     As you have read this course, you may have noticed several side effects mentioned over and over again. Here are a few helpful hints that will help you manage some of the common unintended effects that might appear.

·        Dry mouth- Often dry mouth caused by medication use is the result of the saliva glands being turned off, not from dehydration. Drinking water is good, but you will notice that it is only a temporary fix. A longer lasting solution would be to either turn the saliva gland back on by sucking on something tart like a lemon drop or lifesaver, or utilizing a long-lasting saliva substitute. There are several OTC products you can buy or you can make your own by mixing liquid glycerin, lemon juice, and honey.    

·        Upset stomach- Eating soda crackers works great on drug-induced nausea. Either eat some with the medication or eat them when drug-induced nausea occurs

·        Constipation- Except in patients in danger of fluid overload, doubling the amount of fluid intake is a good first-line therapy. You can also increase the intake of foods that cause diarrhea like prunes, prune juice, or large amounts of other fruits (except bananas and applesauce).

·       Sedation- Sleepiness from medication can actually be taken advantage of. It’s all about coordinating when the greatest drowsiness occurs and when the patient goes to bed. Work with the doctor on when to take the medication. Altering the dose to the lowest effective amount might also help.

·       Dizziness/Less alert- Any prescription that works on mental health has the potential of causing changes in alertness, even stimulants. Be extra vigilant when starting any new mental health drug. It would be wise to be there when a patient transfers from one position to another like getting out of bed or up from the table. It’s much easier to provide a balancing hand than to pick someone up off the floor.

Other concerns

Suicide

      It is not fully understood why there is an increase in the suicide rate for some medications, especially in teens. One possible explanation is there was already a strong desire to commit suicide but the patient lacked the emotional energy to do so. Ironically, when the therapy starts to work, the patient now has the energy to follow through with their plans. So even if the medication appears to be helping, caregivers should remain vigilant for the following warning behaviors.

·        Acting more subdued or withdrawn than usual

·        Feeling helpless, hopeless, or worthless

·        New or worsening depression

·        Thinking or talking about hurting himself or herself

·        Extreme worry

·        Agitation

·        Panic attacks

·        Trouble sleeping

·        Irritability

·        Aggressive or violent behavior

·        Acting without thinking

·        Extreme increase in activity or talking

·        Frenzied, abnormal excitement

·        Any sudden or unusual changes in behavior

Opposite effects

      Some residents react differently than expected. They seem to be mentally wired backwards. Notify the doctor if the resident has new or worsening symptoms or changes in mood, thoughts, or behaviors. 

Compliance

     Cooperating with instructions and staying on mental health drugs long term is a major concern in the management of mental illness. The side effects of a medication sometimes reduce the resident’s desire to continue to take their prescriptions.

The Right to Refuse

      Every resident has the right to refuse a medication, even if it will cause them harm. There are special rules governing a patient’s right to refuse treatment, but a discussion of these is beyond the focus of this CE course. Please talk to the case worker or government licensor for more information.  Often, though, if a resident doesn’t want take a medication, it is an indication of unwanted side effects.

·        Listen to complaints and find out the “Why’s” of refusal. Then address the issues complained about.

·        There are certain medications that should not be discontinued abruptly. It will actually make the resident feel worse. Reminding the resident of that fact, followed by an action plan to address their concerns is often all it takes to regain their cooperation.

·         Greater cooperation can be gained by avoiding simple yes and no questions. Instead of asking, “Do you want your meds now?” ask, “Would you like to take your medication in applesauce or chocolate pudding? …with water or juice? … now or in 15 minutes?”

Feeling Better and Non-compliance

      Mental health medications can be very effective, but they shouldn’t be thought of as a cure.  Medication can provide temporary relief or even sometimes long-term relief of symptoms, creating the illusion of a cure.  But medications rarely eliminate the underlying causes of the mental illness. Once the patient stops taking the drug, the mental illness symptoms often return in full force.  This yo-yo effect can be quite disheartening to the patient. Caregivers must communicate effectively with their residents the lifelong nature of their mental illness and the reality of what is happening to them to prevent the up and down return of their symptoms. 

Special Populations

     The very old, the very frail, and the young have a different metabolism than the average adult patient. Medication effects must be monitored more closely in these populations. Often it takes less medication to achieve the desired results or side effects occur more readily at normal doses.

     Pregnancy and medications are always a special concern. Sometimes though, it is actually more dangerous for the unborn child for the mother to be off of prescription therapy. Counsel with the doctor about the need to take medications during pregnancy. 

     After the baby is born, caregivers should watch for postpartum depression, especially if residents stopped taking their medication during pregnancy.  It is a very rare occurrence in care homes for a resident to breastfeed their child.  If a resident wants to breastfeed their child, the caregiver must warn that psychiatric medication can pass into the breast milk. However, the medication may or may not affect the baby. It depends on the medication and when it is taken. It is a proven fact that breast feeding is of benefit to the newborn, so patients and their caregivers must talk to the doctor about the potential risks and benefits of breastfeeding while on medications.

