Treating nondementia illnesses in patients with dementia.

Physicians increasingly are called on to provide primary care for the growing population of people with Alzheimer-type dementia. However, little attention has been paid to the care of nondementia illnesses in this group of patients. To illustrate how presence of dementia can alter the risk-benefit ratio of treatment of a common medical problem, we present a case study in which a patient with dementia developed disastrous adverse effects to a drug commonly used to treat osteoporosis. This case and 2 composite vignettes illuminate how presence of dementia should influence the decision-making process for treatment of nondementia illnesses. We address issues such as decreased decision-making capacity, problems with reporting adverse effects, decreased cognition leading to problems with treatment adherence, and the role of screening and basic questions about acceptable burdens of treatments in patients with limited prognosis. We suggest ways to improve communication with patients with dementia in an effort to minimize complications and improve care, as well as policy changes to include patients with dementia in clinical trials. JAMA. 2000;283:3230-3235

Songs of innocence and experience: student's poems about their medical education.

Personal creative writing is increasingly used in medical schools to foster self-reflection. This article looks particularly at poetry as a vehicle for expressing personal experiences of professional development. The authors present a series of poems written by students at their medical school. In them, the students reflect on embryology, gross anatomy, telling (or not telling) bad news to trusting patients (and family members), encountering death, and encountering their own anger and frustration with the demands of medicine. These poems not only capture individual students' feelings and imaginations but also demonstrate the students' constant struggle to sustain their idealism about medicine throughout the four years of their education.

Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents.

OBJECTIVE: To determine the impact of OBRA 87 on antipsychotic prescribing in a 485-bed nursing home. DESIGN: Twelve-month retrospective cohort review of medical charts, medication administration records, and computerized pharmacy records. MEASUREMENTS: The percent of residents by diagnostic group and antipsychotic use. MAIN RESULTS: An attempt was made to stop or lower the dose of antipsychotic in 75% of the 107 residents studied. Antipsychotics were stopped in 45% of residents with a dementia-only diagnosis and 25% of residents with a psychiatric diagnosis (P < 0.05). Residents with documented symptoms appropriate for the use of antipsychotic, per OBRA 87, were significantly less likely to have their antipsychotic stopped. Twenty percent of residents whose antipsychotic was either stopped or its dose lowered had the agent restarted or its dose increased. CONCLUSION: OBRA 87 had a significant impact on antipsychotic use in this facility.

The voices of the medical record.

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it 'routine' in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive 'text', it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided.