Friday, September 28, 2012

A Harvest Of Purpose

A Harvest Of Purpose
Just as it only takes a single seed to grow a tree, it takes a single idea to spark revolution. Last year, Velma Stricker, a 94-year-old resident at Arroyo Grande Care Center in Arroyo Grande, Calif., asked Matthew Lysobey, the administrator at the facility, to build her a greenhouse. A former avid gardener, Stricker felt depressed and yearned for a creative outlet.
“She said, ‘If you do build it, I will take charge of it, I will be out there every day,’” says Lysobey. “I said, ‘Okay, we’re going to do it,’ and now she is out there doing her work every day. She now has a reason to get out of bed.”

A Farm Is Born

Last November, Arroyo Grande Care Center, which was ranked one of the top nursing homes by U.S. News & World Report in 2012, permitted volunteers and maintenance workers to break ground on “The Farm,” a one-acre produce and poultry farm.

The Farm, which is located on the facility’s grounds, is completely wheelchair-accessible and was purposely designed to offer residents, many of whom are former farmers, the opportunity to weed, water, and prune crops in addition to tending to chicken coops.

Residents are responsible for their own crops, and all food produced is harvested by the residents themselves.
Arroyo Grande Care Center
After the food is collected, residents are transported across the street to a free farmers market that serves underprivileged elderly community members.

“We mobile all the residents over in their wheelchairs, and they have this huge bounty of chard, carrots, peas, string beans, lettuce, and pumpkin cookies that they made, along with flowers they’re growing so these people have nice flowers, and there are 40 to 50 people lined up every time with their bags,” says Lysobey.

Residents Feel Needed

The need to be needed is essential to the human condition and does not fade in the elderly, health care experts say. Lysobey believes that programs like The Farm are fairly simple to incorporate and can be hugely effective in lowering levels of depression in long term care facilities.

The widely held notion that residents should simply rest and relax through their “golden years” is erroneous, experts say. “There are nonprofits in every community and nursing homes asking to help,” Lysobey says. “Residents just want to be needed and to help.”

Giving Purpose To Residents’ Lives

Arroyo Grande also recently teamed with a local nonprofit, Children’s Resource Network, to open a free clothing and school supply store located on its grounds to benefit disadvantaged youths.

“Advocates in the community, high school and junior high counselors, and homeless shelters can call and place a request. We then print that out, give it to a resident here, and she calls from her room and makes appointments for these disadvantaged teens to shop in the store. Three to four residents work with teens, helping them pick out clothes,” Lysobey says.

Creating opportunities for residents in long term care facilities to team with nonprofits is a no-brainer, according to Lysobey. Health care providers have “been so focused on improving the quality of care, which we have,” he says.

“Quality care has made tremendous strides in the past 20 years—but no matter how nice the infrastructure is, that doesn’t mean people will have need and purpose in their lives.”

Providing purpose to residents is, therefore, as critical—if not more critical—as providing basic health care amenities, he says.
Just as it only takes a single seed to grow a tree, it takes a single idea to spark revolution. Last year, Velma Stricker, a 94-year-old resident at Arroyo Grande Care Center in Arroyo Grande, Calif., asked Matthew Lysobey, the administrator at the facility, to build her a greenhouse. A former avid gardener, Stricker felt depressed and yearned for a creative outlet.
“She said, ‘If you do build it, I will take charge of it, I will be out there every day,’” says Lysobey. “I said, ‘Okay, we’re going to do it,’ and now she is out there doing her work every day. She now has a reason to get out of bed.”

A Farm Is Born

Last November, Arroyo Grande Care Center, which was ranked one of the top nursing homes by U.S. News & World Report in 2012, permitted volunteers and maintenance workers to break ground on “The Farm,” a one-acre produce and poultry farm.

The Farm, which is located on the facility’s grounds, is completely wheelchair-accessible and was purposely designed to offer residents, many of whom are former farmers, the opportunity to weed, water, and prune crops in addition to tending to chicken coops.

Residents are responsible for their own crops, and all food produced is harvested by the residents themselves.
Arroyo Grande Care Center
After the food is collected, residents are transported across the street to a free farmers market that serves underprivileged elderly community members.

“We mobile all the residents over in their wheelchairs, and they have this huge bounty of chard, carrots, peas, string beans, lettuce, and pumpkin cookies that they made, along with flowers they’re growing so these people have nice flowers, and there are 40 to 50 people lined up every time with their bags,” says Lysobey.

Residents Feel Needed

The need to be needed is essential to the human condition and does not fade in the elderly, health care experts say. Lysobey believes that programs like The Farm are fairly simple to incorporate and can be hugely effective in lowering levels of depression in long term care facilities.

The widely held notion that residents should simply rest and relax through their “golden years” is erroneous, experts say. “There are nonprofits in every community and nursing homes asking to help,” Lysobey says. “Residents just want to be needed and to help.”

Giving Purpose To Residents’ Lives

Arroyo Grande also recently teamed with a local nonprofit, Children’s Resource Network, to open a free clothing and school supply store located on its grounds to benefit disadvantaged youths.

“Advocates in the community, high school and junior high counselors, and homeless shelters can call and place a request. We then print that out, give it to a resident here, and she calls from her room and makes appointments for these disadvantaged teens to shop in the store. Three to four residents work with teens, helping them pick out clothes,” Lysobey says.

Creating opportunities for residents in long term care facilities to team with nonprofits is a no-brainer, according to Lysobey. Health care providers have “been so focused on improving the quality of care, which we have,” he says.

“Quality care has made tremendous strides in the past 20 years—but no matter how nice the infrastructure is, that doesn’t mean people will have need and purpose in their lives.”

Providing purpose to residents is, therefore, as critical—if not more critical—as providing basic health care amenities, he says.

Group Urges 'Strong Federal Guidance' On Training For Personal Care Aides

Group Urges 'Strong Federal Guidance' On Training For Personal Care Aides
States will need “strong federal guidance” on the training and supervision of personal care aides (PCAs), as well as permission to reimburse those aides from Medicaid, the Washington, D.C.-based PHI PolicyWorks said in a new study of the burgeoning PCA industry.

Eleven states have no minimum requirements for training and supervising the aides, and another 12 have limited regulations, PHI PolicyWorks said in its study, released late Tuesday.

About 1.5 million American workers are engaged as personal care aides, PHI said. It’s the fastest growing workforce in the United States, and the ranks of PCAs is expected to grow by 70 percent by 2020, PHI said.

PHI, which advocates for higher wages and standards of direct-care workers, said that the largely unregulated PCA workforce will need some oversight as the nation ages.

