Monday, December 24, 2012

Reducing Anger

Have you ever felt a flame of anger igniting when you were provoked—and wished you could keep your cool instead?  New research has a trick that can help do just that.

The trick is to pretend that you have stepped back and are seeing the situation from a distance, as though you are an observer instead of a participant.  From this more distant spot you can look at your feelings.

“Self-distancing” is the term researchers at Ohio State University and the University of Michigan gave to the technique.  The findings of two related experiments were published online in the Journal of Experimental Social Psychology.

“The secret is to not get immersed in your own anger and, instead, have a more detached view,” says Dominik Mischkowski, an Ohio State graduate student and lead author of the research.  “You have to see yourself in this stressful situation as a fly on the wall would see it.”  Mischkowski says the self-distancing approach helped people regulate their angry feelings and also reduced their aggressive thoughts.

Other studies have shown that self-distancing can minimize how angry and aggressive people feel when aggravated, but this research shows that the technique can be learned quickly and can work in the heat of the moment, when people are most likely to act aggressively.

Student participants were provoked to anger in a series of situations, then were assigned to a control group, to visualize the situation again, or to imagine the scene from a distance.  Their levels of aggression were then measured when given the opportunity to retaliate to those who provoked them.

“If you focus too much on how you’re feeling, it usually backfires.  It keeps the aggressive thoughts and feelings active in your mind, which makes it more likely that you’ll act aggressively,” says Brad J. Bushman, a professor of communication and psychology at Ohio State and one of the study’s co-authors.

Another technique sometimes suggested is to use distraction when angered.  Mischkowski says that although this may work in the moment, the anger will return when the person is no longer distracted.  “But self-distancing really works, even right after a provocation.  It is a powerful intervention tool that anyone can use when they’re angry.”  

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, December 17, 2012

Predicting Heart Failure Death in the ER

Ten pieces of information often gathered in the ER may be able to predict the risk of death for people with heart failure within seven days of presentation.

The new tool is called the Emergency Heart Failure Mortality Risk Grade (EHMRG).  To develop the tool lead researcher Douglas Lee, MD, PhD, of the Institute for Clinical Evaluative Sciences in Toronto, and colleagues examined three years’ worth of data from 12,591 heart failure patients in 86 hospitals in Ontario, Canada, from 2004 to 2007.

Within seven days of presentation 2% of the patients had died.  Researchers looked for common links—everything from medications, to lab values and transportation.  After adjustments were made, the 10 factors significantly associated with a greater risk of death in the first week were:

  • Older age
  • Transportation by emergency medical services
  • Lower triage systolic blood pressure
  • Higher triage heart rate
  • Reduced oxygen saturation
  • Higher creatinine
  • Potassium level of 4.6 mmol/L or higher
  • Elevated serum troponin
  • Active cancer
  • Use of metolazone at home
The researchers noted limitations of the study, especially the lack of information about left ventricular ejection fractions and brain natriuretic peptide.  The authors also noted that, “Symptomatic improvement, ability of the patient to seek follow-up care, and social circumstances should also be considered, along with quantification of acute prognosis.”  They indicated that the tool is not for use in patients who have chronic, symptomatically stable heart failure.

Lee is applying for a U.S. patent.

For more details or to read the entire study see the June 5 issue of the Annals of Internal Medicine, Prediction of Heart Failure Mortality in Emergent Care

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, December 10, 2012

Distractions Cut Pain

It is established that distracting mental activities can minimize perception of pain, but how this happens has not been well understood.  A study published in Current Biology online has found that it is related to a spinal process involving opioid neurotransmission.

A study of 20 men with an average age of 27 found that distraction not only takes the focus away from the pain, but can dampen the body’s initial physiological response to pain through endogenous opioids.
Painful levels of heat were administered to the subject while undergoing functional MRIs.  Those doing complex memory tasks were pre-occupied to the extent that they experienced 19% less pain than those doing simpler mental tasks.

“This phenomenon is not just a psychological phenomenon, but an active neuronal mechanism reducing the amount of pain signals ascending from the spinal cord to higher-order brain regions,” said lead author Christian Sprenger, of the University Medical Center Hamburg-Eppendorf in Hamburg, Germany.

Sprenger and his colleagues repeated the experiment with another group of 15 men, average age 25.  This time they administered naloxone to block opioid effect or saline solution.  Perception of pain was 40.5% greater for those with the difficult cognitive task when given the opioid antagonist naloxone. This provided the evidence that endogenous opioids play a role in the distraction phenomenon.

“Our findings strengthen the role of cognitive-behavioral therapeutic approaches in the treatment of pain diseases, as it could be extrapolated that these approaches might also have the potential to alter the underlying neurobiological mechanisms as early as in the spinal cord,” Sprenger and colleagues concluded.  

For more information see the May 17, 2012 online issue of Current Biology.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, December 3, 2012

Therapy by Telephone

Can therapy for depression work when done by telephone?  The short answer is yes.  This type of therapy may be slightly less effective than face-to-face meetings, but patients are less likely to drop out of phone therapy. 

These were the findings of David Mohr and colleagues at the Northwestern University Feinberg School of Medicine published in the Journal of the American Medical Association in June of this year.  Mohr said, “One of the things we’ve found over the years is that it’s very difficult for people with depression to access psychotherapy.”  The authors speculated that reducing time commitments, transportation problems and cost may play a role in the lower drop-out rate for phone therapy.

Around 25% of all primary care visits are with patients who have clinically significant depression, according to the authors.  Cognitive behavioral therapy is an effective treatment for depression, but the drop-out rate is high.

Researchers in the randomized study had 325 people diagnosed with depression undergo 18 weeks of therapy, half by phone and half in person.  The quality of the telephone therapy was calculated to be equivalent to in-person treatment. By the end of the period 53 participants had dropped out of face-to-face therapy compared with 34 in the phone therapy group.

Patients in both groups felt decreased levels of their depression, however six months later patients who met with their therapists in person tended to feel less depressed than those who had phone sessions, but the difference was very small.

“At this point these findings do suggest that psychotherapy for depression can be administered both safely and effectively over the phone. Providers can be comfortable doing that and insurers and payers should feel comfortable” reimbursing for it, Mohr said.  Cognitive behavioral therapy by phone, “can overcome barriers to adhering to face-to-face treatment.” 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, November 26, 2012

Dementia and the Holidays

As fun as the coming holidays can be, they can be packed with hazards for people with dementia. It means caregivers and families need to be especially vigilant about the safety.

Many decorations look like food and may even smell like the real thing.  For instance, a Christmas tree decoration that looks like a gingerbread man may be even scented with gingerbread smell—making doubly appealing to try to eat.  Other small decorations can be choking hazards.  Artificial fruits, vegetables and nuts can look very real.

Candles that smell like pumpkin or apple pie can be a fire hazard if tipped over if a person reaches into it.  Poinsettia leaves, contrary to popular belief, are not poisonous—but they will make a resident nauseated if he or she eats them.

People with dementia need routines—the same activities, in the same place, at the same time.  Families should consider this carefully before deciding to take a loved one home for a holiday.  The excitement, the car ride, change in surroundings and many people talking can cause the confused person with dementia to become agitated or upset.

Here are some tips for family members planning to take a loved one home for a holiday.


