Long-Term
Links
Published by END OF LIFE CARE in the NURSING HOME Part 1
the Steven Zweig, M.D., MSPH
Missouri Professor and Associate Chair
Association of Department of Family & Community Medicine
Long-Term University of Missouri-Columbia
Care Physicians
and the
Department Challenges for Caring for the chronic living-dying interval. The
of Family & Dying in Nursing Homes special needs of this phase of life are
Community Twenty-four percent of not adequately assessed by the
Medicine deaths in the U.S. occur in nursing Minimum Data Set (MDS). Engle4
at the homes (28% in Missouri).1 There- has called for other quality indica-
University of fore, both nursing home staff and tors, such as the proportion of resi-
Missouri- attending physicians need to pro- dents who die in the nursing home
Columbia vide high quality end-of-life care. (rather than the hospital) who re-
School However, providing excellent care ceive adequate treatment of pain,
of Medicine to dying nursing home residents is dyspnea, and fatigue; who have
full of clinical, ethical and regulato- spiritual and religious needs met;
ry challenges.2 and who are withdrawn from artifi-
cially supplied food and fluids as
INSIDE: It may be difficult to identi- requested in advance care direc-
·Megestrol Acetate in fy the terminal stages of decline. tives. In the dying resident, these
the Management of Mal- Patients with advanced dementia goals supersede maintaining body
nourished Institutional- become less mobile and less verbal, weight and normal serum albumin
ized Elderly levels.
Page 5 often developing eating problems
even with maximal assistance. Fre-
·Case report : Gone quent hospitalizations may indicate Unfortunately, OBRA ’87 efforts
fishin’ inevitable decline in residents with to improve the quality of life in nurs-
Page 8
congestive heart failure or those on ing homes may have inadvertently
·Calendar dialysis. In fact, any hospitalization jeopardized the quality of death by
Page 8 of a nursing home resident should focusing too much on a series of de-
precipitate a review of advance care clines that inevitably occur in many
planning with the resident who re- nursing home residents.3
tains decisional capacity, or with
the proxy decision-maker. Not Advance Care Planning
surprisingly, there is an association Ideally, advance care planning
between recognition of a nursing should be addressed prior to nursing
home resident’s poor prognosis and home admission. A preceding hospi-
the likelihood of meeting high talization creates a good opportunity
standards of end-of-life care.3 to discuss prognosis and possible lim-
its on future care. Existing docu-
Vol. 10 No. 4
Many permanent nursing ments or past expressions of choice
Winter 2001
home residents likely fall within a should be reviewed.
If this subject has not advanced care.5 In advising
Continued: been addressed, it is incum- patients and families, a rea-
END of LIFE CARE bent upon the facility and the sonable statistic to quote for
in the attending physician to ad- the outcome of CPR would
NURSING HOME dress it soon after admission. be a 1% to 5% likelihood of
Steven Zweig, MD
Many nursing home resi- surviving the resuscitation,
dents are cognitively im- spending time in the inten-
paired; however, for those sive care unit, and returning
who retain decisional capaci- to the nursing home alive.
ty, a discussion with the res- Due to this lack of success,
ident and any potential some have recommended
Long-Term proxy decision-maker is key. changing the default policy
Links There is still time to create a for permanent nursing home
written advance care di- residents to “no CPR at-
· rective and to name a dura- tempted unless requested.”
ble power of attorney for Evidence recommends fur-
Published quarterly by
the Missouri Associa-
health care. Forms meeting ther limits to CPR if other
tion of Long-Term the standards of Missouri circumstances exist. (See
Care Physicians and law have been developed by Table 1 on Page 4.)
the Department of the Missouri Bar Association
Family and Communi- and the Midwest Bioethics DNR is just the first
ty Medicine at the Center (available from Long of the life-sustaining treat-
University of Mis- Term Links). A written “liv- ments that should be dis-
souri-Columbia School ing will” requires two wit- cussed with most permanent
of Medicine, Columbia nesses, and the naming of a nursing home residents or
MO 65212. Phone their proxies. The document
durable power of attorney
(573) 882-4991. Fax
(573) 884=4122. for health care requires a created by the Center for
notary public. Neither re- Ethics in Health Care at the
Editor: quires a lawyer. Oregon Health Sciences Cen-
Steven Zweig, MD ter provides such a template.