“There are no federal training standards for PCAs, as there are for home health aides and certified nurse aides [CNAs] employed by Medicare-certified agencies,” the group said in a news release announcing its findings. “Both of these occupations—which require many of the same skills as PCAs—require 75 hours of pre-employment training.”

PHI PolicyWorks’ findings drew a warm endorsement from Sen. Herb Kohl (D-Wis.), chair of the Special Committee on Aging. “We are facing severe shortages of health care workers who are adequately trained and prepared to care for older and disabled Americans,” Kohl said in a statement through PHI.

“As we work to meet this critical need, we must build on the successes of the direct-care worker demonstration projects that were enacted as part of the health care reforms in order to help begin developing uniform training standards for personal and home care aides. In order to achieve our goal of allowing older and disabled Americans to live as independently as possible, we must have a well-trained workforce.”

PHI researchers found that: 
• Thirty-five percent  of states have a requirement for training hours;
• Just 22 percent of states have a state-sponsored PCA curriculum;
• Only 35 percent of states require an exam; and
• Only 18 percent of states require PCA certification.  

The group urged Washington lawmakers and regulators to come up with “comprehensive” training standards for aides, a “credentialing process that ensures that PCA training articulates with federal training standards” for home health aides and CNAs.

PHI also called for what it called a “training infrastructure that offers accessible, learner-centered teaching, which is effective for adults with multiple learning barriers.”

For more information on the study, go to: http://phinational.org/policy/pca-training-requirements/.  

Studies more firmly tie sugary drinks to obesity

(No big shocker here)
Studies more firmly tie sugary drinks to obesity












 
New research powerfully strengthens the case against soda and other sugary drinks as culprits in the obesity epidemic.
A huge, decades-long study involving more than 33,000 Americans has yielded the first clear proof that drinking sugary beverages interacts with genes that affect weight, amplifying a person's risk of obesity beyond what it would be from heredity alone.
This means that such drinks are especially harmful to people with genes that predispose them to weight gain. And most of us have at least some of these genes.
In addition, two other major experiments have found that giving children and teens calorie-free alternatives to the sugary drinks they usually consume leads to less weight gain.
Collectively, the results strongly suggest that sugary drinks cause people to pack on the pounds, independent of other unhealthy behavior such as overeating and getting too little exercise, scientists say.
That adds weight to the push for taxes, portion limits like the one just adopted in New York City, and other policies to curb consumption of soda, juice drinks and sports beverages sweetened with sugar.
Soda lovers do get some good news: Sugar-free drinks did not raise the risk of obesity in these studies.
"You may be able to fool the taste" and satisfy a sweet tooth without paying a price in weight, said an obesity researcher with no role in the studies, Rudy Leibel of Columbia University.
The studies were being presented Friday at an obesity conference in San Antonio and were published online by the New England Journal of Medicine.
The gene research in particular fills a major gap in what we know about obesity. It was a huge undertaking, involving three long-running studies that separately and collectively reached the same conclusions. It shows how behavior combines with heredity to affect how fat we become.
Having many of these genes does not guarantee people will become obese, but if they drink a lot of sugary beverages, "they fulfill that fate," said an expert with no role in the research, Jules Hirsch of Rockefeller University in New York. "The sweet drinking and the fatness are going together, and it's more evident in the genetic predisposition people."
Sugary drinks are the single biggest source of calories in the American diet, and they are increasingly blamed for the fact that a third of U.S. children and teens and more than two-thirds of adults are obese or overweight.
Consumption of sugary drinks and obesity rates have risen in tandem - both have more than doubled since the 1970s in the U.S.
But that doesn't prove that these drinks cause obesity. Genes, inactivity and eating fatty foods or just too much food also play a role. Also, diet research on children is especially tough because kids are growing and naturally gaining weight.
Until now, high-quality experiments have not conclusively shown that reducing sugary beverages would lower weight or body fat, said David Allison, a biostatistician who has done beverage research at the University of Alabama at Birmingham, some of it with industry support.
He said the new studies on children changed his mind and convinced him that limiting sweet drinks can make a difference.
In one study, researchers randomly assigned 224 overweight or obese high schoolers in the Boston area to receive shipments every two weeks of either the sugary drinks they usually consumed or sugar-free alternatives, including bottled water. No efforts were made to change the youngsters' exercise habits or give nutrition advice, and the kids knew what type of beverages they were getting.
After one year, the sugar-free group weighed more than 4 pounds less on average than those who kept drinking sugary beverages.
"I know of no other single food product whose elimination can produce this degree of weight change," said the study's leader, Dr. David Ludwig of Boston Children's Hospital and the Harvard School of Public Health.
The weight difference between the two groups narrowed to 2 pounds in the second year of the study, when drinks were no longer being provided. That showed at least some lasting beneficial effect on kids' habits. The study was funded mostly by government grants.
A second study involved 641 normal-weight children ages 4 to 12 in the Netherlands who regularly drank sugar-sweetened beverages. They were randomly assigned to get either a sugary drink or a sugar-free one during morning break at their schools, and were not told what kind they were given.
After 18 months, the sugary-drink group weighed 2 pounds more on average than the other group.
The studies "provide strong impetus" for policies urged by the Institute of Medicine, the American Heart Association and others to limit sugary drink consumption, Dr. Sonia Caprino of the Yale School of Medicine wrote in an editorial in the journal.
The American Beverage Association disagreed.
"Obesity is not uniquely caused by any single food or beverage," it said in a statement. "Studies and opinion pieces that focus solely on sugar-sweetened beverages, or any other single source of calories, do nothing meaningful to help address this serious issue."
The genetic research was part of a much larger set of health studies that have gone on for decades across the U.S., led by the Harvard School of Public Health.
Researchers checked for 32 gene variants that have previously been tied to weight. Because we inherit two copies of each gene, everyone has 64 opportunities for these risk genes. The study participants had 29 on average.
Every four years, these people answered detailed surveys about their eating and drinking habits as well as things like smoking and exercise. Researchers analyzed these over several decades.
A clear pattern emerged: The more sugary drinks someone consumed, the greater the impact of the genes on the person's weight and risk of becoming obese.
For every 10 risk genes someone had, the risk of obesity rose in proportion to how many sweet drinks the person regularly consumed. Overall calorie intake and lifestyle factors such as exercise did not account for the differences researchers saw.
This means that people with genes that predispose them to be obese are more susceptible to the harmful effects of sugary drinks on their weight, said one of the study leaders, Harvard's Dr. Frank Hu. The opposite also was true - avoiding these drinks can minimize the effect of obesity genes.
"Two bad things can act together and their combined effects are even greater than either effect alone," Hu said. "The flip side of this is everyone has some genetic risk of obesity, but the genetic effects can be offset by healthier beverage choices. It's certainly not our destiny" to be fat, even if we carry genes that raise this risk.
The study was funded mostly by federal grants, with support from two drug companies for the genetic analysis.
---
Online:
Obesity info: http://www.cdc.gov/obesity/data/trends.html
BMI calculator: http://www.nhlbisupport.com/bmi/bminojs.htm
New England Journal: http://www.nejm.org
---





