Courts Shouldn’t Practice Medicine Says Elizabeth Landsverk, MD

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Elizabeth Landsverk, MD, with ElderConsult Geriatric Medicine is against CA Bill SB 938 requiring a court to approve use of psych meds for dementia patients.

Elizabeth Landsverk, MD

SB938 is not the answer. Bringing courts into the mix of medical decision making will only delay medical decisions that might be life-saving.

For the last several years, there has been great public concern about using psychoactive medications (anti-depressants, anti-psychotics, anxiety meds and so on) especially in people with dementia. Now, there is a bill pending in Sacramento—SB938—that would require a court to approve the use of all psych meds changes after the initial approval of “dementia powers” granting the conservator use of psychoactive medication.“This affects the person with dementia that is “conserved,” that is, a person who can no longer manage his or her affairs and has a “conservator” as a guardian. Psychoactive medications cannot be given if a person refuses, unless there are “dementia powers” from the court,” says geriatrician and dementia specialist and adjunct clinical professor at Stanford University Medical School Elizabeth Landsverk, MD.

“People are right to have concerns,” says Dr. Landsverk. Studies have shown in Australia that up to 80% of antipsychotic use can be stopped in elders without serious consequences. “But SB938 is not the answer. Bringing courts into the mix of medical decision making will only delay medical decisions that might be life-saving, and protect an elder from eviction for serious behaviors. It will not add to our elders’ quality of life. Rather, it will damage that quality of life for a significant number of elders needing medical treatment, says Dr. Landsverk.”

Dr. Landsverk adds that as a lead educator for the California Coalition for Culture Change, a multidisciplinary group working to decrease antipsychotic use and improve care of people with dementia, we work to educate the public, facility staff and doctors on best practices. “As a geriatric specialist, I focus on the behavioral challenges of dementia. I provide house calls around the San Francisco Bay Area, and I always tell the families of my patients that psychoactive drugs should be used with great care,” says Dr. Landsverk.

Antipsychotics have a 2% increased stroke risk and a 1% increased sudden death risk. Narcotics can be over-sedating and constipating. Tranquilizers and “anti-anxiety” drugs may increase the risk of falls, which can be life threatening in the frail elderly. Acute withdrawal can be serious as well and look like worsening dementia. “We almost never use Xanax, Ativan or sleeping pills in our practice; rarely Ativan for a needed procedure or active death,” says Dr. Landsverk.

Because of these risks, many doctors and advocates insist that psychiatric medications should not be used in the care of patients with dementia. Others say they may be used in particular situations: for instance, in some with serious behaviors related to Parkinson’s disease or frontal dementia. In the field, it’s a common adage that when an elder with dementia act outs, it’s because the patient’s needs are not being met. The idea is that if you love and care for a patient enough, the problem behavior will disappear.

According to Dr. Landsverk, many times, this is true. Dementia patients certainly act out if they’re in pain, if their routine changes unexpectedly, if they’re confused and afraid. The care team should eliminate all those possible problems first. Which brings up the problem with not giving elders with severe pain any narcotics, but that is another discussion.

Many elders with dementia act out simply because the course of their disease has damaged their brain. No matter how well their care team meets the needs of these patients, some elders will lapse into violent, often disturbing, behavior: they will try to bite or hit their caregivers. They may make inappropriate sexual advances. They may try to climb out a window or over the wall, or be so distressed from delusions that each day is a misery; thinking they don’t have money for care, the food is poisoned, their spouse is unfaithful. “I see this every day in my practice. In these cases, conservative use of psychoactive drugs may be the only thing that keeps the elder at home, or in their care facility. says Dr. Landsverk.

If SB938 were to be passed, court approval would be necessary before any change in psychoactive medications could be administered to a conservatee.

According to Dr. Landsverk, “of course, the medical profession is not infallible. Doctors need much, much more training in how to care for our ever-increasing population of frail elders. Doctors need to be held accountable when things don’t work out. Let’s use big data from insurance companies and credit card companies to address those cases when elders are left on tranquilizers, antipsychotics and other psycho-active meds for years without any attempt to decrease doses. Let’s work to avoid the over-medication of some elders. Data could be collected from pharmacies to get a handle on prescribing patterns without violating patient privacy.”

Dr. Landsverk adds, “but let’s not pretend that this issue can be solved with a law that requires courts to get involved in each medication change for individual dementia patients. Each patient is particular. Each medication is particular. Each situation is particular. It takes years of medical training and experience to decide what might work in a particular case.”

Dr. Landsverk believes that geriatric trained doctors are much more like likely to have this insight than judges. And what about the deluge of cases that would clog the courts should SB938 pass? It now takes four to six months to get a conservatorship hearing. “Many of my patients would die if they had to wait that long for a medication decision. We need better methods and data to get a handle on outcomes in care of our frail elderly. We need to address the issue of behavioral problems and medication in our elders. But SB938 is not the way,” concludes Dr. Landsverk.

Elizabeth Landsverk, MD, is founder of ElderConsult Geriatric Medicine, a house calls practice in the San Francisco Bay Area that addresses the challenging medical and behavioral issues often facing older patients and their families. Dr. Landsverk is board-certified in internal medicine, geriatric medicine and palliative care and is an adjunct clinical professor at Stanford University Medical School.

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