  • Plan ahead.  Let the facility staff know several days ahead so they have time to obtain medications and clothes.
  • Allow extra time for everything, don’t rush the person.
  • Try to keep as much as possible to their daily routine.
  • Use ribbon instead of sharp hooks when hanging decorations.
  • Holly and mistletoe can be poisonous and berries pose a choking hazard.
  • Begin new traditions by letting another family be the host but try to go to a place familiar to your loved one.  
  • Assign tasks to other family members so you do not become overloaded and stressed, which in turn causes your loved one to be stressed.
  • Provide a nap before festivities. If you know the day will be long, you may want to attend only the most important part of the event.
  • Plan for a quiet place for your loved one to go to if he or she becomes overwhelmed.
  • Avoid alcohol.
  • Be aware of their diet and diet restrictions. Cut up food into small bites.
  • Let your loved one know who is coming to visit.
  • Have visitors and family call ahead to determine best time to visit.
  • Small groups of visitors or family is advisable. Have them wear name tags as this might help with recognition.
  • Reintroduce yourself as necessary. “Mary, my name is Betty.” And when she asks, “Are you my granddaughter?” say “yes” and shake her hand and act very comfortable about this introduction.
  • If your loved one begins talking about the past, try not to reorient him or tell him he is wrong.  Enter his reality and live his truth.  Ask about the past memory.
  • Reminisce about the past.
  • Play holiday music familiar to your loved one.
  • Read holiday cards aloud.
  • Stuff stockings, watch a holiday video, look at family slides or pictures or albums, read scriptures, etc.
The Kitchen
  • Monitor your loved one while in the kitchen.
  • Give your loved one task to help with baking or decorating. Try baking cookies, making pudding, folding napkins, polishing silver, etc.
  • Always check the microwave before turning on in case something was put in that is flammable.
  • Check all trash cans before throwing out garbage
  • Don’t leave your loved one in the car or in the front of the store.  If you can’t take them in with you, try to arrange for someone to stay with your loved one.
  • Shop during hours when stores are less crowded.
  • Dress your loved one in a bright yellow shirt which is easy to see if you become separated. Be sure they have a purse or wallet with identification.
  • Shop in smaller stores rather than the mall.
  • People with dementia should never travel alone.  Hire a personal care aid to travel if a family member is unable to accompany the resident.
  • Be aware of balconies and other hazards in hotels.
  • Travel may not be appropriate even with a companion if the person has:
  1. Consistent disorientation or agitation in familiar settings
  2. Wanting to go home when away from home on short visits
  3. Delusional, paranoid, aggressive or disinhibited behavior
  4. Problems managing continence
  5. Teary, anxious, withdrawn behavior in crowded, noisy settings
  6. Agitated or wandering behavior
Please visit our website to download additional resources for Caregivers.

Monday, November 19, 2012

Respect Counts More Than Money

Happiness in life may be related more to how much you are respected than how much money you have.

An article published in June in Psychological Science reports that in a series of four studies they tested the hypothesis that higher sociometric status might make a difference in overall happiness.  Sociometric status might be defined as respect and admiration in face-to-face groups such as among friends, in the neighborhood, or on an athletic team.

“We got interested in this idea because there is abundant evidence that higher socioeconomic status—higher income or wealth, higher education—does not boost subjective well-being (or happiness) much at all. Yet at the same time, many theories suggest that higher status should boost happiness,” said psychological scientist Cameron Anderson of the Haas School of Business at UC Berkeley.

“Having high standing in your local ladder leads to receiving more respect, having more influence, and being more integrated into the group’s social fabric,” said Anderson.

One possible explanation for the results is that people adapt. “One of the reasons why money doesn’t buy happiness is that people quickly adapt to the new level of income or wealth. Lottery winners, for example, are initially happy but then return to their original level of happiness quickly,” said Anderson.

Adaptation of this sort may not occur with local status. “It’s possible that being respected, having influence, and being socially integrated just never gets old,” Anderson said.

For more details visit and use the search word “respect.” 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, November 12, 2012

Patients Hesitate to Disagree

Patients don’t want to disagree with their doctors, even though they would like a say in treatment decisions, according to a survey published in the Archives of Internal Medicine, July 9, 2012.

When asked, more than 9 out of 10 people said they could visualize asking questions and discussing preferences with their doctors, and 80% said they had the ability to disagree.  But when it came down to it, only 14% of patients reported that they would actually challenge their doctor if he or she recommended a treatment that conflicted with their preferences.