Detour to a stress free life (CNN)

Your detour to a stress-free life - CNN.com
CNN.com

Cognitive behavioral therapy and mindfulness techniques can actually change your brain in a positive way.
Cognitive behavioral therapy and mindfulness techniques can actually change your brain in a positive way.
(Health.com) -- Ever feel overwhelmed by worries? Do you find yourself dwelling on concerns big (is my job safe?) and small (that darn clogged sink!)?
It's official: You're human and living in the United States. Anxiety levels in this country are the highest they've been in seven decades, surveys show.
Not surprisingly, money and work woes top most people's freak-out lists (thank you, lingering recession). All that e-mailing, texting, and tweeting aren't helping; social technology has reduced actual face time (a known stress reliever) and made us compulsively available to everyone at all times.
Women suffer most -- we're twice as likely as men to be diagnosed with generalized anxiety disorder, which involves excessive worry about a wide range of things (and requires medical attention).
"Women are more likely to feel responsible for taking care of others' well-being," says Robert Leahy, director of the American Institute for Cognitive Therapy and author of "The Worry Cure: Seven Steps to Stop Worry from Stopping You."

Dogs deliver stress relief for students
And in this you-can-do-it! era, some of us think we can power through anxiety, which only exacerbates the problem.
Chronic stress has been linked to weight gain, depression, and even cancer. But this doesn't have to be your fate.
You can actually train your brain to be less anxious. Recent studies have found that both cognitive behavioral therapy (CBT) -- more about this in a minute -- and mindfulness techniques can make positive changes to your gray matter, ones actually visible in a brain scan.
Health.com: 7 steps to instant calm
What is CBT, anyway?
CBT centers on the idea that we can free ourselves from a lot of angst by becoming aware of our distorted view of situations, particularly stressful ones, and adjusting our behaviors accordingly.
A 2012 review concluded that CBT can enlarge the prefrontal cortex -- the part of the brain associated with weighing thoughts and making decisions -- and reduce the size of the amygdala, the region associated with stress and fear.
In another study of patients with social phobia that compared the effects of CBT and the antidepressant citalopram, both treatments triggered changes in the parts of the brain that help us process, and act upon, fears.
"Our brains are constantly being shaped, most often unwittingly," says Richard Davidson, director of the Lab for Affective Neuroscience at the University of Wisconsin-Madison. "But there are things we can do to purposefully shape them and reduce anxiety."
You can try CBT on your own with the exercises that follow, or, for a more in-depth experience, find a therapist who specializes in it.
The more you incorporate these very doable techniques into your life, the more second nature they'll become when anxious thoughts rear their ugly little heads. Try them all, then do the ones that work best daily; in about two weeks, you'll start to see a calmer, happier you.
Health.com: Which type of talk therapy is best for you?
Stay calm now, worry later
"Much of feeling anxious is that sense of urgency: 'I've got to know -- is this mole cancer?'" Leahy notes. "But research shows that 85% of things people worry about actually end up having a positive or neutral outcome."
Write down exactly what's worrying you, then don't look at your note again for three or five hours. Chances are, it will feel less worrisome, and you'll be better able to consider productive actions, like scheduling a skin check at the dermatologist.
Think small
Too often, anxieties swell to epic size: I'll never get out of debt!
"Things feel more manageable when you remove worry's distortions," notes Tamar Chansky, author of "Freeing Yourself from Anxiety."
Take it step by step instead: I can't pay off all the bills now, but I can chip away at them every month.
Health.com: 9 things to stop worrying about
Give yourself a pep talk
Write down or say out loud the ways you are prepared to handle a situation: I generally get things done. I know how to ask for help. Remind yourself how capable you are.
Let George Clooney help
Imagine the issue from an outside perspective, Chansky suggests. What would your best friend -- or your favorite celebrity -- say? Conjure up that person's voice as they guide you to calm. George: Listen, woman, that CEO has a bark much bigger than his bite. You've totally got this. You: You are so right.
Use your senses
Mindfulness, an ancient practice that focuses your brain on the present, is as old as Buddha. But it's experiencing a surge of popularity; companies like Google and General Mills have mindfulness programs for employees.
Like CBT, it conditions your mind to be more stress-resistant. In a 2012 study, students trained in a mindfulness technique had a significant decrease in stress-related cortisol and an increase in signaling connections (called axons) in a part of the brain that controls emotions.
Health.com: Head-to-toe solutions for stress
"When we feel anxiety, our thoughts are rarely in the present," says Jenny C. Yip, a cognitive behavioral therapist in Los Angeles. "We are either ruminating about past mistakes or worrying about future consequences."
Zooming in on what you can see, hear, taste, smell, or feel shifts your mind to the present. The more you practice this, the better equipped you'll be when anxiety strikes, and the quicker you'll calm down. Try this four-step exercise:
1. With eyes closed, imagine yourself and your surroundings from above.
2. How does the floor, mat, or chair feel? How's the temperature in the room?
3. What are the sounds? Maybe an electrical appliance is humming, or trees outside are rustling.
4. Now tune into all these things at once.
Hard, right? That's the point -- to fill your thoughts with the present. When your mind wanders (and it will), bring it back to your senses. It may just bring -- as famously said on "Seinfeld" -- serenity now.
Copyright Health Magazine 2011

The power of 40 weeks




Pat Bradley, RN,C, BS, thought something was amiss. The director of obstetrics at Edward Hospital & Health Services in Naperville, Ill., had noticed an increase in the number of nonmedically indicated elective deliveries before 39 weeks gestation — elective early-term deliveries, as the March of Dimes calls them.

Bradley, a veteran nurse with more than 40 years of obstetrics experience, suspected this trend was heightening the risk of complications for mothers and babies. But without data it was difficult to prove her theory. Then one week a perfect storm of events confirmed her suspicions.

First, the hospital’s clinical quality group informed her that 28% of the hospital’s births in 2010 were elective early-term deliveries. The national average, according to the Leapfrog Group, was 17%. Then she discovered neonatal outcome data that confirmed her fears. Studies have exposed the consequences of the practice of scheduling early delivery dates, which include increased risks for NICU admission, transient tachypnea of the newborn, respiratory distress syndrome, ventilator support and feeding problems.