Editorial Board: For those who have The Physician Orders for
David Mehr, MD lost the capacity to decide, Life-Sustaining Treatment
Larry Lawhorne, MD
Michael Hosokawa, EdD we should elicit from a (POLST) form describes
Marilyn Rantz, RN, PhD knowledgeable person the possible limits and non-
Managing Editor: resident’s past expressions of limits of care based on pa-
Susan Kauffman preferences regarding care tient preferences. It includes
near the end of life. We need a place to record who was
Missouri Association of
Long-Term Care Physi- to frame the question as present for discussions, a
cians what the resident would want, physician signature, and a
President: not what the proxy wants the section to document continu-
Charles Crecelius, MD care providers to do. Not ing review of such prefer-
St Louis only is this ethically appro- ences.6 (See also this issue’s
Vice-President: insert from AGS on end-of-
Randall Huss, MD, Rolla,
priate, but it is also compas-
Secretary-Treasurer: sionate care. Families often life care.)
Cary Bisbey, DO feel relieved not to assume
Lake Ozark the burden for deciding how New discussions
Past President: to limit care. must occur as prognosis
Steven Zweig, MD
Columbia
changes. Urgent indications
Numerous studies for initiating end-of-life dis-
have shown the futility of cussions include: imminent
Official state chapter
cardiopulmonary resuscita- death, talk about wanting to
tion (CPR) in the nursing die, inquiries about hospice
home due to the frailty of or palliative care, recent hos-
most subjects and the lack of pitalization for severe pro-
monitoring and proximity to
__________________________________________________________________________________________
Long-Term Links Page 2 Winter 2001
gressive illness, or severe listeners and good negotia- Staff training
suffering and poor progno- tors. Though inservice
sis.7 These discussions and training and educational ini-
physician determinations of IV or Tube Feeding tiatives are essential to im-
prognosis should be regular- Terminally ill pa- proving end-of-life care, they
ly documented in the record. tients do not appear to suffer often fail due to staff turno-
when nutrition and hydra- ver. The frequent turnover
Helping Family Members tion are not forced upon of certified nursing assistants
Family physician and them.9 A recent review has (CNAs) makes any change in
palliative care expert Dr. Ira also shown that there is no practice difficult. This turn-
Byock points out that it enefit from enteral tube feed- over rate is driven by many
isimportant to emphasize ings in patients with ad- forces, including injuries re-
that in the vast majority of vanced dementia.10 Despite ceived on the job, the un-
cases, family members are this and other evidence, both addressed grief CNAs feel
acting out of love for their ill health care providers and with resident die, a feeling
relatives and that they too family members are often that they are not respected
are suffering.8 Often, by al- reluctant to withhold forced or valued, and low pay and
lowing each person to ex- nutrition and hydration in benefits.14
press those feelings, and the nursing home. The sym-
thereby getting down to bolic importance of feeding Any change in the
their intentions, the physi- and hydration should not be nursing home is difficult un-
cian can help uncover the underestimated, but some- less the facility embodies the
main concerns and address times providing information principles of continuous
them directly. This allows and discussing alternative quality improvement and the
the family member to join ways to manage symptoms use of practice guidelines.15
with the health care team in may provide reassurance. Once consensus is achieved
determining and implement- within the facility, a search
ing needed care for the resi- Symptom management for validated guidelines can
dent. Effective manage- be initiated. For example,
ment of symptoms, most both the American Geriatrics
Byock reminds us to commonly pain and dyspnea, Society and the American
state the obvious in the fami- requires skills in assessment Medical Directors Associa-
ly meeting: “Regardless of and treatment. Pain assess- tion have developed pain
what we do, your father is ment instruments are gener- management guidelines.11,12
very likely going to die with- ally available.11,12 Physicians,
in the next few months. The nurses and others can partic- (To be continued in next issue)
reason issue then becomes ipate in Education for Physi-
how we can best care for him cians on End-of-Life Care References
in whatever time he has left. (EPEC) training programs End of Life Care in the
We need to look at how we or local versions of that cur- Nursing Home, Part 1
can make the last part of his riculum. (See EPEC.net to 1. Teno J. Brown Site of Death
life as good as it can be.” download a free Participants Atlas of the U.S. 2000.
