Jonathan Rosenfeld's Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog | Lawyer & Attorney : Strellis & Field Law Firm | Bed Sores, Senior Neglect, Elder Abuse, Sexual Abuse: Chicago, Illinois

Autonomic dysreflexia (or hyperreflexia) is a dangerous condition that can occur with bed sore patients or patients with spinal cord injuries above the middle of the chest (usually above T-5).  Autonomic dysreflexia occurs when an irritation or pain below the level of the spinal cord injury sends a signal that fails to reach the brain.  

Over time, the bodies a delayed pain response results in changes to the sympathetic portion of the autonomic Nervous System (helps people adapt to changes in the environment and is associated with the “flight-or-fight” response), resulting in muscle spasms and a narrowing of the blood vessels.  This in turn can cause blood pressure to rise and heart rate to drop, which can lead to stroke, seizure, or even death. 

Signs autonomic dysreflexia may include:

• Pounding headache
• Goose bumps
• Red blotches on the skin, above the level of the spinal cord injury
• Sweating, above the level of injury
• Cold, clammy skin, below the injury
• Nasal congestion
• Slow pulse (< 60 beats/minute)
• Restlessness
• Hypertension (blood pressure greater than 200/100)
• Nausea

Autonomic dysreflexia can be prevented.  Specific precautions include:

• Frequent pressure relief in bed / chair (turning the patient to change positions)
• Avoidance of sunburn and scalding from hot water
• Maintain a regular bowel program
• Proper nutrition and fluid intake
• Compliance with medications
• Proper maintenance of indwelling catheter (keep tube free of kinks, keep drainage bags empty, check catheter daily for deposits)
• Perform routine skin assessments

Treatment of autonomic dysreflexia can be as easy as changing positions or removing the cause of irritation.  However, treatment must be initiated quickly in order to prevent further complications.  Many stimuli can cause autonomic dysreflexia including anything that would have been painful, uncomfortable, or physically irritating before the injury.  

The most common causes are:

• Overfill bladder – this can be due to a blockage in urinary drainage device, bladder infection, inadequate bladder emptying, bladder spasms, or bladder stones
• Bowel full of stool or gas – due to constipation, hemorrhoids or anal fissures, or infection and irritation
• Skin irritations – due to wounds below the injury, pressure sores, ingrown toenails, burns, or tight/restrictive clothing
• Broken bones

If the trigger cannot be identified and removed or if problems persist, medications can be used to treat the autonomic dysreflexia. 

People suffering from spinal cord injuries are particularly susceptible to pressure sores because of sitting or lying in the same position for an extended period of time.  In addition, spinal cord injuries can reduce or eliminate sensations, making it more difficult for the person to know when a pressure sore is developing.  These pressure sores can cause a dangerous condition known as autonomic dysreflexia in patients with spinal cord injuries.  

Autonomic dysreflexia is a potentially life threatening condition resulting from over activity in the Autonomic Nervous System, which can cause high blood pressure leading to seizures, stroke, and even death.  

Therefore, it is important that nursing home staff pay special attention to residents suffering from spinal cord injuries.  This includes frequently turning the resident to relieve pressure, regulating bladder and bowel output, properly maintaining catheters, and regularly checking for skin irritations.  Prevention of pressure sores is key to maintaining the physical health of residents with spinal cord injuries. 

Related:

Are bed sore patients at risk for amyloidosis?

Can bed sores cause osteomyelitis?

Is necrotizing fasciitis related to bed sores?

If bed sores are not timely treated, can gangrene develop?

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In its seemingly endless series of well-done articles regarding the 'state of nursing homes' in Illinois and throughout the country, the Chicago Tribune, recently highlighted a well traveled Chicago psychiatrist-- Michael Reinstein.

Putting it mildly, Dr. Reinstein has a very unique style of practicing medicine-- one that commonly entails use of the powerful psychotropic medicine, clozapine.  Among Reinstein's unusual practice 'accomplishments':

• In 2007, he prescribed medication to 4,141 Medicaid patients
• According to an audit report, Reinstein sees 60 patients per day, 365 days per year
• He is a the psychiatric medical director at 13 nursing homes in the Chicagoland-area
• Reinstein personally write more prescriptions for clozapine than all the physicians in the state of Texas combined write for their patients.

