I am a Stanford and Harvard-trained geriatric specialist practicing in the San Francisco Bay Area, specializing in eldercare education and house calls for elderly patients from San Jose to Napa.
I am very concerned about a bill now making its way through the state legislature: Assembly Bill 2171, sponsored by Member Robert A. Wieckowski (District 25, Fremont), Assembly Member Mariko Yamada (District 4, Davis), and State Senator Mark Leno (District 13, San Francisco). Last month, the bill moved out of committee and will soon come to a vote. It seeks to create a "bill of rights" for elderly patients.
That sounds terrific, and sorely needed, right? Unfortunately, this bill is too broad and its terms are too ill defined. I am concerned that this bill will actually make things worse for the most vulnerable patients, those with dementia who become aggressive, angry or delusional.
As written, the bill blames residential facilities for the problems that arise in residential care. The bill gives facilities very little leeway in resolving problems, other than taking steps to please the elder and/or the elder's family. Facilities may not even have the ability to evict patients if necessary. The penalties for violating the standards set by the bill are high: as much as $1,000 a day.
There is a myth in our society that problem behaviors in dementia patients always result from unmet needs. The thinking goes like this: The elder with dementia is frustrated because of some problem that he or she cannot explain and acts out until the problem is solved. Sometimes, this is the case.
But sometimes -- more often than most geriatricians will admit -- we can try everything and still the problem behavior persists. We can meet every need. We can address every physical ill. We can try to engage the patient. Yet still, they act out.
Already, I get desperate calls from families as far away as Gilroy or the San Joaquin Valley. These families cannot find any facility nearby to admit their loved one because the elder's behavior is too disruptive. I am concerned that if this bill is passed, it will become even more difficult for vulnerable elders with behavior issues to find a spot in residential care.
There is another myth in dementia care: Anti-psychotic medications should never be used in dementia patients, and prescribing them to patients is an "inappropriate use" or "chemical restraint," to use the terms in the proposed bill.
Actually, there are some behaviors such as psychosis, delusions and repetitive behaviors that sometimes respond only to anti-psychotic medications. I do not advocate using these medications as a first-line treatment. Of course, pain or underlying medical problems should be ruled out before these powerful drugs are used.
But again and again, I am confronted with patients for whom all other interventions have been tried, and still, the behavior persists. Often, the behavior is so disruptive and disturbing that it is nearly impossible to care for the patient.
At some time in our lives, almost all of us will have to cope with this vexing problem, either our own failing mental capacities or that of a loved one: Approximately 10 percent of those over age 65 suffer from failing brain function. After age 85, that figure rises to approximately 50 percent, according to the Alzheimer's Association.
Caring for dementia patients is never easy. It is seldom straightforward. The proposed bill simply does not recognize this. We do need a "bill of rights" for elderly patients. But we don't need AB 2171.
Elizabeth Landsverk is a medical doctor practicing at ElderConsult Geriatric Medicine in Burlingame.