The goals of care are broad- Handbook.) Its 16 units ad- www.chcr.brown.edu/dying.
ened beyond withholding dress a variety of communi- 2. Lawhorne LW. Avoidable and
care or treatments when we cation and symptom man- unavoidable decline and the
naturalness of dying: The nurs-
ask, “After your father dies agement challenges in end- ing home dilemma. Ann
and you think about this of-life care. Another pock- LongTerm Care 1999a; 8:309-12.
time, what would have made etsize handbook (available 3. Keay TH, Taler GH, Redman L,
it a ‘good death?’” This im- for less than $20) provides Levenson SA. Assessing medi-
age should include the roles useful algorithms for symp- cal care of dying residents in
nursing homes. Am J Med Qual
of comfort, dignity, and tom management applicable 1997; 12:151-6.
community. When there are to all settings of care.13 4. Engle VF. Care of the living,
multiple family members and care of the dying:
no power of attorney, Byock Reconceptualizating nursing
home care. J Am Geriatr Soc
again reminds us to be good
__________________________________________________________________________________________
Long-Term Links Page 3 Winter 2001
1998; 46:1172-4.
5. Zweig SC. An alternative poli- Juncker A. Comfort care for 13. Wrede-Seaman L. Symptom
cy for CPR in nursing homes. terminally ill patients: The ap- Management Algorithms: A
Bioethics Forum 1998; 14(1):5- propriate use of nutrition and handbook for palliative care.
11. hydration. JAMA 1994; Intellicard, P.O. Box 8255,
6. Physician Orders for Life- 272:1263-6. Yakima WA 98908. Phone
Sustaining Care Task Force. 10. Finucane TE, Christmas C, (509) 965-9266. Fax (509)
Physician orders for life- Travis K. Tube feeding in pa- 965-5447.
sustaining treatment. Center tients with advanced demen- 14. Callahan J. The CNA shortage:
for Ethics in Health Care, 1997, tia : A review of the evidence. A crisis at the heart of quality
Oregon Health Sciences Uni- JAMA 1999; 282:1365-70. care. Briefings on Long-Term
versity, 3181 S.W. Jackson Park 11. American Geriatrics Society Care Regulations 1997; (No-
Rd., L101, Portland OR 97201- Panel on Chronic Pain in Old- vember): 6-8.
3098. (503) 494-4466. er Persons. The man- 15. Lawhorne LW. End-of-life
7. Quill TE. Initiating end-of-life agement of chronic pain in care in the nursing home – is a
discussions with seriously ill older persons. J Am Geriatr good death compatible with
patients: Addressing the “ele- Soc 1998; 46:635-51 regulatory compliance? Bioeth-
phant in the room.” JAMA 12. CPG Steering Committee. ics Forum 1999b; 15(3):23-
2000; 284:2502-7. Chronic Pain Management in the
8. Byock I. Interviewed by Joanne Long-Term Care Setting. Co-
Kaldy in Caring for the Ages lumbia MD: American
2000; 1:12-16. Medical Directors Association,
9. McCann RM, Hall WJ, Gorth- 1999.
TABLE 1. A CPR Policy in the Nursing Home
1. Due to the low likelihood of successful resuscitation for most nursing home residents, no CPR shall be
the default policy. Residents and surrogate decision-makers shall be informed of this policy prior to ad-
mission, accompanied by information describing CPR, risks and benefits as described in the literature,
and the outcomes of attempted CPR in the residents’ nursing home. The residents also shall be told
whether advanced life support services are available at the facility and what additional care will be pro-
vided by EMS services and hospitals. Patients with complex, multi-system problems such as end-stage
dementia, metastatic cancer, sepsis, severe metabolic abnormalities, or persistent vegetative state shall
not be offered attempted CPR.
2. For those residents who request CPR after receiving this information, an order to “attempt CPR” shall
be written. The following principles should guide the use of CPR for those who request it:
a. Basic CPR is initiated by nursing home personnel in a pulseless resident who has suffered a witnessed
arrest, while the EMS team is called.
b. CPR is not administered in the context of an unwitnessed arrest unless the resident was seen func-
tioning normally within the last few minutes.
c. Advanced life support is discontinued if the patient’s initial cardiac rhythm is unfavorable (asystole or
EMD), if resuscitation has been unsuccessful after 15 minutes, or if after ongoing resuscitative efforts,
the patient arrives in the emergency department without a pulse or blood pressure – all conditions
pointing to unsuccessful CPR.