Conclusion

     Caregivers are responsible for the welfare of their residents. A large portion of the therapy that those residents are under is medication based. Mental health and medications are particularly interconnected and complicated. Caregivers must not only know when and what to give but also what the medication is supposed to do and what side effects are possible.  No matter how well the medication is tolerated, there is always the possibility of unintended, sometimes serious, effects that have to be monitored for.  Even if there are adverse effects, sometimes they can be managed and the medication will be continued. An informed caregiver is better prepared to handle any unintended medication effect that may arise so it is advisable to read the drug information material that comes with each mental health medication and all other prescriptions.     

References

1. Leonard Holmes, Tardive Diskinesia. Mental Health, About.com 6/ 02/10

http://mentalhealth.about.com/cs/psychopharmacology/a/tardtive.htm

2. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Safety, FDA

http://www.fda.gov/Safety/MedWatch/default.htm

3. Tardive Dyskinesia. Wikeperdia The free encyclopedia

http://en.wikipedia.org/wiki/Tardive_dyskinesia

4. Tardive  Dyskinesia. NAMI, National Alliance on Menatl Illness

http://www.nami.org/Content/ContentGroups/Helpline1/Tardive_Dyskinesia.htm

5. Introduction: Mental Health Medications. Mental Health Medication, NIH, National Institutes of Health. NIH Publication No. 08-3929, Revised 2008.

http://www.nimh.nih.gov/health/publications/mental-health-medications/index.shtml

6. Extrapyramdial Side effects. Wikipedia the free encylcopedia

http://en.wikipedia.org/wiki/Extrapyramidal_side-effect

7. Various drugs listed in article. Drugs.com

http://www.drugs.com/

An Unintended Effect

Side Effects of Mental Health Drugs

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Caregivers Are from Venus but Medical Administration Records Are from MARS

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Caregivers Are from Venus but Medical Administration Records Are from MARS

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Caregivers Are from Venus but Medical Administration Records Are from MARS

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1.5- Approximate time required: 90 min. 

Educational Goal: 

To provide instruction and motivation to properly fill out and use the medication administration record system.

Educational Objectives:

Procedure:            

1. 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. 

*notes- Registration is only required once. On subsequent visits you may go straight to login.

          If you get lost, click [AFC-CE.com] in the black admin strip at the top of the page to return to the Welcome page.

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. The information in this article is not meant to supplant training provided by any government agency.

Caregivers Are from Venus but Medical Administration Records Are from MARS

     One of the most hated chores of residential caregiving is filling out the MARS, or medical administration records. To a lot of caregivers, it seems so tedious, so unnecessary and so unfamiliar. Such feelings are understandable.  Before professional caregiving, you never had to keep track of when and why you gave medication.  You never had to worry about keeping records and being accountable for every little thing. Admit it, some of you look at the MARS and prescriptions and think they are written in an alien dialect. It’s almost as if caregivers are from Venus and those who print medical administration records are from MARS. (Pun intended.)

     Seriously though, filling out the MARS does require a different way of thinking that is unfamiliar to most new caregivers. Often this leads to neglected records. When push comes to shove, the forms are hurriedly filled in all at once.  I admit that I have felt that way, too, in the past.  But the longer I am in the trenches of the healthcare battlefront, the more I have come to appreciate this often underutilized and unappreciated caregiving tool.  That’s right, I said caregiving tool. A tool that, if used correctly, can improve the health of those you care for, make your communications easier and clearer, make your job easier and more organized, and protect you and your clients from harm and legal action.

     So let’s start to change the way you think about the MARS. Let’s align our minds with the principles and reasons behind record keeping. I think that once this is done, you will start to see the benefit of keeping a good MARS, and it won’t seem like such an alien way of doing things.

Principle No. 1: You have to. It’s legally required.

     Like it, love it, leave it, or lump it, it doesn’t matter. You still HAVE to do it. It’s the law. Those who regulate the industry are going to check to see if you have done it and have done it right. If you want to make a living as a caregiver, then you have to do it- period. It will be of NO use to complain or make excuses. No one will listen, so don’t even try.  Not keeping records is NOT an option.  Now that’s out of the way, we can move on.

Principle No. 2: It’s a legal document, admissible in court.

     Caregiving, and healthcare in general, is a very powerful profession. You are intimately involved in the welfare of another individual. When things go wrong, you can be held legally accountable for your actions or the lack thereof. Caregiving is one of those professions where every single working day you could get sued, fined, or even jailed when bad things happen.  It doesn’t even have to be your error. You could potentially be held responsible for not catching and preventing someone else’s mistake.