The dangers of clozapine

Clozapine (the generic medication for Clozaril) is an anti-psychotic medication approved for use in schizophrenia and for reducing the risk of suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Clozaril carries five black box warnings-- the FDA's strongest warning.  Consequently, Clozaril is only approved for use in limited circumstances and the FDA requires ongoing monitoring of the patients to minimize the risk of complications.

1) Agranulocytosis-  An abnormally low white blood cell count. Since white blood cells are necessary to fight diseases, this is a potentially fatal side effect. Patients being treated with Clozapine must have a baseline white blood cell (WBC) count and absolute neutrophil count (ANC) before initiation of treatment as well as regular WBC counts and ANCs during treatment.

2) Seizures- Seizures have been associated with the use of Clozapine.  Studies have conclusively demonstrated that the the incidence of seizures increases as the dosage increases. Additionally, patients taking Clozapine, should be advised not to engage in any activity where sudden loss of consciousness could cause serious risk to themselves or others.

3) Myocarditis- Inflammation of heart muscle.  The incidence of myocarditis has been demonstrated to substantially particularly in the first month of use.

4) Orthostatic hypotension- A large, sudden decrease in blood pressure upon standing that can result in fall.

5) Increased Mortality in Elderly Patients With Dementia- Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs, such as Clozapine, are at an increased risk of death compared to placebo. 

Not surprisingly-- especially when medicating such a large group, many with high clozapine dosages-- some of Dr. Reinstein's patients have suffered adverse effects and even death related to clozapine intoxication.  Who is responsible, the drug itself or the man responsible for prescribing it? Would his patients be better served with another type of treatment?

Related Nursing Homes Abuse Blog Entries

Medication Aides In Nursing Homes: A Push To Save Money Or Improve Patient Care?

Nursing Home Employees Plead 'Not Guilty' To Charges Related To The Intentional Chemical-Sedation Of 22 Elderly Residents

Pile On The Medication

Administrator Charged With Elder Abuse After Intentionally Over-Medicating Nursing Home Patients

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As we reported in a recent blog entry,  thirty-two nursing homes made it onto the first-quarter 2009 “violator list” published by Illinois Department of Public Health (“IDPH”) in March.  Today we shine a spotlight on one of those facilities: Clearbrook East.

Clearbrook East is a 92-bed, non-profit nursing home facility, located at 3802 South Old Wilke Road in Rolling Meadows, Illinois, that serves adults with developmental disabilities.  Its website proclaims that it is committed to “creating innovative opportunities, services and support for persons with disabilities.”   Regrettably, the IDPH report suggests that Clearbrook East fails to do all that it should to protect its clients from neglect.

On January 8, 2009, the IDPH issued Clearbrook East a violation notice and fined it $15,000.  It found that the facility did not ensure that there were adequate protections in place for resident safety.  Most significantly, Clearbrook East staff failed to develop and implement the facility’s policy to prevent neglect. 

IDPH found, for example, that the staff’s failed to properly follow residents 'care plans'.  During the course of its survey, IDPH investigators determined that the staff's failure to follow its policy resulted in a resident suffering a seizure and another resident suffering multiple multiple falls with serious injuries on another. 

With respect the the fall incident, investigators determined that Clearbrook East staff held a meeting specifically to discuss this particular client’s extensive history of injuries from falls and how to prevent such falls in the future.  However, just four months later, the client fell again, this time sustaining two fractured ribs.  The staff’s failure to follow-through on the preventative measures constituted a violation of the policy barring neglect.

The IDPH regulates nursing home facilities and establishes basic guidelines to ensure that residents of nursing homes are protected.  A facility’s failure to follow IDPH regulations can result in needless neglect and abuse of residents.  In the Clearbrook East, clear policies on neglect could have prevented a resident prone to seizures from a painful injury caused by a fall. 

Our firm is committed to protecting the rights of residents-- especially those with disabilities-- to live free from injury and neglect and we appreciate the work of the IDPH in monitoring these facilities for compliance with basic standards.  If you would like to discuss an incident involving neglect at Clearbrook East, or any other facility, we would be honored to discuss you situation.  (888) 424-5757

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