"A single practitioner may not see increased complications caused by elective deliveries between 37 and 39 weeks, but when you look at large numbers of newborns, you start to see the trend," Bradley said.

RNs have begun raising public and provider awareness about the risks of elective early-term deliveries.
Risky business

Although the percentage of elective early-term deliveries at Edward Hospital sounds high, a study in the February 2009 issue of the American Journal of Obstetrics & Gynecology shows otherwise. Researchers collected data over a three-month period in 2007 and found that of the 15,000 births that occurred at 37 weeks or later, 6,500 were planned. Of the planned deliveries, 71% were nonmedically indicated. Additionally, data from the Centers for Disease Control and Prevention show the rate of births between 37 and 38 weeks increased by nearly 50% between 1990 and 2006.

Medically necessary reasons for early deliveries include premature rupture of the membranes, gestational hypertension, preeclampsia and gestational diabetes.

At Sutter Medical Center in Sacramento, Calif., studies about the potentially negative effects of elective early-term deliveries motivated hospital leaders to examine outcomes at their facility and use these cases to educate obstetrical care providers about the risks.

"It always helps to have data and cases from your own institution to demonstrate that our practices could also be improved," said Mary Campbell Bliss, RN, MS, CNS, a perinatal clinical nurse specialist at Sutter. Without larger studies, the effects of this trend initially were difficult to determine. But some hospitals began to explore cases that called into question the wisdom of elective early-term deliveries.
Taking action

Obstetric nurses such as Bradley and Bliss were concerned the rates of elective deliveries in their hospitals were too high, but they knew they needed help to change an established practice at their facilities.

In the summer of 2010, when the March of Dimes announced it needed hospitals to participate in a pilot program using a new toolkit aimed at reducing the number of elective early-term deliveries, Bradley and Bliss were eager to participate. The free toolkit, initially developed by the California Maternal Quality Care Collaborative, included data on the increased maternal-infant risks associated with nonmedically indicated elective deliveries and strategies to change hospital policies.

Bradley met with hospital administrators and physicians and presented data from the toolkit, and her audience was surprised by what they learned. For example, a study published in Obstetrics & Gynecology in 2009 found that in 21 hospitals in Idaho and Utah, rates of respiratory distress syndrome were 22.5 times higher for infants born at 37 weeks and 7.5 times higher for those born at 38 weeks compared with infants born at 39 weeks. The same study found the rates of NICU admissions were more than double for infants born at 37 weeks versus 39 weeks. The toolkit also explained brain growth in the last several weeks of gestation is important because an infant’s brain at 37 weeks weighs only 80% of what it would weigh at 40 weeks.

Although it may be tempting to blame healthcare providers for the trend of earlier scheduled deliveries, Bradley suggested patients also have contributed to the shift.

"A lot of moms are looking to deliver early because they are uncomfortable or because a caregiver for other children will be available at a certain time," she said. "There have also been a lot of advances in neonatal medicine, so people feel like their chances of [having] a healthy baby are high at 37 weeks."
Effecting change

During the pilot program, Edward Hospital started using a new scheduling form included in the March of Dimes toolkit. Physicians were required to fill out information about the infant’s gestational age and list why the early-term delivery was medically necessary. If a form did not meet the criteria for an early delivery, then the physician champion would call the fellow physician to see whether the delivery could be delayed.

The program was so successful that the elective early-term delivery rate dropped to less than 1% in one year. The hospital has been collecting outcome data for these deliveries.

At Sutter Medical Center, the toolkit pilot program also was successful. The rate of elective early-term deliveries dropped from 15% in 2010 to 5.5% in 2011.

"The biggest change has been waiting to schedule repeat C-sections until 39 weeks," Bliss said. "One of the concerns providers have is that if a woman who has previously had a C-section goes into labor, there is a risk of her uterus rupturing, but we have not seen this occur. The majority of these women do not go into labor prior to 39 weeks, and for the ones who do, we have performed successful C-sections."

Once the hospital implemented the new program, the number of spontaneous births also increased, translating to more deliveries on the night shift, Bliss said. As a result, the hospital has increased the number of nurses working that shift.
Go the full 40

In December 2011, the Association of Women’s Health, Obstetric and Neonatal Nurses launched a public education campaign to teach expectant mothers about the benefits of waiting until at least 40 weeks gestation to induce labor unless they have a medical reason to do so earlier.

The "Go the Full 40" campaign lists 40 reasons to wait until the expected due date. Catherine Ruhl, RN, MS, CNM, director of women’s health programs at the AWHONN, encourages nurses to read the list and educate their patients.

"For many women, it dawns on them what they have signed up for with an elective delivery once it is too late, but I hope we can change that," Ruhl said. "Ideally this education should start prenatally, but it can also happen when pregnant women come to the hospital when they mistakenly think they are in labor and are sent home. This is a perfect time for nurses to educate these women about the importance of waiting." •

Heather Stringer is a freelance writer.