     A very important message that you must understand in this principle is, if it wasn’t written down, it didn’t happen. That will automatically be the belief of any government inspector, and that will certainly be the position of the lawyers in court.

     The best way to protect yourself from liability is to document what you do. When you stand up in front of a government inspector or a courtroom judge and say, “It wasn’t my fault,” you will be believed more often if you can say, “It wasn’t my fault, and here are the records that prove it.”  Think of the MARS as a protective insurance policy that doesn’t cost anything.

     For employees who are reading this article, filling in the MARS is protection from being fired.  Remember, the owner is going to take the same position as an inspector. If it wasn’t written down, it didn’t happen.  Your boss is going to get dinged at government inspection time and possibly fined if you mess up.  So, protect your job and fill out the MARS.

Principle No. 3: The MARS makes caregiving easier.

    A properly filled out and reviewed MARS makes caregiving easier. This happens because of better communication, uniform caregiving, enhanced professional appearance, and better therapy outcomes.

Better communication and uniform caregiving

     Keeping your client healthy is not a simple task. It takes the efforts of an entire team of health care specialists. Doctors, dentists, pharmacists, nurses, therapists, case workers, care providers, and family members’ efforts must be combined and coordinated around all the twists and turns of the client’s health outcomes. Every member of the team must be able to communicate effectively way with each other. If not, there will be a lot of extra confusion and adjustments. All of which boils down to more work for you, the primary caregiver. 

     I’ve seen it happen. Patient A goes to doctor B for one complaint. Then they go to doctor B with another complaint, but don’t tell doctor A. Doctor B sends the patient to therapist C. Visiting nurse D shows up to help and reports back to doctor A but not doctor B. A Family member sees a commercial for product E and buys it for the patient. On and on it goes until the patient has totally forgotten what they are doing for their health.  Fifteen drugs later, the patient is in a real mess despite all the sincere efforts of the caregivers involved.

    Or maybe you’ve experienced the following. Caregiver A gives the meds in a certain way, then goes for her days off. Caregiver B gets new instructions from the doctor, which temporarily changes the way the meds are given so that they can safely perform an upcoming procedure. Caregiver B forgets to tell caregiver A the new instructions, so when caregiver A comes back to work, it’s business as usual. When it’s time for the procedure, the patient is unprepared and everyone has to start all over, or worse the patient gets harmed.  The above is a perfect example of “If it wasn’t written down, it didn’t happen.”  It’s also a good example of why an incomplete MARS can get you sued.

    A properly filled out and maintained MARS cuts through all that confusion. Everyone knows what’s going on, and is up to date with all the therapies involved. There is no duplication or wasted effort, making caregiving easier.

It makes you look professional

     Let’s face facts. Everyone assumes that in-home caregivers are at the bottom of the totem pole. They assume that the only reason you’re in health care is that you couldn’t find anything else to do. Don’t you hate it when you’re treated like a teenage babysitter? That prevailing attitude is unpleasant to work under, and it takes a lot of extra work to overcome. Besides, no one likes to be thought of as a stupid simpleton.

     It’s very gratifying to see the change in attitude when a condescending health professional, who assumed you were a country bumpkin, looks through your professionally filled-out MARS.  A neat and orderly MARS earns you respect. When people listen to you, you get more cooperation and your job gets easier.  

Better outcomes

     A properly filled-out MARS includes the PRN and incident logs. They can give vital information about the patient to medical decision-makers. Trends, patterns, side effects, and worsening conditions can be detected. Filling out and paying attention to the MARS allows you to see the tip of a large iceberg of problems before you run into it. Consider the following example.

     When she looks at the MARS report, caregiver Jane notices the client Sue has been taking a lot more anxiety meds this month. Client Sue is quiet and never complains, so caregiver Jane knows something is wrong and sends her to the doctor. The doctor is able to see a manic episode coming on and is able to control it before client Sue gets out of hand. The MARS once again made taking care of a client that much easier.

Principle No. 4: MARS prevents errors.

     Modern health care is complex, pressured-filled, and constantly changing.  As a result, errors will and do occur.  To list all the ways mistakes can be made would just be depressing. To sum it up, I’ll just reference the Institute of Medicine’s July 2006 report Preventing Medication Errors, which says medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs.  And you thought you were the only one who makes mistakes.

     If you pay attention to what is on the MARS and fill it out as you give the medication, you can catch medication errors before they get to the patient. You will catch the mistakes that others make and prevent the ones that you might make yourself.

      Never assume that strange orders or different-looking pills are just a change from the doctor that you didn’t know about. Remember the principle, “If it’s not written, it never happened.”  When things are different and undocumented, verify them. “When in doubt, shout it out,” will keep your clients safe from the potential harm of medication errors.

Diversions

     Another mistake that the MARS can prevent is an error in judgment - an unwise decision by either the patient, family member, or caregiver to steal a client’s medication. Diverting a client’s medication for personal use is illegal and immoral. It harms the abuser and the patient who needs the medication.

    Drug diversion needs to be stopped. The best way I know of is to keep track of the number of drugs that are supposed to be on hand. With some calculations, the MARS can tell you how many pills are supposed to be left at any given time. Sometimes the drugs will be taken and charted as if the patient took the drug. The PRN log can be verified with the patient to see if they actually got the medication. If the patient is complaining of unresolved health issues, double-check the PRN logs to see if the patient is getting the meds that have been charted.

For those in charge

      A messy, gap-filled MARS sends up a big red warning flag that should send you running to count those pills and account for every single one.

     It would be well worth the effort of care homeowners to periodically count the narcotic drugs in their homes. It sends a loud message to potential thieves - I’m watching.

   When your counting doesn’t turn up any discrepancies, you might think that it’s all a wasted effort. I would have to say you’re wrong. Your efforts are succeeding. You can tell because there are no discrepancies. 

The Basics of Filling Out a MARS?

• Who’s responsible for filling out a MARS? Simply: everyone. If you do the action, then it’s your job to record it. Write in your initials when you chart and record your full name by your initials on the signature log.
• When do you fill out the MARS? Right after you give the medication. Never before. That causes errors. Never later, trying to catch up all at once. That’s just plain sloppy and lazy. You’ll never get the full benefit from the MARS that way.
• What do you fill out a MARS with? An ink pen, never anything that can be erased or smudged out. Always have a spare pen stuck right in the MARS binder just in case you misplace the first one.  
• Where do you store the MARS binder? Any place that is easily accessible to caregivers but not to the public. Privacy laws protect the personal information about your clients and needs to be protected from prying eyes. Don’t go overboard. Too much secrecy and you’ll discourage caregivers from filling it out in a timely fashion.
• What do you do if you make a charting mistake? Never erase or use white out- ever. Just draw a line thru the error and initial it. Then leave a brief explanation if needed. The principle is that anyone should be able to read and understand what went on, even years afterwards.
• What needs to be charted in a MARS? At the bare minimum, medication administration events, but if used properly, anything the doctor wants to keep track of. That includes PRN logs, medication refusals, adverse effects, patient vitals, and  patient is absence (vacations, overnighters, family visits, etc.). You have to be a bit flexible here. Some government officials might want some client details charted elsewhere. You can’t blame them. If you had the go through as many MARS as they do, you would want it simplified too. For such limitations, consult with the government inspector.
• How much details do you have to chart? Chart facts, not opinions, and be brief. It’s OK to write the same thing over and over. This is not great literature, it’s a MARS.  Headache resolved written 11 times in a PRN log is perfectly OK if it tells what needs to be said. But keep a couple of blank pages in the MARS binder just in case a longer explanation is needed. Then place the proper reference so the paper trail can be followed. Example- therapy failed, see progress notes page 2.
• What are the Five R’s? You might have heard about the Five R’s. It’s a simple method to prevent errors. When giving meds and charting, always be sure it’s the 1. Right person, 2. Right drug, 3. Right dose, 4.Right time, 5. Right route. If you are frazzled or tired, double check yourself by going through the Five R’s backwards. I would paste the Five R’s right inside the MARS Binders.

Charting in the MARS

     Recording information in the MARS is more than just simple recordkeeping. It is a living document that grows and can be used for several different purposes by multiple people.  Here are a few important details to remember:

• A check mark means nothing. Always use initials.
• Never chart for another employee.
• Never leave blank spaces. Account for every space. Example- POH- patient out of home. At the very least, put a line through each space.
• Keep it up to date. Record changes right away. Then make sure whoever  prints out the fresh MARS get the changes as well.
• Always review the new MARS when it come out. You’ll catch more mistakes if you assume it’s wrong until the MARS is proven accurate.
• Review the MARS for changes at the start of every shift.
• This is legal document. Spelling and handwriting neatness count.
• Do not record a personal opinion unless it’s noted as such.
• Don’t forget to chart the additional info required for PRN  medications.

Miscellaneous

The following are a few miscellaneous items that don’t quite fit anywhere else.

Abb.- abbreviations

     There is not a lot of room on a MARS so abbreviations are OK as long as you use generally accepted ones. If you make up your own, then you’ll have to put in an abbreviations key in the chart notes. Here is a list of common abbreviations;

For a more complete list consult http://en.wikipedia.org/wiki/List_of_medical_abbreviations

Dispensing Medication

     Dispensing medication is a routine task that can lull you into a false sense of security. Even though it can get monotonous, you should remember that you can cause harm with every single dose given incorrectly.   Here’s a list of good  medication-dispensing techniques.

• Double check the Five R’s.
• Never leave the medication in front of the residents.
• Watch the patients take the medication. Verify it’s taken when in doubt.
• Chart immediately afterward.  
• If it doesn’t look right, assume it’s wrong.
• Listen to the input from the patient and the family. (Example: I have never taken that medication before.)
• Never use a middle man to hand out the meds.             

Use the Info in the MARS

     Actually use the information recorded in the MARS. Get the full benefit from the effort. 

• Follow up and communicate all ineffective PRN medications. Consider each episode as the tip of a larger iceberg of trouble.
• Pay attention to the frequency of the PRN meds. It’s an important clue to how the underling condition is changing.
• Copy important observations and send them to the doctor or other medical practitioner.
• Watch for side effects.
• Find out why the resident refuses medication.
• Suspect inappropriate caregiving when the MARS is sloppily filled out. You know the state inspector is going to.
• A neat MARS equals an easier inspection, which leads to a happier inspector.

The right to refuse and what to do about it

     Every client has the right to refuse a medication regardless of the consequences. Even though no medication was given, it is still a significant event and has to be charted in the MARS and followed upon. Each facility has its own procedures on how to chart a refusal. If you don’t have one, I suggest the following.

1.      Find out why they are refusing and address any underlying problem, then offer the med again.

2.    If they refuse again, put off that particular medication until last. Then offer it again.

3.    If they refuse the third time, then chart it with refused or a capital R making a special note of what R means on the signature log. Then chart the reason for the refusal.

4.    Notify the facility manager and the manager will notify the prescriber. (The prescriber won’t want to be bothered unless it is significant or a pattern starts to develop.) 

     Refusals are important clues about drug therapies. Asking the why questions can reveal problems with side effects, lack of patient understanding and the appearance of significant changes in patient health. Once you have determined the true reason why the patient refuses, chart it if they continue to refuse.    

    You will have fewer refusals if you give the patient a choice other than yes and no. The second time the drug is offered, give them a choice on how to take it. Instead of saying, “Do you want your meds now?” say “Do you want to take it with water or juice.” Or, “Do you want me to put it in applesauce, pudding, or cheese sauce?”  

Caregiver notes-

     I recently asked a state inspector what gets dinged the most in their inspections of the MARS. He said the three most common deficiencies are:

1.      Physician’s orders are not copied to the MARS exactly. I know it’s most likely the pharmacy's fault, but you are the one getting dinged. Take time to review each new MARS that you get. Then make sure that it is exactly the same as your doctor’s orders. It’s OK to ask the pharmacy to change the MARS and send you a new one.

2.    Other doctor orders are sometimes forgotten. Like using diabetes test strips or treatments. If the doctor writes the order, you have to chart it.

3.    Pharmacies keep track of drug allergies. You have to keep track of all allergies. The common one that is forgotten is hay-fever or seasonal allergies. If the resident gets allergy medicine,  the inspector is going to look for which allergies are listed.

     Work with the pharmacy and the doctor’s office to make everything match up. Sometimes the easiest is for you to write up a note and send it to the doctor for a rubber stamp approval.

Example. The doctor writes give 100mg ibuprofen twice daily. The pharmacy sends you ibu 200mg give one- half twice daily. It’s the same thing, but you’re going to get dinged for it. Just send a note off to the doctor saying ibu 200mg give ½ twice daily-  yes ___ no ____? 

Conclusion

     Caregivers may not be used to charting in a MARS. It does require a new way of thinking about caregiving and medication administration. Once the caregiver gets used to the task, they will find that filling out the MARS can benefit them in many ways. The MARS can be a source of important information about the client and their changing health. It can help protect against medication errors. It will coordinate care efforts and increase cooperation between caregivers and other medical practitioners.   When done properly, the MARS improves the overall quality of health care in the home.

As always, good luck in your caregiving efforts.

Mark Parkinson, RPH

References:

1. Provider Manual For Medication Administration by Unlicensed Personnel, RN Orientation Curriculum, Book 1. West Virginia Department of Health and Human Resource . rev1/14/13

http://www.wvdhhr.org/ohflac/amap/resources/amap_rn_curriculum_book_1.pdf

2. Medical Orders and Medication Administration Record (MAR). Ensuring Quality Care, chapter 11 Medication Administration.  Oregon Department of Human Service. SDS 0341.Rev 12/02.

http://www.oregon.gov/dhs/apd-dd-training/EQC%20Training%20Documents/Medical%20Orders%20and%20Medication%20Adminstration%20Record.pdf

3. Medication Administration Course, Training Program, Presenter’s Guide. Illinois Department of Human Service. 02/01/11

http://www.dhs.state.il.us/onenetlibrary/27896/documents/by_division/division%20of%20dd/medicationadministration/section5presentersguide.pdf

4. Key Facts About Patient Safety. National Patient Safety Foundation

http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-facts-about-patient-safety/

5. Medical Abbreviations. Wikipedia The Free Encyclopedia

http://en.wikipedia.org/wiki/List_of_medical_abbreviations

Caregivers Are from Venus but Medical Administration Records Are from MARS

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“What did you just say?”