Nearly half of those unwilling to disagree feared being labeled as “difficult”; 40% worried such actions would damage their relationship with the physician; and more than half thought disagreeing with their doctor might negatively affect their care.

The online research involved 1,340 adults who were told to imagine that they had heart disease.  They were then asked the extent to which they would like to be involved in their treatment decisions.  The treatments might include options such as medications, bypass surgery or angioplasty—which have similar long-term outcomes, said Dominick Frosch, from the Palo Alto Medical Foundation Research Institute and the University of California, Los Angeles.

Nearly 70% of the survey participants said they preferred making medical decisions together with their doctor, each contributing equally to decisions about treatment.

“We know when patients are surveyed directly they really want to participate in their medical decisions, but are very nervous about this idea of pushing back against doctor recommendations for fear of being labeled a ‘bad patient,’” said Dr. Michael Barry, president of the Informed Medical Decisions Foundation and a primary care doctor at Massachusetts General Hospital in Boston. 

Barry did not participate in the research but his foundation financed it. “I think getting over that culture—that there’s a right answer based as a clinician on your preferences—is what we’re facing. Clinicians are the experts in the options and the outcomes of the options, but patients are experts in what’s best for them.”

Despite current focus on patient-centered care, the authors found that these fears prevent shared decision making.  They noted that poor communication itself can cause inferior outcomes.   A study published in July, 2012 in the journal Perspectives on Psychological Science reinforced this with findings that patients’ feelings of autonomy, competence and relatedness were associated with better mental and physical health.

Frosch cited patients who won’t take their hypertension medication because they didn’t want it in the first place as an example of miscommunication that can lead to worse outcomes.  Frosch said that when it comes to doctors they need to “create a safe space for patients to be able to speak up and express their preferences.” 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Tuesday, November 6, 2012

Hospice Impacts Spouses' Survival: Live Longer

Using hospice not only benefits patients, there is some evidence that it may help surviving widows and widowers live longer.

Some time ago researchers at Harvard Medical School and the University of Pennsylvania Department of Medicine examined death rates of surviving spouses of 195,553 elderly American couples.  The premise was that the 30,838 people who used hospice had “good deaths” that were less stressful for their spouses and would result in living longer.

The results of the matched retrospective cohort study suggest that the supportive end-of-life care provided by hospice has a beneficial impact on spouses.  “Hospice may attenuate the ordinarily increased mortality associated with becoming widowed,” concluded authors Nicholas Christakis and Theodore Iwashyna.  The results were statistically significant in both men and women.

After adjusting for variables, 5.4% of bereaved women died by 18 months after the death of their husbands when hospice was not used compared with 4.9% when hospice had been used.  Of the surviving husbands, 13.7% died within 18 months when their wives had not had hospice care compared with 13.2% when their wives died with hospice.

The support of hospice care appears to not only improve quality of life for patients, but reduces the stress on survivors to the extent that they live longer.   

For more information see Social Science & Medicine, 2003, vol. 57, issue 3, pages 465-475.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, October 29, 2012

Morphine Labeling

New Look

For many years now the most common concentration of oral morphine solution used in hospice has been 20 mg per mL.   Although the concentration is exactly the same, you may begin seeing different labeling.  It may now read 100 mg per 5 mL.

The Food and Drug Administration worked with Roxane, the largest manufacturer of oral morphine solution to change the labeling and the look of the product to reduce the possibility of errors.  The intent of this labeling is to help differentiate this product from another product with a concentration of 20 mg per 5 mL.

The volume of liquid is unchanged:

  • 5 mg = 0.25 mL
  • 10 mg = 0.5 mL
  • 20 mg = 1 mL
Although the label prominently says 100 mg per 5 mL, you will also see (in smaller letters) 20 mg per mL. 

The new labeling may mean a little change in our mathematics, but remember that the concentration has not changed. 

If you have any questions about the concentration or labeling, call Pathways (1.888.755.7855) and we will be glad to double check your calculations with you. 

