"Non-Chemical" Therapies Reduce ADRs

by Richard G. Stefanacci, DO, CMD

Like many, I thought I had always been well aware of potential adverse drug reactions (ADRs) despite not being taught much about the subject. As pointed out in a recent article in the Journal of the American Medical Association, US medical students have little exposure to information on adverse drug events. However, this really came home to me when a patient's daughter--who herself was an active 75-year-old--asked me what "chemicals" I was going to be prescribing for her mother.

I had always thought of chemicals as something intrinsically dangerous that I might use with great caution to clean the floor. Medications were what I prescribed safely for my patients. But viewing medications as chemicals allows us to more fully consider the possible--and in the elderly, highly probable--ADRs. And so it's time to start thinking more about non-pharmaceutical--or rather "non-chemical"--approaches to treatments.

Pet Therapy

One non-chemical approach that has shown positive outcomes is pet therapy. Studies have demonstrated that introducing pets into the home and LTC facilities can reduce hypertension and improve depression and loneliness (see references). Although pet therapy may be more "high touch" than "high tech," one can get more information on the Web, by going to such sites as Project Pooch (www.pooch.org; click on "Pet Therapy") and the Center to Study Human-Animal Relationships and Environments (www.censhare.umn.edu).

Computer-Based Therapy

Instead of prescribing that next SSRI for depression, consider the use of computer-based therapy. In a way similar to that of recreational therapy, computer-based therapy offers a non-chemical treatment approach to improving outcomes. The passive occupation of television viewing, for example, can be replaced by active Internet Web exploring.

On many sites, Web users can view streaming video, as well as print material, on a wide range of topics. They may be simply entertaining or, in fact, educational. For instance, sites such as the Alzheimer's Association (www.alz.org) and the Alzheimer's Disease Education & Referral Center (www.alzheimers.org) can aid in increasing understanding of the disease, learning about living with and caring for people with Alzheimer's, obtaining knowledge about diagnosis and treatment options, and finding local Alzheimer's chapters and support groups.

Computer-based therapy may also include game playing. Unlike activities that require the coordination of an entire group, computer games can be played at the participants' own pace and skill level.

But perhaps the best use of computer-based therapy is for communication via e-mail and forums. Communication with family and friends can take place with much greater ease than by writing and mailing letters. Furthermore, e-mail affords added speed and an ability to respond that is only possible by using this technology. Seniors can stay more connected to their loved ones and develop new relationships more easily through the Internet.

Hardware & Software

Hardware, software, and support are needed for any such project. We recently received six personal computers from Aetna USHealthcare as a donation to our Program of All-inclusive Care for the Elderly (PACE) site, for use in our members' computer-based therapy. Most therapeutic computer groups that I have been in contact with have set themselves up through either donations or the use of old equipment, supported by trained volunteers. Unfortunately, in our case, we received only the hardware and needed to come up with all of the required software, including an operating system.

When making hardware decisions, remember that you can buy something as simple as an Internet appliance that works with a television set for around $100, or the new Apple iMAC computer, which costs close to two thousand dollars.

Before purchasing hardware, it's important to assess your facility's needs. That will help you avoid acquisition of unneeded hardware. Of course, if the equipment is older or donated, these decisions may already be made for you. If not, an excellent source of basic hardware advice can be found at the Wall Street Journal's site, where columnist Walter Mossberg provides a guide to PCs (www.ptech.wsj.com).

But software is really what will end up driving the entire program. A good way to get started on choosing software is to sit down with a core group of participants and staff and decide whether your computer-based therapy will involve e-mail, games, Internet exploring, or a combination of such activities. Once you understand the purpose of the computer lab, the software package can be developed. The form will follow the function.

Remember that the Field of Dreams philosophy--"If you build it, they will come"--probably only works with baseball fields. Even with all the "right" hardware and software, many computers go unused because of lack of support. Most of the programs that I have encountered have remedied this situation by using an underutilized resource in our communities--namely, volunteers. Support staff are essential in attracting and maintaining participation.

One organization that has taken an aggressive move toward developing computer-based therapies is the Internet Empowerment Project (http://www.med.unc.edu/wrkunits/7ahec/ahec/program/s02nlt.pdf). The project is led by rheumatologist John McCain, MD, at the Area Health Education Center, UNC School of Medicine Program on Aging in Wilson, NC. The project operates from the belief that seniors' intellect is a valuable asset that often sits unused instead of being harnessed. A computer can remove the physical barriers to activity and help free elders' intellect. This project started with a budget of some $25,000 for hardware and software and for the training of 8 to 12 senior volunteers to manage the computer learning center.

Internet Appliances

Another project that has been well documented was developed by Presbyterian Homes in Evanston, IL, which has 390 independent and assisted living residents. In less than a year, some 300 residents were trained by volunteers. Monthly workshops complemented the classroom training. Presbyterian Homes decided to use Internet appliances because participants were primarily interested in Internet activities. Thus, it was not necessary to invest in expensive hardware.

We refer to our patients/residents/members in the PACE program simply as "participants," since they must actively participate in computer-based therapy (in contrast to pharmaceutical therapy, which is a passive process).

Participant advocate liaison (PAL) personnel serve as a link between participants and the care team, and help to ensure that the care plan is carried out in a timely manner. PALs are volunteers from every area of our staff, from CNAs to administrators. PALs gain a great understanding of what our participants experience, as well as our care-team responsibilities. PALs and participants stay in touch by regularly exchanging e-mails.

In light of all this, when we sit down to hammer out a treatment plan, we need to consider our residents as participants in their own care. And we need to move to active treatment modalities rather than passive forms. Nursing home treatment plans need to be filled with more non-chemical treatment options that are not subject to ADRs, such as computer-based therapy.

Dr. Stefanacci, a geriatrician in Philadelphia, PA, is a member of Caring's Editorial Board. For more information on technology in long-term care, send e-mail to: DrStefanacci@aol.com.

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