Hearing and Hearing Aids

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“What did you just say?”

Hearing and Hearing Aids

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1. - Approximate time required: 60 min. 

Educational Goal:

Provide caregivers with a basic understanding about hearing and how to take care of hearing aids.

Educational Objectives:

      1. Describe the anatomy of the ear

      2. Describe the physiology of hearing

      3. Explain about ear wax from a caregivers perspective

      4. Expound about the basics of hearing aids and their care

Procedure:           

1. 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.

“What did you just say?”

Hearing and Hearing Aids

            Caring for people in a home (non-institutional) setting can be challenging at times. Caregivers take on the responsibility for looking out for ALL of their clients’ needs. Suddenly, you must know what to do about… well, everything.  For example, all care providers have to know how to maintain, handle, and clean the hearing aids of their clients. Too often, however, the owner’s manual is long gone. How are you supposed to know what to do? Hopefully, by the end of this article, you’ll have the answers you need.

            Hearing loss is more common than you might think. Ten percent of Americans - about 30 million people - have hearing loss. That figure is going to rise as noise exposure, trauma, disease, heredity, and the aging process all take their toll.  In the care home setting, the incidence of hearing loss is much higher than the general population. It is increasingly common even at homes for the developmentally disabled and mentally ill to have to deal with hearing impaired clients and hearing aids. How do you take care of the hearing impaired and their hearing aids?

The Anatomy of Hearing

Let’s start with an understanding of hearing and hearing loss. Hearing is the process of turning sound waves into nerve impulses that our brains can comprehend.  How that happens is very interesting.  The ear is comprised of three parts called the auditory system:

·         The outer ear, which is made up of the pinna (the portion of the ear outside the head) and the ear canal.

·         The middle ear, which contains the eardrum and an air-filled chamber that houses three of that smallest bones call the ossicles.

·         The inner ear, or cochlea, which is a spiral fluid-filled chamber filled with tiny hair like structures connected to the nerves responsible for hearing.

How we hear

Sound travels through the air in waves. These waves of air pressure are collected by the pinna and travel down the ear canal. The waves strike the eardrum and cause it to vibrate, which, in turn, causes the ossicles to also vibrate. This converts the sound waves into mechanical energy.  That energy strikes the fluid-filled inner ear and creates waves that travel down the spiral. When the waves reach those tiny hair like structures they bend over, causing the nerves to fire. The combination of intensity and frequency of the waves determines which nerves fire, creating the nerve impulses we perceive as hearing.

Hearing is more than just nerves firing. It is also an active process of understanding what we hear.  To do that, our brain collects all input it receives and combines it to better understand what it is listening to.  Sight, smell, touch - all the senses - affect how we understand what we hear. We can even focus on a particular sound, filtering out competing input as background noise. It’s truly an amazing ability.

Protecting the Auditory system

            Our ears are a complex system of interrelated parts, all working together. To protect it, the body does several things.

·         The outer ear is lined with hairs that keep out foreign objects.

·         Specialized sweat glands produce ear wax or cerumen that traps particles and dirt and gradually moves them out of the ear.

·         The eardrum itself creates a barrier that nothing gets past.

·         The delicate inner-ear parts are surrounded by boney structures that protect them from damage.

As you can imagine, with a system as complex as the ear, things can and do go wrong. If any part of the system is clogged or damaged, hearing is impaired. The causes of hearing loss fall into three categories.

·         Conductive hearing loss arises from an interruption of the sound waves traveling through the outer or middle ear. Common causes would be earwax build-up, a torn ear drum, or fluid or infection in the middle or outer ear.

·         Sensorineural hearing loss occurs when auditory nerves fire incorrectly. It arises mainly in the inner ear and is the result of damaged hair filaments or nerve fibers. Common causes are excessive noise, trauma, disease, or old age. Sensorineural is also called nerve deafness. 

·         Mixed hearing loss is a combination of both conductive and sensorineural hearing losses.

Caregiver notes:

Ear wax

There are many causes of earwax build up. Dead skin layers can accumulate, hearing aids can gradually block the natural process of removing cerumen, Ear hair can grow too long. An immobile or sedentary lifestyle can reduce earwax movement. All result in poor hygiene. As you go about your caregiving duties, don’t forget the ears. Keep them clean and trimmed. But be careful: Eardrums can be torn, scratches can become infected, and fungi can grow in an overly moist ear canal. It is even possible to clean the ear too much. The ear needs some earwax as a barrier against bacteria, fungal spores, and other foreign material. Ironically, mothers who keep their children’s ear canals too clean actually create more ear infections in their children. 