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, October 22, 2012

ALS: Amyotrophic Lateral Sclerosis

What is ALS?

Often called “Lou Gehrig’s Disease,” ALS is a degenerative disease of the nerve cells in the spine and brain.  As the neurons that connect the brain to muscles begin to die, the brain can no longer control muscle movement.  In later stages the patient may be totally paralyzed; for most, their minds are not affected.   

  • About 5,600 cases are diagnosed annually; 60% are men, 93% are Caucasian
  • Most people are between 40 and 70 years old
Early Symptoms

ALS may start with simple muscle stiffness and can differ a lot from one person to the next.  But 60% begin with muscle weakness.  A person may trip over carpet edges, have trouble lifting, or have slurred speech. They may drop things, have abnormally tired arms and legs, or even uncontrollable crying or laughing.

Later Symptoms

The rate of progression can vary, with an average survival time of 3 to 5 years, but many live 5, 10 or more years.  In a small number of people, ALS stops.  Later symptoms are:

  • Muscle weakness in hands, arms, legs or muscles for speech
  • Twitching and muscle cramping, especially in hands and feet
  • “Thick” speech and difficulty speaking loudly
  • Difficulty breathing and swallowing
End Stage ALS

Changes that may mean the death is nearing include a sense of breathlessness or the onset of a lower level of consciousness.   As respirations fail, the resident becomes less and less aware, then unconscious.   Nearly 60% of people with ALS have a sudden rapid decline and die within 24 hours.  Death also seems to happen most often at night when breathing naturally becomes slower and more shallow. 

Pain in ALS

Pain is common in later stages, probably from stiff joints, muscle cramps, or pressure on the skin and joints from immobility.  A combination of anti-inflammatory, anti-spastic and non-narcotic pain relievers may work until later stages when morphine often achieves the best pain relief.

Treating the Whole Person

Since the awareness and thinking usually remain intact, every effort should be made to continue communicating with the resident, even when he or she is too weak to speak.  This may mean using a communication board.

Knowing that death is near can lead an individual to seek resolution of “unfinished business.”  Hospice chaplains can provide spiritual support for the resident and reassure him that his family will have ongoing bereavement support.  Volunteers may supplement visits from family members.   Together we can support all the resident’s needs through the rest of his life.  Families will remember the end-of-life care you give for the rest of their lives.

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, October 15, 2012

Cutting Down on Antipsychotics


CMS, the Centers for Medicare & Medicaid, announced in May that they are embarking on a multi-year initiative to cut the use of antipsychotic drugs in skilled nursing facilities by 15% by the end of this year. CMS cited statistics showing that nearly 40% of residents with dementia were getting antipsychotics even though they did not have a diagnosis supporting their use.

Other statistics from CMS indicate that in 2010 more than 17% of SNF residents received antipsychotic doses that were over the recommended levels.

“In 2013 we will set another goal,’’ said Alice Bonner, director of the nursing home division of CMS. “At that point, we will be looking at even more significant reductions.’’

CMS plans to achieve the cuts through training state inspectors and nursing home staff on alternatives to using antipsychotics for agitation and aggressive behaviors.  Participation in the reduction program is voluntary, but SNF trade groups pledged to work with CMS.

“We believe these antipsychotics are overprescribed,’’ said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, a SNF trade group. “Many clinicians, physicians, and family members believe these medications are useful and necessary, but data show otherwise.’’

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, October 8, 2012

Sundown Syndrome

Sun Sets, Confusion Rises

Sundowning is the term that refers to increased confusion and disorientation in the late afternoon and early evening.  As many as 20% of people with dementia experience sundown syndrome. 

This behavior usually is at its most severe during the middle stages of Alzheimer’s, becoming less as the disease progresses.  Some studies show that sundowning is associated with faster decline in the ability to think and with faster disease progression.

People who have sundown syndrome may have mood swings and may be suspicious, agitated, yelling, lashing out at caregivers, pacing more, and have tremors.  They may have difficulty sleeping, and wander more and “want to go home” as light fades and shadows appear.  They may also be aware of their own confusion which can frustrate them more.