3. Residents and family members shall be reassured that all other forms of medical therapy will be offered
and available to nursing home residents, including, but not limited to, comfort care near time of death.
from Zweig 1998
If you haven’t paid your MALTCP dues, now is the time!
Call Susan Kauffman, Executive Secretary
if you need another copy of the brochure
. (573) 882-4991
__________________________________________________________________________________________
Long-Term Links Page 4 Winter 2001
MEGESTROL ACETATE in the MANAGEMENT OF
MALNOURISHED INSTITUTIONALIZED ELDERLY
Hosam K. Kamel, MB BCh, F.A.C.N.
Division of Geriatric Medicine, Saint Louis University School of Medicine
was largely driven by the tide Y and corticotropin re-
pharmaceutical industry, leasing hormone (two major
Weight loss is a
common problem among
nursing home residents.1 resulted in several research
The reported prevalence of presentations and publica-
weight loss and protein en- tions addressing the use of
ergy malnutrition in this MA in nursing home pa-
population ranges from 15% tients with weight loss. This
to 85%,2-4 and its occurrence article reviews the current
is linked to the development knowledge on the pathogen- central appetite modula-
of pressure ulcers, cognitive esis of geriatric cachexia and tors).10-12 The positive effects
impairment, postural wasting and the possible of MA on appetite and
hypotention, infections, and mechanisms by which MA weight in cancer and AIDS
anemia.5 may stimulate appetite and patients is believed to be due
weight gain. The published to its ability to down-
Weight loss in the studies of the use of MA in regulate the production of
nursing home may often be nursing home settings will proinflammatory cytokines,
attributed to one or more of also be discussed. articularly TNF-, IL-1 and
multiple interacting factors IL-6.13,14
(Table 1). Early detection Megestrol acetate is
and management of causa- a synthetic progestational Recently, there has
tive factors is a key to pre- agent that has been shown to been interest in investigating
vent weight loss and associ- be effective in improving ap- the efficacy of MA in manag-
ated complications. Provid- petite and promoting weight ing unexplained cachexia and
ing assistance with feeding, gain in cachectic cancer and wasting in older adults. This
and serving oral nutritional AIDS patients.6,7 MA is cur- interest is partly attributed
supplements between meals rently approved by the Food to our increased understand-
may help prevent and re- and Drug Administration ing of the mechanisms in-
verse weight loss. Provid- (FDA) for the treatment of volving the pathogenesis of
ing enteral nutrition by AIDS-related anorexia and geriatric cachexia and wast-
feeding tube may be needed cachexia. This condition is ing. Aging is associated with
in nursing home residents attributed to the increased increased concentration of
with impaired swallowing production of glucocorticoids and
or gag reflexes, as well as in proinflammatory cytokines, catecholamines and de-
patients in whom nutrition- especially interleukin-1 (IL- creased levels of growth
al needs are not met 1), IL-6, and tumor necrosis hormone and sex steroids, a
through eating alone. factor (TNF)-.8,9 These cy- pattern similar to that seen
tokines act to inhibit feeding in patients with chronic
Recently, there has been by causing nausea and vom- stress.15 This pattern of
an increased interest in in- iting, decreasing gastric and hormonal changes is accom-
vestigating the use of intestinal motility, and/or by panied by elevated levels of
megestrol acetate (MA) in modifying gastric secretion. several proinflammatory cy-
the management of geriatric These effects may be the re- tokines that has been linked
cachexia and anorexia, par- sult of a direct action of these to the development of wast-
ticularly in the nursing cytokines on the gastrointes- ing and cachexia in both an-
home. This interest, which tinal tract or indirectly due imals and humans. Roubenoff
to CNS effects of neuropep- et al16 studied elderly partic-
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Long-Term Links Page 5 Winter 2001
ipants in the Framingham elevated in all 711 subjects. ties in community-dwelling
Heart Study and found that Elevated IL-6 levels were elderly,17 osteoporosis,18 and
IL-6 concentrations were linked to functional disabili- fatigue.19 In addition, IL-1
levels have been reported to not significantly different ment of deep venous throm-
be increased with increasing among from the placebo bosis and pulmonary embo-
age.20 Increased IL-1 levels group, subjects who received lism. Bolen et al25 recently
have been linked to the oc- MA reported significant im- reported that 6 out of 18
currence of cachexia of un- provement in appetite, en- nursing home residents de-
known etiology in older in- joyment of life, and well- veloped deep venous throm-
dividuals.21 being. MA was well tolerat- bosis as a result of treatment
ed by subjects. with MA. This complication
There have been occurred on average after 4
three published studies in- Raney and col- months of treatment with
vestigating the effects of MA leagues24 used 480 mg of megestrol acetate (range: 57-
in the management of wast- MA/day, resulting in an av- 244 days). Finally, the cost of
ing and cachexia in institu- erage weight gain of 3.5 kg MA is substantial ($400-
tionalized elderly.22-24 Castle in five of the six study sub- $800/month).