Docs Can Prevent Car Crashes Among Elderly




Docs Can Prevent Car Crashes Among Elderly


Physicians' warnings to patients that they are potentially unfit to drive can prevent car crashes, researchers reported.
The annual rate of car accidents among patients who were so warned fell about 45% in the year after the doctor's intervention, compared with the 3 years before, according to Donald Redelmeier, MD, of Sunnybrook Health Sciences Centre in Toronto, and colleagues in the Sept. 27 issue of the New England Journal of Medicine.
The "data suggest that practicing physicians may be able to help prevent serious trauma from road crashes," the authors concluded.
Redelmeier and colleagues noted that there was no significant change in the rate of accidents in which the patients were passengers or pedestrians. But there may have been psychological repercussions: emergency department visits for depression rose and patients saw their physicians less frequently after they were warned off driving.
The Canadian province of Ontario, the country's most populous, has some 9 million licensed drivers and in 2008 – the midpoint of the study – recorded 229,196 car accidents resulting in death, disability, or property damage.
Of those accidents, 17,929 required the driver to visit an emergency department, for an overall annual rate of about 1.98 events per 1,000 drivers.
Since 1968, the researchers noted, Ontario doctors have had the duty to report a driver who is unfit to operate a motor vehicle by reason of a condition such as alcoholism, dementia, sleep disorders, or depression without psychosis.
But few doctors followed through, Redelmeier and colleagues noted, so that in 2006 the province introduced a payment to doctors for the process. That change offered a chance to test the effectiveness of medical warnings in reducing accidents, they wrote.
Between April 1, 2006, and Dec. 31, 2009, the researchers identified 100,075 patients who got a medical warning from a total of 6,098 doctors. The study period included the first 4 years after the change to the medical warning program, as well as at least one year of follow-up for each patient.
Between 10% and 30% of warnings resulted in the patient having his or her license suspended, Redelmeier told MedPage Today in an email, but "not all suspended drivers stop driving."
The primary endpoint of the study was the change over time in the annual rate of accidents in which the patients were driving a vehicle and needed emergency hospital care.
So, for each patient in the cohort, the researchers looked for emergency room visits – before and after the warning -- with diagnostic codes for injuries that resulted from accidents in which the patient was the driver. Crashes in which the patient was a passenger or a pedestrian were excluded from the primary analysis.
In the 3 years before they were warned, patients who subsequently received a warning were the drivers in 1,430 car crashes that led to emergency care. That worked out to an annual rate of 4.76 such accidents per 1,000 people – more than twice the rate in the general population.
During the year after the warning, patients were the drivers in 273 crashes that led to an emergency department visit -- equivalent to an annual rate of 2.73 accidents per 1,000 persons, Redelmeier and colleagues reported.
Although the latter rate is still higher than what was seen in the general population, the observed decline was equivalent to a 45% relative reduction in the risk of accident (95% CI 36 to 52, P<0.001).
Analysis by subgroups found a similar reduction in risk regardless of demographics, physician characteristics, the timing and type of accident, or the severity of injuries.
The intervention had no effect on the yearly rate of emergency department visits for which the patient was a pedestrian -- 1.30 events per 1,000 patients before the warning and 1.29 afterward. There was also no effect on the rate of emergency department visits in which the patient was a passenger -- 3.08 events per 1,000 patients annually before the warning and 3.04 after.
On the other hand, Redelmeier and colleagues reported, emergency department visits for depression rose from 19.15 per 1,000 patients annually before the warning to 23.91 afterward – a 27% relative increase.
The warning may also have affected the doctor-patient relationship, the researchers suggested, since 29% of the warned patients saw their doctor less often afterward than they had before.
The study results should apply more widely than just Ontario, since six U.S. states, including California, Pennsylvania, and New Jersey, have similar regulations, Redelmeier told MedPage Today.
The study comes as a prominent Irish gerontologist, Desmond O'Neill, MD, of Dublin's Trinity College, argued in bmj.com that mandatory medical screening of older drivers -- which has been imposed in some European countries and is proposed in the U.K. -- is unwarranted and has dangerous consequences, including an increased risk of older people being injured as pedestrians.
Age-related medical screening should be abolished, he argued, adding that "this must not imply professional neglect of medical fitness to drive among older drivers."
Redelmeier commented that "such medical determinations are not easy."
"That's why medical judgment is needed and why an effective policy must not be taken to excess," he added.
The study was supported by the Canada Research Chairs program, the Canadian Institutes of Health Research, and the University of Toronto Faculty of Medicine. The researchers did not report any financial links with industry.
O'Neill did not report any external support for his article or any potential conflicts.

Primary source: New England Journal of Medicine
Source reference:
Redelmeier DA, et al "Physicians' warnings for unfit drivers and the risk of trauma from road crashes" N Engl J Med 2012; 367: 1228-1236.
Additional source: BMJ
Source reference:


 

Michael Smith
North American Correspondent
North American Correspondent for MedPage Today, is a three-time winner of the Science and Society Journalism Award of the Canadian Science Writers√Ę€™ Association. After working for newspapers in several parts of Canada, he was the science writer for the Toronto Star before becoming a freelancer in 1994. His byline has appeared in New Scientist, Science, the Globe and Mail, United Press International, Toronto Life, Canadian Business, the Toronto Star, Marketing Computers, and many others. He is based in Toronto, and when not transforming dense science into compelling prose he can usually be found sailing.

Tuesday, September 25, 2012

Clinicians Should Promote Sex Among Nursing Home Residents

Arthur L. Caplan, PhD
Posted: 09/05/2012 Hi. I'm Art Caplan in the Division of Medical Ethics at the New York University Langone Medical Center. Today I want to talk to you about a fascinating issue that concerns personal choice, freedom, and autonomy. I know that some of you are starting to think, "Uh-oh, here we go again. It must be about end-of-life care or about involvement in research ethics." No, this is a lot more basic, ordinary, and everyday.
A paper[1] came out recently that caught my eye. It argued that people in nursing homes ought to have the right to have sexual relations and that this is not something that doctors bring up with either the patients or the families when someone is getting ready to go to long-term care. It is a problem that I have been aware of, but the article reminded me that it is important to put this issue forward and talk about it -- something we don't like to talk about, which is sex in the elderly. I think a lot of us like to think that the elderly, whatever else they might be doing, are not having fun and romping around in the bedroom.
Well, the data do not support that. Plenty of people are married and sometimes one of them has to go to assisted living or into a nursing home setting. That does not mean that their marriage has ended and that does not mean that their relationship and intimacy are over. They need to have a situation in which they can talk about how they are going to spend time with one another.
One of the big problems is that nursing homes are set up to afford people very little privacy for legal and safety reasons. There are almost always double rooms and it is hard to lock a door. There is no place to go. When you are talking about this with a patient or a family, you first need to broach the idea that romance might still be in the cards. Second, you have to talk to the administrators and see how they handle this sort of thing. Can they find a private spot? Can they lock a door? What is the attitude of the organization and the institution? All of these should be discussed.
What if the patient is not married? What if he goes to the nursing home and he finds someone that he likes? That happens, too. Are you going to handle a request for erectile dysfunction drugs? Are you going to do what it takes to facilitate sexual or romantic encounters? Intimacy can be achieved in a lot of ways without sex. That can be explained to people in nursing homes. I don't have a moral problem if somebody says, "I'm here. I have met somebody that I like and I would like to have a relationship." But children of those older parents might, and they need to be involved in the discussion so that they are not outraged, objecting, or trying to interfere in things that are not their business. We are talking about a competent adult.
The bottom line is this: We fret about how to give people autonomy when it comes to dialysis, a feeding tube, or pain medication if they are very ill and dying. Those are all great issues around autonomy. I suspect that a lot of the time, the people we are talking about don't have much autonomy left. They are too sick. What they care about are things like whether they can have visitors, whether they can go for a walk, or whether they can have romance. These take place much earlier in the nursing home or assisted-living setting, and that is where autonomy could really be put to good use.
My suggestion is that part of the emphasis when having discussions with elderly people -- particularly when the issue comes up about being taken care of in a nursing home -- should be that sex is a part of old age.
This is Art Caplan at the New York University Langone Medical Center. Thanks for listening.
 References
  1. Tarzia L, Fetherstonhaugh D, Bauer M. Dementia, sexuality and consent in residential aged care facilities. J Med Ethics. 2012 Jun 25. [Epub ahead of print]


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Why Hospital Workers Should Be Forced to Get Flu Shots


Author

Arthur L. Caplan, PhD

Director, Division of Medical Ethics, New York University Langone Medical Center and School of Medicine, New York, New York

Disclosure: Arthur L. Caplan, PhD, has disclosed no relevant financial relationships.