Although the causes of sundown syndrome are not proven, many experts believe that in Alzheimer’s the changes to the brain affect the part that regulates our bodies’ rhythms of sleep and wakefulness—the cluster of nerve cells that keeps the body on a 24-hour clock. Other possible causes include:

  • Mental and physical fatigue, making the resident less able to cope with stress
  • Low lighting, increased shadows
  • Discomfort due to pain, urinary tract infection, fecal impaction, etc.
  • Medications
  • Hunger
  • Noisy sleeping environment
  • Lack of organized evening activities
  • Too much sleep during the day
  • Change of shift activity with many people coming and going

This is especially the time to apply basic techniques for dealing with people who have dementia:
  • Reassure the resident in a calm way; tell them they will be all right and that they are in a safe place.
  • Don’t argue with the resident or ask why they are confused.
  • Try to find out if they have a need; are they cold, hungry, wet, in pain?
  • Remove the resident to a calmer place, such as outside or his room—somewhere with fewer people and noises.
  • Change caregivers if there is a chance that this is upsetting the resident.
  • Reminisce with the resident about bedtime activities they followed with their children when they were young parents.
Consider alternative techniques such as: aromatherapy, a pet, calming sounds (bubbling brook, birds, wind in the trees), soothing food or warm milk, singing a favorite song or hymn, reading a familiar poem or children’s book, gently brushing hair, putting on a favorite movie, or massaging shoulders (only with the resident’s permission and in a common area). 


Preventing problems is the best form of managing them.  These suggestions won’t work for every person, but persistence pays off if you keep trying:
  • Maintain a consistent sleep schedule and daily routines; limit daytime sleep to short naps.
  • Increase activity during the day including some physical activity such as walking or dancing.
  • Monitor diet; avoid caffeine, or serve only in the morning.  Offer a light, bedtime snack.
  • Let residents choose where they are most comfortable sleeping. 
  • Consider the use of melatonin to promote sleep.
  • Keep a dim light on at night and the room uncluttered.
  • Have the resident occupied during shift change if this seems related to the sundowning.
  • If sundowning occurs at a certain time every evening, plan for it.  Have the resident involved in an activity during this time.
Seek medical advice if other measures don’t work.  There may be medical conditions contributing to the sundowning.  The physician can also review the resident’s medications to check for drugs that can be eliminated.

Always keep in mind that this behavior is not done on purpose—the resident may be as baffled by it as you are.  But good planning can help prevent and manage sundown syndrome.

References: Mayo Clinic online; Web MD; Alzheimer’s Association, Care & Compliance Group.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, October 1, 2012

A Twist on Cultural Diversity

In the Bay Area, where diversity is the norm, caregivers often represent cultures from all over the world, while the residents they care for may be mostly white, Anglo-Americans whose only language is English.  Perhaps a look at Anglo-American culture will reveal ways to improve interactions between caregivers and residents.

In an ideal world, two people trying to communicate would each reach out to understand the other’s culture.  Realistically, residents may not be capable of learning about the caregiver’s culture to meet the caregiver halfway.  It defaults to the caregiver to bridge the gap.


Although no statement about someone in a particular culture holds true for all members of that culture, we can make useful generalizations that steer us in the right direction.  For example, Anglo-Americans tend to be:

  • Time oriented and more rigid about times: 10:45 means exactly 10:45.
  • Direct, with less socializing before getting down to business.
  • Less formal, speaking and acting casually.
  • In general, Anglo-Americans want to be pain-free and may not be as stoic as some other cultures.  They may ask for pain medication where a person from another culture might “tough it out.” 
Comfort zones

Anglo-Americans may be more open about discussing personal matters, illness, and dying than others. 

If a resident wants to talk about a subject that makes you uncomfortable, you may want to find someone else who might be able to interact with him more directly—perhaps someone from social services, a chaplain, or another caregiver.