Earwax removal products

Occasionally, you may need to buy an earwax-removal product. There are some controversial questions for caregivers to consider:

·         Do you need a doctor’s permission before using an earwax-removal product? In my opinion, you can keep yourself out of trouble by getting a doctor’s OK. An easy strategy is make it a part of the doctor’s standing orders.

·         Which product should you buy? Fortunately, all OTC products have the same active ingredient. Choose whichever is cheaper and follow the instructions.

·         What about ear candles? Avoid them - always. There is something about putting an open flame and hot wax even near the ear just screams LAWSUIT when things go wrong.

·         What if OTC products don’t work (I had a few new move-in clients  that were that bad) Let the doctor handle it. That’s what they’re there for, right? 

Compensating for Hearing Loss

As mentioned above, hearing is more than just auditory nerves firing. It’s a process of actively combining all inputs and filtering out unneeded stimuli. When the client’s hearing is impaired, you can take advantage of all the other hearing factors, so that you can be heard.

·         Get the client’s attention first.

·         Stand in front of the patient so he/she can see your face.

·         Remove or limit distractions and unwanted noise.

·         Give visual clues about the subject matter.

·         Talk in a lower-pitched voice (high-pitched sound is the first to go in normal hearing loss).

·         Talk slowly to give the client more time to process the sound input.

·         Get closer, to make it easier for the client to focus on what you are saying.

·         Don’t chew gum when talking - it changes the way your mouth looks when talking.

Hearing Aids

Most hearing loss can be mitigated, but not cured. Some medical procedures can alleviate conductive hearing loss. However, nerve deafness, which makes up about 90 percent of hearing losses, is permanent.  Most deafness comes on gradually with most patients suffering only partial impairment.

Those who do not seek help tend to become depressed, paranoid, insecure, and emotional.  Although sight connects you to the world, hearing connects you to people, so those with hearing losses tend to become socially isolated.  With the help of hearing devices, most of those effects can be avoided or eliminated. The hearing aid connects you back into the world.

There are several kinds of hearing aids. In general, the smaller they are, the fewer features they have and the more expensive they are. Also, the smaller the batteries are, the more frequently they must be changed.

·         Behind-the-ear (BTE) aids use a case filled with the electronics that goes behind the ear, a connecting tube and an ear mold or dome. They are generally more durable and have room for larger batteries and features. 

·         In-the-ear (ITE) aids put all components in the ear mold itself. 

·         In-the-canal (ITC) aids are generally smaller versions of ITEs.

·         Completely-in-the-canal (CIC) aids are the smallest type.

·         Cochlear implants are surgically implanted devices that bypass damaged ear parts and feed electrical signals directly to auditory nerves

·         A bone-anchored hearing aid (BAHA) is surgically connected to the bones of the skull. This allows the skull to be the pathway of sound into the inner ear. It is used in patients with conductive hearing loss, such as a child born without ear canals.

How do hearing aids work?

The basic hearing aid has four main parts: a microphone to pick up the sound of the environment, an amplifier that magnifies the sound, a receiver or speaker that changes the electric signal back into sound that is directed into the ear, and a battery that powers the device.

Hearing aids can’t totally replace normal hearing activities. They only supplement what remains of the patient’s original hearing.  Hearing aids sound different than normal hearing and they take some getting used to.  The patient must also get used to the feel of the devices in the ear. Because of the small size of the devices, patients must get used to keeping track of them. It is far too easy to lose a hearing aid at bedtime or during bathing.  Since they are electronic devices, the signal can produce feedback, creating a high-pitched whining noise. That feedback whine can be a sign of ill-fitting or improperly worn device. 

Accessories

In addition to their basic function of amplifying sound, hearing aids can also offer many extra features. Directional microphones allow you to hear sound directly in front of you better. Telecoils helps patients use phones better. Other features are low-battery indicators, automatic volume control, earwax guards, and manual volume control. Some devices even include a connection port that allows the wearer to plug into other sound devices like a radio.

Cost

Hearing aids can be one of the most expensive of your client’s possessions. The average cost can be between $1,000-3000 (and sometimes a lot more). You must also factor in the cost of visits to a hearing-aid professional and batteries that will be used. Most costs are not covered by traditional insurance. You can buy less expensive OTC hearing aids, but they will not be custom fit, so there will be comfort and feedback issues.  Most hearing aids last between five to 10 years. 

Batteries

Hearing-aid batteries are tiny. Don’t force them into the device. They last between five  days to a couple of weeks. The smaller they are, the faster they run out. Battery size is determined by a number, such as No. 612. Swallowed hearing aids can cause serious damage.