 Why Hospital Workers Should Be Forced to Get Flu Shots

Arthur L. Caplan, PhD
Posted: 09/13/2012


Hi. I am Art Caplan from the New York University Langone Medical Center in New York City where I head the Division of Medical Ethics. Today I want to talk to you about an ethical issue that I think pertains to doctors, nurses, and other healthcare workers but not so much their patients.
It is about to be flu season, and we are starting to see the signs go up at pharmacies, drugstores, and other retail outlets: They have the flu shot, so come get one. I think that doctors responsibly tell their patients to get a flu shot. The problem is that we don't get our flu shots, and I am talking about doctors, nurses, nurses' aides, pharmacists, and other people who work in healthcare settings.
The average rate of flu shots among the workforce in American hospitals varies from about 80% in physicians down to 60% in nurses. In nursing homes, you are often looking at rates that are 30% or lower. Who is likely to get harmed by the flu? Who is at great risk? It is not the healthy 30-year-old. They may get sick and they may have some time in which they cannot go to work. It's not a good thing and I think they should get a flu shot, but they are not going to die.
The elderly are at high risk, babies are at high risk, and people who are immune-comprised due to HIV or transplants are at high risk too. Where are they going to be? In nursing homes, hospitals, and healthcare settings.
Therefore, it is of crucial importance that doctors, nurses, nurses' aides, and people who work in healthcare settings get their shots. I know that a lot of people have said that it ought to be voluntary, that it ought to be something that I choose to do. I do not lose my right as a doctor or a nurse to say that I don't want to do that.
Well, I think you do. Ethically, your first obligation is to do no harm. If you are there to do no harm and that is your primary obligation, then you cannot put your personal choice or your personal reluctance to get that shot above doing harm. And you are likely to do harm to others if you do not get that shot.
Also, every code of ethics that I have seen -- medical, nursing, and others -- says that we put patient interests first. It is not in the patient's interest for you to not get a flu shot. If we are putting patient interests first, if that rhetoric is what we believe in our codes of ethics, what we teach in our medical and nursing schools, there is no excuse for not getting a flu shot.
I think the obligation is there to do it, and I will go further. I think that every hospital and every nursing home should require as a condition of employment that you show that you got a flu shot every year. I think it is also important, if you are talking with families or patients who might have a relative in a high-risk category, that you remind them to ask their healthcare providers whether they have had a flu shot. When you go to visit Grandmom in the nursing home or if you are going to see the newborn baby, is everybody vaccinated there? That is a question that they need to be asking, and you need to remind them.
At the end of the day, it's flu season and we can do something about this. We can protect the weakest and most vulnerable that are among us, but we have to set the right example. Our moral duty is to get our flu shots and prevent harm to others who can't protect themselves or who are especially at risk for the flu. It's the time of the year to do it. I think it is important that we set the right example.
I am Art Caplan at the Division of Medical Ethics at NYU Langone Medical Center. Thanks for listening.


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Friday, September 14, 2012

Bridging The Gap In Dementia Care

 Bridging The Gap In Dementia Care

Physicians say caregivers need to view patients with dementia in a new way.
 
bridging dementia gap
Before “Maggie” developed severe dementia, her gregarious personality had led her to find much joy in her many social activities. 
But after the diagnosis, and after her condition worsened to the point that she could no longer live in her own home, her family moved her into an assisted living facility.
The facility was large and unfamiliar to her. Staff tried to pull her into social activities, but she resisted, and as time went along she became increasingly withdrawn and isolated.
What had given her so much joy throughout her life was now inaccessible to her.
Maggie’s family tried to compensate by increasing the time they spent with her, but it seemed to do little if any good. They were losing their mother, even more than they already had.

Consider The Person With  Dementia, Not The Disease

G. Allen Power, MD, author of “Dementia Beyond Drugs: Changing the Culture of Care,” proposes a simple yet, for many providers, radical idea: Stop thinking of dementia patients as people with diseases to be treated, and start thinking of them as people with a terrifying, shifted reality who still have lots left to give if their trust can just be earned.
Negative attitudes toward people with dementia are a big factor in the combative atmosphere that can arise at times between those with the disease and their caregivers, writes Power in his recent award-winning book.

“We look at the person with dementia from a single viewpoint—that of a broken person in need of medication to mitigate the decline,” he writes. “Our standardized tests reduce” the elder to a list of “disordered thinking processes, while we ignore the complex cognitive and emotional qualities that can be retained even in advanced stages” of the disease.

In other words, just because someone has a brain disorder doesn’t mean the person isn’t still experiencing life, a growing number of health professionals say. Their life histories, values and spirituality, and coping styles, for example, remain.

In fact, anecdotal evidence points to people with dementia being more exquisitely attuned to their environment, relationships, and spirituality than those without the disease.

But the challenges of experiencing dementia are overwhelming for the sufferer, and that must be recognized, Power says.

A board-certified internist and geriatrician, Power has been a full-time long term care physician for nearly 20 years and an Eden Mentor at St. John’s Home in Rochester, N.Y., for more than a decade.

Culture Change Critical To Dementia Care Model

During his time at St. John’s, Power has helped shepherd the skilled nursing facility’s journey toward accomplishing the goals set forth by the Eden Alternative. He admits they still have a long way to go—the not-for-profit residence is home to almost 500 patients, two-thirds of whom are on Medicaid, and the facility still has long hallways and central nurses’ stations—but the transformation is taking place. In fact, St. John’s just opened its first two Green Houses to be in the mainstream community.

The years of caring for people with dementia have taught Power many lessons, some painful, some inspiring. Today, changing the way people with dementia are cared for has become something of a mission for him.

“The most important [message] is that we need to change the way we look at people with dementia,” Power tells Provider. “We need to see the whole person, what their strengths are, and not just their disability.”

Critical to making this happen is culture change, because without it, “no matter what philosophy you adopt, the philosophy will die,” he warns. “The system will kill it.”

In his book, Power details a new method of approaching dementia care, which posits that individuals with the disease, rather than merely being victims of a decline into oblivion, are full human beings who have experienced a radical, frightening shift in perception, and their “difficult behaviors” are their attempts to gain their footing, achieve control, cope with stressors, problem-solve, and communicate unmet needs.

Verbal or not, people’s personalities are still in there, and they’re communicating, Power says. Providers are just not understanding them. And because they don’t understand, and because they’re steeped in a medical point of view, they ascribe residents’ “difficult” behaviors to their disease and try to solve it with a pill, he says.