Researchers have demonstrated that Anglo-Americans generally require a larger personal space around them—in other words, they don’t stand as close when talking as people of other cultures do.*  For instance, they may become uncomfortable and step back if they feel another person is standing too close.


Anglo-Americans as a whole tend to be more individually oriented and like control. They leave less to fate and want to direct their own lives. American law requiring informed consent is based on the principle of autonomy—freedom of choice for the individual.  In other cultures the family or physician may make decisions for a patient, whereas in the US the individual is considered more important to decision-making than the family. 

Many Anglo-Americans see themselves as having a pioneer spirit and prefer not to be dependent on their children for care or support, while in other cultures it is expected that older people will live with their adult children. 

Best practices

Whenever cultures differ there is plenty of room for misunderstandings.  Usually neither is right or wrong—just different.  The best practice for communicating smoothly is to ASK.  Ask family members or the resident about how things are done in their family.   People are usually grateful that you are asking and appreciate that you are trying to learn about how they like to do things.

*The New York Times, “In Certain Circles, Two Is a Crowd,” Nov. 16, 2006.

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, September 24, 2012

Managing Stress

Set Worries Down

The instructor of a stress management class walked into the room holding out a half glass of water. Everyone in the class thought they knew what was coming: “Is the glass half full or half empty?”

But the instructor surprised the students by asking with a smile, “How heavy do you think this glass of water is?”  People called out answers ranging from 6 ounces to 20 ounces.

The teacher replied, “It changes.  It depends on how long I hold it—the absolute weight doesn’t matter.  If I hold it a minute, it is light.  If I hold it an hour, it is heavy and I will have an ache in my arm.  If I hold it for a day, it will be too heavy to lift and I will drop it. 

“It seems the longer I hold it, the heavier it becomes.  If, however, I set it down when it feels heavy and rest a while, I have the strength to hold it again.

“It is the same way with stress,” she said.  “If we carry our burdens all the time, sooner or later, the burden becomes too heavy and we won’t be able to carry on.

“Just like with the glass of water, you have to put down your burdens for a while and rest before shouldering them again.  When you are refreshed, you will be able to take up the burden, stronger again.”

So, put aside your burdens whenever you can; they will still be there after you have rested and you will be able to carry on as strong as ever.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, September 17, 2012

Old Person Smell

Is there really such a thing as “old people smell,” or is it in your imagination when you visit seniors who look right at home among their antiques?  A recent study says young people really can identify such a smell, and old men smell the best.


Just how do you go about proving this?  Johan Lundström and his colleagues at the Monell Chemical Sense Center in Philadelphia collected the underarm scents of people in three age groups: 20-30 years old, 45-55 years old and people 75-95 years old.  Then they had other young people (ages 20-30) sniff the armpit pads.

Collecting Scents

The researchers had the participants wear the same T-shirt to bed for five nights.  The shirts and sheets had been washed with scent-free detergent and the participants washed with scent-free soap every night.  They also agreed not to smoke, drink alcohol or eat foods that are known to cause body odors. Special pads were sewn into the underarms of the T-shirts to collect their body’s scent.


The people doing the sniffing rated the pads on pleasantness and intensity and had to guess which of two odors came from older participants.  Then they were instructed to label all of the armpit pads by age category. 

Although they had trouble distinguishing between the young and middle aged people’s pads, they were able to correctly determine which came from old people more often than would be randomly expected.  Evaluators used words such as “earthy” and “mild, like stale water” to describe the odors of older people.

“These elderly odors were very distinct and easy to group together,” says Lundström.  The study found that the armpit pads from old men were rated the most pleasant, especially compared with middle-aged men, although the odors from old women were rated behind those of middle-aged women.

Lundström and his colleagues concluded that if you associate the scent of old people with something negative, it is likely to have more to do with context than the actual odor.