et al22 administered MA (400 jects after eight weeks of
mg/day) to 4 elderly nursing therapy. MA was well toler- In conclusion, exist-
home residents with weight ated by subjects. ing data do not provide
loss equal to or greater than enough evidence to justify
90% of their ideal body These three studies, recommending megestrol
weight. After 6 weeks of in spite of their small size acetate in the management of
therapy, 2 out of the 4 study and multiple limitations, nursing home patients with
subjects gained weight ( an highlight the need for large- weight loss. MA may have a
average of 4.1 kg). One sub- scale placebo controlled tri- future role in the manage-
ject experienced delirium als to study the role of ment of a selective group of
which reversed upon stop- megestrol acetate in treating patients with geriatric ca-
ping the drug. Residents unexplained geriatric ca- chexia (probably those with
with the highest IL-6 con- chexia and wasting. Report- high levels of
centration showed the great- ed increments in body proinflammatory cytokines).
est weight gain in response weight were small and were Long-term, large-scale, pla-
to the treatment. Yeh et al 23 largely due to increased fat cebo-controlled trials are
administered MA (800 mass and not lean body needed, however, to further
mg/day) for 12 weeks using mass. The safety of long- define this select group of
a double-blind, placebo- term MA administration to patients, and to evaluate the
controlled design. Nine out frail elderly is largely un- cost-effectiveness and safety
of 36 patients who received known. Potential side effects of prolonged administration
MA (34.6%) gained weight include worsening heart fail- of megestrol acetate to pa-
(1.05+1 kg) compared to 7 ure, hypertension, and diabe- tients with geriatric cachex-
out of 33 residents (28%) tes, as well as the develop- ia. These trials should also
who received placebo ment of delirium, impotence, address questions related to
(0.9+0.7 kg). Although the adrenal suppression, and a the optimum dose and dura-
weight gain among the hypercoagulable state that tion of therapy.
megestrol acetate group was may promote the develop-
TABLE 1. Common Causes of Weight Loss in the Nursing Home
1. Depression 8. COPD
2. Medications 9. CHF
3. Swallowing disorders 10. Rheumatoid arthritis
4. Therapeutic diets 11. AIDS
5. Inadequate staffing to provide 12. Cancer
assistance with feeding 13. Hyperthyroidism
6. Acute and chronic infections 14. Malabsorption syndromes
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Long-Term Links Page 6 Winter 2001
7. Dementia-related behavior
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Long-Term Links Page 7 Winter 2001
References Balasubramaniam A, Dayal R, 39:19-27.
Megestrol Acetate et al. Hypothalamic concen- 21. Cederholm T, Wretlind B,
tration and release of neuro- Hellstrom K, et al. Enhanced
peptide Y into microdialysates generation of interleukin 1beta
1. Abbasi AA, Rudman D. is reduced in anorectic tumor and 6 may contribute to the
Undernutrition in the nurse bearing rats. Life Sci 1994; cachexia of chronic disease.
home: Prevalence, conse- 54:1869-74. Am J Clin Nutr 1997; 65:876-
quences, causes and preven- 13. Montovani G, Maccio A, Esu 82.
tion. Nutr Rev 1994; 52-113- S, et al. Medroxyprogesterone 22. Castle S, Nguyen C, Joaquin
22. acetate reduces the invitro A, et al. Megestrol acetate
2. Morley JE, Kraenzle D. Caus- production of cytokines and suspension therapy in the
es of weight loss in a commu- serotonin involved in anorex- treatment of geriatric anorex-
nity nursing home. J Am ia/cachexia and emesis by pe- ia/cachexia in nursing home
Geriatr Soc 1994; 42:583-5. ripheral blood mononuclear patients. J Am Geriatr Soc
3. Silver AJ, Morley JE, Strome cells of cancer patients. Eur J 1995; 43(7):835-6 (letter).
LS, et al. Nutritional status in Cancer 1997; 33:602-7. 23. Yeh S, Wu S, Lee T, et al.