When a resident with dementia begins to express him- or herself in ways that are difficult for staff and other residents to handle, Power says, using antipsychotics should be a last resort, rather than the first thing doctors turn to, as is too often the case. Rather than rely on antipsychotics that mostly just sedate patients with dementia and sink them into a state in which they’re even less able to communicate and are more confused, Power has come up what he calls the experiential model of care.

Nonpharmacological Interventions Key To Model

The essential element in making the experiential model work is transforming the mindset of the residence’s staff from a medical/institutional viewpoint to one that prioritizes building meaningful relationships with each resident and partnering with the resident in each caregiving event and activity of the day.

This requires consistent staffing, the elimination of agency staffing, and incorporating meaningful communication between two people—resident and care partner (a term that implies a two-way street in which residents participate in their own care, rather than the term “caregiver,” which implies all the giving occurs on the provider’s side)—who are getting to know and trust each other.

It’s only when the care partner really understands the resident—including history, current views and preferences, spirituality and values, and what tends to trigger anger or unhappiness—and gains the person’s trust that effective, nonpharmacological interventions can take place. All people are more likely to open up about what they’re really feeling to a friend than to a stranger.

The model also requires that caregivers learn how to see through the eyes of an individual battling dementia, which takes a great deal of thoughtfulness and learning about both the disease and the individual, because just as no two people are the same, no two experiences of dementia are alike, Power says.

Resident's Life History Provides Major Clues

American Medical Directors Association President-Elect Jonathan Evans, MD, agrees with Power’s approach.

Understanding the reasons why someone is behaving in what seems like an unusual or disruptive way makes acceptance easier for staff, Evans says.

“This isn’t premeditated, conscious mischief, this is someone responding to their environment in a way other people don’t want. We need to substitute something meaningful for behavior that might be undesirable.”

Evans recounts the story of a man living in a nursing home who would roll his wheelchair over to other people’s wheelchairs and polish the chair’s chrome, which would distress the person sitting in it. Or he would go around polishing door-knobs in the building.

But because the clinical team knew his life history, they could understand what he was doing and that it wasn’t a threat to anyone. “In his life, he’d had two jobs simultaneously. He worked as a car salesman and in the evening as a volunteer fire fighter,” and both of those jobs involve polishing up the chrome on the cars or the fire engine. “He’d shined chrome objects for so long that it was overlearned behavior. He was just working,” Evans says.

Another example: A nurse who developed Alzheimer’s disease and lived in a nursing facility would push other residents in their wheelchairs, sometimes right onto the elevator, push buttons, and send them down. That sometimes led to fighting.

“So, why would she do that? The environment she was in looked just like her place of work for decades,” Evans says. “The environment was telling her she’s at work. The behavior was really entirely predictable. The challenge for us is how to allow her to be fulfilled, to continue to make a contribution. If the environment is telling her to do something, how can we possibly expect to convince her to do otherwise?”
The facility’s nurses’ hearts went out to their colleague struggling with dementia, and they put a lot of thought into how to involve her in meaningful but safe ways.

“At times if they saw she was causing distress to others, they would call her name and say it was time to make rounds, and they would hand her a clipboard and distract her with some tasks,” says Evans. “Her attention span wasn’t too great, and she would lose interest, but they could do it over and over again by acknowledging her as a nurse rather than trying to convince her that her professional life was over.” Well, Evans notes, telling someone they’re wrong doesn’t even work well with spouses or teenagers, so why would it work better with someone with dementia?

Interpersonal Relationships Work

Most people in long term care like these ideas, Power says, but are worried that having caregivers engage in meaningful conversations with residents as they provide care—or merely as they see them in the common areas—would take up so much time that they wouldn’t be able to fulfill all the regulatory requirements.

“Those are always the concerns,” he tells Provider, but these well-meaning people are viewing the issue from within the constraints of the current, institutional system. “The way you do things now, you don’t have time for this. You need to change how you do things. Most people are very caring; they just need to know how to get there.”

Although Power writes about changing the environment to suit the needs of the person with dementia, he doesn’t primarily mean the physical environment of the facility—in fact, physical renovation is the last step he recommends—but primarily the interpersonal environment.

Consistent Staffing A First Step

The first step toward transformation is consistent staffing. Residents won’t be able to develop meaningful relationships with constantly changing caregivers, Power says. And he recommends entirely eliminating agency staffing, for the same reason.

Secondly, thoroughly educate everyone who interacts with residents—from administrators to housekeeping and maintenance staff—about the basic concepts of learning to see through the eyes of a person with dementia, how to interpret facial expressions and body language, and the kinds of nonpharmacological interventions that might be useful, always tailoring those to each individual resident.

Next, find ways to restore choice and control to both the resident with dementia and those closest to him or her. This helps restore self-determination to individuals with dementia, but it also causes residents, families, and staff to collaborate, which counteracts the us-vs.-them mentality that can develop.

Ways to ensure residents have choice in their lives involve such things as including them in meetings to plan their care (and speaking directly to them, not only to other interdisciplinary care team members), or just something as simple as asking them if they’d like to wear this blouse or that one, or what food on their plate they’d like to eat first.

Rebuilding residents’ sense of usefulness is also critical, because life without any meaning is terrible, Power says. Involve these residents in group decisions that affect others’ lives as well as their own, such as discussions about fun things to do or what they’d like to see on the menu.

Further, Power has seen in his own long years of practice that people with dementia can be exceptionally caring and giving, and allowing them to continue to express these basic needs—to care for and give to someone other than themselves—will go far in helping them to feel useful and give their lives meaning.

“People with dementia can almost always give care on some level,” writes Power, “whether by reading to a child, watering a plant, stroking a cat—even ‘nurturing’ a doll, as people with advanced dementia may do.”

Experts Join Forces To Improve Care

Evans and Power joined many other dementia care experts recently at the National Dementia Initiative (NDI) meeting June 29 in Washington, D.C.

The NDI is a collaborative effort of 70 diverse dementia care experts across the country—experts from the practice, policy, and research sectors who’ve shown longstanding commitment to enhancing knowledge, understanding, and practices to advance quality outcomes, according to Karen Love, founder of CCAL—Advancing Person-Centered Living, who organized the event.

These experts gathered June 29 to form consensus recommendations on dementia care. Their first recommendation was that care be person-centered.

“Within all of us resides the need to be whole,” said Oliver Sachs, MD, summing up the basic humanistic need.

Person-centered care, wrote Love in an e-mail to Provider, reframes the entire conversation.

“Understanding and addressing the wholeness of the person living with dementia changes the need to even have ‘interventions.’ The approach to care becomes inclusive and addresses proactively rather than reactively,” she says.