Hearing Aid Professionals

Regular hearing aids are considered Class I medical devices and are regulated by the U.S. Food & Drug Administration. As such, state governments license hearing-aid professionals.  It is rare, but some family doctors (usually in very rural locations) can sometimes handle hearing aids. Ear, nose and throat specialists (Otolaryngologists ) also dispense the devices. Most hearing-aid professionals are either Audiologists or Hearing Aid Specialists.  An Audiologist is the better trained of the two (look for “Au.D.” after the name).

Caregiver notes:

            When you take care of a client who uses a hearing aid, you must take care of the hearing device, too. That means you must keep track of it, supply it with fresh batteries when needed, maintain it, and keep it clean. Sometimes, you can get the client’s relatives involved, but be careful: It often just makes things more complicated.  Some tips:

·         Provide a special container for the hearing aid when not in use (e.g. at bath time).

·         Create a battery-replacement schedule.

·         Double-check for proper fit if the hearing aid whines.

·         See if the hearing aid has different programs built into it, then select the right setting (Example phone use).

·         Negotiate with an independent Audiologist can be dickered with to obtain lower prices for clients.

·         Disconnect batteries when the device is not in use to make them last longer.

·         Remember to turn off the hearing aid when not in use.

·         Excess heat makes batteries die sooner. Be careful with battery storage.

·         Mark the battery-change date on a calendar to remember when to change.

·         Remember, a properly fit and functioning hearing aid makes it much easier to communicate with and care for your client.

·         Audiologists sell used hearing aids that are cheaper.

·         Liquids, soaps, solvents, and water (even sweat) are the enemy of hearing aids.

·         Hearing aids typically include a trial period where the hearing professional can make adjustments. Have patience with your clients. But if needed,  send them and their devices back to the audiologist. 

·         Hearing aids are electric machines and must be periodically checked and cleaned by professionals. Frequency of maintenance depends on the brand and the owner’s ability to pay.

·         Wipe the device dry - never use a blow dryer or a microwave to dry a hearing aid

·         Remove the hearing aid first if you’re applying any lotions or liquids near the ear, including perfume, cosmetics, insecticide, cologne, or hair spray.

How to clean a hearing aid

Follow the specific instructions from the manufacturer. The client’s hearing aid professional will be able to tell you the brand and type. In general:

·         Wipe the hearing aid daily with a soft cloth.

·         Clean the device over a soft surface, so if you drop it, it won’t get damaged.

·         Wipe the batteries if moisture is present.

·         If the client doesn’t have a multitool for cleaning consider buying one.

·         Use the wax pick to remove earwax buildup.

·         Use the brush to clean vents and sound outlets. Never insert anything into the sound outlets unless instructed by the manufacturer

·         Replace wax filters as directed and as needed

·         Replace the dome as needed (every four weeks) if there is one.

Conclusion

The ability to hear is an important measure of your client’s quality of life. Communicating with your clients is an essential element of caregiving. When hearing becomes impaired, quality of life decreases and caregiving becomes more difficult. Hearing devices help bring life back to normal for your clients. To operate properly, hearing aids must be properly understood, used, and maintained by the client and the caregiver.

I hope you found this article useful and, as always, good luck in your caregiving.

Mark Parkinson, R.Ph.     

References:

1. Hearing Loss. Nation Institute of Health, Senior Health.

http://nihseniorhealth.gov/hearingloss/hearinglossdefined/01.html

2. Hearing Loss. Mayo Clinic.

http://www.mayoclinic.com/health/hearing-loss/DS00172

3. Hearing aid. Wikipedia the free encyclopedia.

https://en.wikipedia.org/wiki/Hearing_aid

4. Hear well in a noisy world. Consumer Reports.org, July 2009.

http://www.consumerreports.org/cro/2012/12/hear-well-in-a-noisy-world/index.htm         

5. Hearing Aids. Mayo Clinic.

http://www.mayoclinic.com/health/hearing-aids/HQ00812

6. Consumer guide to hearing aids. AARP, 2007

http://assets.aarp.org/www.aarp.org_/articles/health/docs/hearing_guide.pdf

7. Sergei Kochkin, Ph.D., Your Guide to buying hearing aids. Better Hearing Institute

http://www.betterhearing.org/hearing_loss_treatment/hearing_aids/buying_hearing_aids/index.cfm

8. How clean hearing aids at home. Health Hearing. June 12,2012

http://www.healthyhearing.com/content/articles/Hearing-aids/Fitting/50291-How-to-clean-hearing-aids-at-home

9. Care and cleaning of your hearing system. Phonak.com

http://www.phonak.com/content/dam/phonak/gc_hq/b2b/en/products/more_products/_documents/Brochure_Care_and_Cleaning_of_your_hearing_system_028-1128.pdf

10. Hearing. Wikipedia the free encyclopedia

http://en.wikipedia.org/wiki/Hearing

11. Stephanie  Watson. Hearing Aid Basics.  Discovery fit and health

http://health.howstuffworks.com/medicine/modern-technology/hearing-aid1.htm

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