an academic nursing home. J 14. Beck S, Tisdale M. Effect of Improvement in quality-of-life
Am Geriatr Soc 1988; 36:487- megestrol acetate on weight measures and stimulation of
91. loss induced by tumor necrosis weight gain after treatment
4. Shaver HJ, Loper JA, Lutes factor alpha and a cachexia- with megestrol acetate oral
RA. Nutritional status of inducing tumor (MAC16) in suspension in geriatric cachex-
nursing home patients. J Pa- NMRI mice. Br J Cancer 1990; ia: Results of a double-blind,
renter Enteral Nutr 1980 ; 62:420. placebo-controlled study. J
4 :367-70. 15. Wilder RL. Interleukin-6 in Am Geriatr Soc 2000; 48:485-
5. Morley JE, Silver AJ. Anorex- autoimmune and inflammatory 92.
ia in the elderly. Neurobiol of diseases. In: Papanicolaou 24. Raney MS, Anding R, Fay V,
Aging 1988; 9:9-16. DA, moderator. The patho- Polk G. A pilot study to as-
6. Eliu J. Gonzales-Baron M, physiology roles of interleu- sess the use of megestrol ace-
Berrocal A, et al. Usefulness kin-6 in human disease. Ann tate to promote weight gain in
of megestrol acetate in cancer Intern Med 1998; 128:130-2. frail elderly persons residing
cachexia and anorexia: A pla- 16. Roubenoff R, Harris TB, Abad in long-term care. J Am Med
cebo-controlled study. Am J LW, Wilson PW, Dallal FE, Dir Assoc 2000; 1:154-8.
Clin Oncol 1992; 15:436-40. Dinarollo CA. Monocyte cy- 25. Bolen J, Anderson R, Bennett
7. Oster MH, Enders SR. Sa- tokine production in an elderly R. Deep vein thrombosis as a
muels SJ, et al. Megestrol ace- population: Effect of age and complication of megestrol ace-
tate in patients with AIDS and inflammation. J Gerontol A tate therapy among nursing
cachexia. Ann Intern Med Biol Sci Med 1998; 53:M20-6. home residents. J Am Med Dir
1994; 121:400-8. 17. Ershler WB, Sun WH, Binkley Assoc 2000; 48:248-52.
8. Moldawer LL, Rogy MA, N, et al. Interleukin-6 and ag-
Lowry SF. The role of cyto- ing: Blood levels and monocu-
kines in cancer cachexia. J lar cell production increase
Parenter Enteral Nutr 1992; with advancing age and in AMDA Publishes
16(suppl):43S-9S. vitro production is modifiable Protocols
9. Roubenoff R, Roubenoff RA, by dietary restriction.
Cannon JG, et al. Rhematoid Lymphokine Cytokine Res 1993;
cachexia: Cytokine-driven 12:225-30.
Physician Notification:
hypermetabolism accompany- 18. Girasole G, Jilka RL, Passeri Assessing Copies of Protocols
ing reduced body cell mass in G, et al. 17beta-stradiol inhib- for Patients and Collec Copies
chronic inflammation. J Clin its interleukin-6 production by of Protocols for Physician No-
Invest 1994; 93: 2379-86. bone marrow-derived stromal
10. Montuschi P, Tringali G, Cur- cells and osteoblasts in vitro:
tification: Assessing Patients
ro D, et al. Evidence that IL- A potential mechanism for the and Collecting Data on Nurs-
1b and TNF inhibit gastric antiosteoportic effect of ing Facility Patients are avail-
funds motility via the 5- estrogenes. J Clin Invest 1992; able from AMDA for $20 for
lipoxygense pathway. Eur J 89:883-91.
Pharmacol 1994; 252:253-60.
members and $30 for non-
19. Papanicolaou DA, Petrides JS,
11. Suto G, Kiraly A, Plourde V, Tsigos C, Bina S. Recombi- members. To order: (410)
et al. Intravenous IL-1b and nant interleuki-6 effects on pi- 740-9743.