The NDI is preparing a white paper expected to be finished by mid-October.

A Nurturing Environment

Interestingly, a fairly recent study by the Macklin Intergenerational Institute based in Findlay, Ohio, found that preschoolers who interacted regularly with people with dementia were nearly six months ahead of their peers once they started school in such areas as cooperation, expressing emotions, and social abilities.

A follow-up study found that those children were 11 months ahead of their peers. The study’s authors theorized that this advancement was because the loneliness, boredom, and helplessness suffered by residents were counteracted by preschoolers’ need for interaction, guidance, and exploration—needs people with dementia were able to meet.

A care partner who knows a resident well can inject more meaning into his or her life merely by knowing what topics of conversation he or she will care most deeply about, what gestures of friendship will be touching, or what activities will tap into that resident’s greatest interests.

And, speaking of activities, those that occur spontaneously are more meaningful to a resident than those for which they must wait for the scheduled time to come around.

“These are the attributes of home,” writes Power, “nurturing relationships with people you know well, choice and control over daily life, opportunities to give care, variety, spontaneity, and meaning in everyday life. This is the foundation of the transformed environment, and its impact on the care of people with dementia is enormous.”

Doesn’t That Take Time?

In reality, done right, time is actually saved by developing in-depth, consistent relationships with people with dementia and treating them in ways that feel comfortable to them, says Evans. And not only does it serve the resident, it heightens the job satisfaction of staff, resulting in less turnover.

“I’ve yet to meet a nurse who went into nursing school hoping that if things went well they would spend the majority of their time pushing a med cart,” Evans says. “Or a doctor who wanted to do a lot of paperwork. That’s especially true for people in primary care and people who gravitate toward long term care.

“First of all, we’re all trying to find meaning and fulfillment through our jobs,” he says. “We’re trying to do our life’s work. Particularly CNAs [certified nurse assistants] and nurses and therapists and food service people in long term care—everybody’s there for a reason. There’s something each of us needs from the people who live there,” says Evans.

“We give comfort and receive comfort at the same time.”

It’s a calling for most people, and people are most fulfilled when they are given the tools and time to fulfill their calling, Evans says. “Fundamentally, most people work in long term care because that’s what they feel that they’re called to do; they want to make a difference in the lives of others, and it’s often easy to see that impact in long term care” where the residents have already experienced so much loss, he says.

Rethinking The Job

However, Evans acknowledges that “sometimes the job gets in the way of the work” of spending time caring for people they care about. “The leadership in facilities has an obligation to help all of their staff do things that are maximally important to others.”

But it’s a fallacy, he says, that talking in-depth with residents—not just when they’re admitted but as caregivers wake them up in the morning, sit with them at meal time, or just meet them in the hall—is time that can’t be reimbursed and so is time wasted in terms of the facility’s financial bottom line.

“It’s actually time well spent,” Evans says. “When someone is in distress, that requires attention and it cannot be ignored, but it’s seemingly unpredictable and hard to plan for.” And calming a resident who’s upset certainly takes longer than doing simple things that prevent the disturbance from ever happening.

In addition, when front-line staff deeply understand the people they care for, that empowers them to help this individual whom they’ve grown to care about, which is much more satisfying to the CNA (as well as to the resident) than having a doctor jump in with his magic pill, Evans says. “Being able to identify a situation and solve problems is very satisfying. That’s why a lot of people go into health care in the first place.

“I’m excited about the future because we’re just beginning to understand this condition, and the sky is literally the limit in helping others in need.”

Postscript: Maggie’s Case

The story of Maggie, the resident with dementia whose case was alluded to at the beginning of this article, has a happy ending.

When Maggie’s family realized she just wasn’t going to get any better on the path the facility was taking, they researched local options for dementia care and settled on English Rose Suites, an assisted living chain that features family homes in Minneapolis neighborhoods. English Rose, which has spent decades developing its own program of person-centered solutions for people with dementia, worked with both Maggie and her family to write up Maggie’s life story so they would know what things had been pleasurable or comforting to her in the past, and so they could identify things that might trigger feelings of fear, uneasiness, or anger.

Getting to know Maggie intimately resulted in gaining her trust and allaying her fears.

It took a lot of work, and it never stops being hard work; Maggie doesn’t have a perfect day every day. She just has hard days much less frequently, and she has moments of joy now where before everything was psychic pain and confusion.

English Rose caregivers have learned that striving for excellence must become a way of life, not a plateau to achieve and then rest.
Kathleen Lourde is a freelance writer based in Dacoma, Okla.

Tuesday, September 11, 2012

Utah CNA classes

Thanks. They actually offered me the position today. They wanted someone that has been a CNA for longer but they were really impressed with me in my interview. I am really excited. Thanks for the fanatastic training I received @ CCCNA. It is a major stepping stone in my obtaining my BSN and beyond. Again, thank you.
Michelle Hancock

My sister's PICC line

My sister got a PICC line after surgery last week. She has Von Willebrands and has to have clotting factor. It's a funky new kind of dressing I hadn't seen before.

Von Willebrand disease

 Von Willebrand disease is the most common hereditary bleeding disorder.

Causes, incidence, and risk factors

Von Willebrand disease is caused by a deficiency of von Willebrand factor. Von Willebrand factor helps blood platelets clump together and stick to the blood vessel wall, which is necessary for normal blood clotting. There are several types of Von Willebrand disease.
A family history of a bleeding disorder is the primary risk factor.

Symptoms

Note: Most women with heavy or prolonged menstrual bleeding do not have Von Willebrand disease.

Signs and tests

Von Willebrand disease may be hard to diagnose. Low von Willebrand factor levels and bleeding do not always mean you have von Willebrand disease.
Tests that may be done to diagnose this disease include:

Treatment

Treatment may include DDAVP (desamino-8-arginine vasopressin), a medicine to raise von Willebrand factor level and reduce the chances for bleeding.
However, DDAVP does not work for all types of  von Willebrand disease. Tests should be done to determine what type of von Willebrand you have.  If you are going to have surgery, your doctor may give you DDAVP  before surgery to see if your von Willebrand factor levels increase.
The drug Alphanate (antihemophilic factor) is approved to decrease bleeding in patients with the disease who must have surgery or any other invasive procedure.
Blood plasma or certain factor VIII preparations may also be used to decrease bleeding.

Expectations (prognosis)

Bleeding may decrease during pregnancy. Women who have this condition usually do not have excessive bleeding during childbirth.
This disease is passed down through families. Genetic counseling may help prospective parents understand the risk to their children.

Complications

Bleeding may occur after surgery or when you have a tooth pulled.
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can make this condition worse.