TNF inhibition of gastric emp- tuitary secretion in humans. J
tying : Involvement of invest Med 1996; 44:A266
central corticotrophin- (abst).
releasing factor and prosta- 20. Liao Z, Tu JH, Small CB,
glandin pathways in rats. Di- Schnipper SM, Rosenstreich
gestion 1996; 57:135- DL. Increased urine IL-1 lev-
40. els in aging. Gerontol 1993;
12. Chance WT,
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Long-Term Links Page 8 Winter 2001
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Long-Term Links Page 9 Winter 2001
Case report:
Gone fishin’ Solemn Indian Chieftain
Cathleen Casey Slaughter
Even a severe stroke Mark your
can’t keep a good fisherman Calendar Cross-legged upon the ground he
away from the water. In sat
May of 1996, Frank L. had Before an open fire …
His weathered brow a furrow deep
the acute onset of a left hem- AMDA Annual Symposium Pressed over eyes that held no
iplegia due to a large March 15-18, Atlanta. lightning now.
intracerebral hematoma. He MALTCP business meeting While locks of white
was partially aphasic and had will be March 16 at 6:30. Streamed out upon the chilly air
Sometimes his restless soul
post-stroke seizures, but af- MALTCP has submitted two Seemed worn quite bar …
ter recovery he was eager to House of Delegates resolu-
continue his lifelong hobby. tions. Stop by the display Once a strong young brave he’d
area booth – or volunteer been
His family was able your time! Once he’dknown these hills
Roaming free upon the well-known
to take him fishing and hold land
a pole for him, but this was Supervisory and Survival To squint his beady eyes
not fully satisfying for Skills for Nurses: A Nurse To see yon familiar skies …
Frank. With a lot of family Professional Development His heart yearned to find
Its way back to those earlier years
ingenuity and adaptability, Program March 27 in Kan- …
they were able to accommo- sas City, March 29 in St. When he’d known no fear –
date his need to be an inde- Louis. Sponsored by Mis- Once he’d shot his arrow far
pendent fisherman. souri Association of Homes With precision and with skill –
for the Aging. For infor- Even now was strong his will.
But his mind possessed the
The wheelchair- mation contact Mary knowledge
adaptable device requires Rackers at (800) 966-0043. That his days of usefulness
inexpensive PVC pipe to be Were fast approaching their end
formed into a holding tool Cox Springfield Symposi- And his steps would soon take him
Homeward to a happier hunting
for his pole that allows um April 27-28, Clarion Ho- ground.
enough movement that he is tel Convention Center.
able to set the hook, and then MALTCP will have a busi- The oak leaves upon their autumn
reel in his fish with only ness meeting Friday evening. branches
minimal assistance from his Slowly now were dying, and the
Info: Mary Creach, (417) Indian Chieftain
family. 269-5062. Knew that such was his life …
Slowly dying upon its late autumn
Construction re- American Geriatrics Socie- branches
quired the use of PVC pipe of ty Annual Meeting, May 9- But he felt no compelling sadness
For memories warm summer past
a size appropriate to fit into 13, Hyatt Regency in Chica- Came whispering to him now.
the end portions of an ad- go. For updates, visit
justable wheelchair. A mid- www.americangeriatrics.org. The excitement of past buffalo
section connector into which hunts
the butt of the fishing pole The familiar color of festive dances
7th Annual HCFA Midwest The young brave’s victory dances –
can be inserted allows a Consortium Conference on And as he rested cross-legged
screw to be placed into the Quality of Life, May 15-17, Before the first, wisely he did not
pole through the connector St. Louis. Informational mind
to hold it in place fairly se- The furrowed brow nor the snow of
tracks on developmentally his hair.
curely. This new device al- disabled, long-term care, For he knew that once he left the
lowed Frank to continue a regulatory issues and more. golden memories behind
lifelong hobby, and to find Contact: Helen Hoetz, Dept. He would find himself at home
pleasure in the outdoors. Social Services, (573) 526- In the happier hunting ground of
David Brunworth, MD tomorrow.
8553.
Washington MO Medical Group Mrs Slaughter, a 78-year-old patient of
Phone (636) 239-0194 mine, brought me some of her poetry at a
recent clinic visit.
Steven Zweig, MD, Editor
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Long-Term Links Page 10 Winter
2001