The study was reported online May 30, 2012 in PLoS ONE.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, September 10, 2012

Romance Reduces Pain

New Love

The dizzy stage of early romantic love seems to reduce the sensation of physical pain.  So say the results of research at Stanford University School of Medicine.  The participants reported significantly lower levels of pain when looking at pictures of their beloved than when viewing photos of friends.

“Love engages very deep primitive reward systems that directly impact on our overall experience of pain,” says researcher Sean Mackey, whose team looked at the effects of romantic feelings on pain.

Fifteen students, aged 19-21, who were in the first nine months of a romantic relationship and described themselves as “intensely in love” were recruited for the experiment.  They were instructed to bring a photo of their sweetheart as well as one of a good-looking acquaintance of the same sex as the sweetheart.

While sitting in an MRI scanner to record their brain activity, the students held a block whose temperature could be controlled to cause high, moderate or no pain.  Their pain ratings were noted while focusing on the picture of their loved one, the acquaintance, and a word-puzzle distraction.

Both the photos of romantic partners and the distraction puzzle reduced pain by nearly identical amounts.  But the students had significantly less pain relief when looking at the photos of the attractive acquaintance.

Although the sweetheart photos and word puzzles both provided relief, they worked in different parts of the brain.  The part of the brain activated by love was the brain’s reward center which is also activated by chocolate and drugs like cocaine.

It turns out that the writers of all those romantic songs and poems were right—love truly is a powerful thing.

This article was originally published in Pathways & Partners - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, September 3, 2012

Benefits of Dogs

Healthier Living

Most people know that people who own dogs live longer, have lower blood pressure, less anxiety and better immune systems.  They also have more social interactions, Alzheimer’s patients with dogs in the home have fewer outbursts and men with dogs have lower triglycerides and cholesterol.  These are the scientific conclusions of research about family pets that can be easily found. 

But there are even more benefits and some of them are pretty astounding.  Dogs are being trained to assist in the medical field.  For instance, dogs can be trained to sniff out low blood sugar in diabetics, picking up odors beyond human capacity.  Dogs can also be taught to prod the diabetic with a cold nose, fetch a blood glucose testing equipment or press a phone button that calls 911.

It could be scent or it could be a subtle change in behavior, but some dogs are able to sense a seizure coming on as much as 30 minutes before it occurs.  This means the dog may be able to alert the person, go for help, move objects out of the way and lay down next the person during the seizure.

More and more people with post traumatic stress disorders, such as soldiers returning from war zones, are benefiting from dogs as companions because they can they can ease anxiety in a number of ways.

Dogs also have the remarkable ability to detect certain kinds of cancers.  One example is being able to reveal the presence of bladder or prostate cancer cells in urine.  Some researchers have shown that dogs can recognize lung and breast cancers by smelling the patient’s breath, and they can spot melanoma by licking a person’s skin.

A dog’s brain may be only one tenth the size of a human’s, but his nose more than makes up for it: dogs have 40 times as many scent receptors as humans.  It is truer than ever that dogs really are man’s best friend. 

References: My Health News Daily; Web MD.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Wednesday, August 29, 2012

One from the Heart Awards Breakfast #OFTH

If you only attend one event this fall,
it should definitely be One from the Heart!

Be a part of Pathways’ compassionate and caring mission. This inspirational breakfast has become a “must attend” for nearly 650 friends and supporters of Pathways, corporate and community leaders, and medical professionals. One from the Heart annually honors individuals and organizations that have made an enduring contribution to Pathways and end-of-life care.

Over the past twenty-one years, the One from the Heart Awards Breakfasts have raised over $4 million for Pathways to ensure extraordinary hospice and home health care for the Bay Area.

One from the Heart Awards Breakfast
Friday, October 5, 2012, 7:30 to 9:30 am
Crowne Plaza Cabana Hotel, Palo Alto

Tables and individual seats available.

For more information about the One from the Heart Awards Breakfast or other events, contact Holly Smith, Event & Sponsorship Manager, 408.730.1200 or or visit

Join the conversation:
on Twitter using #OFTH
on our Facebook event page
on our Linked event page

Learn more about our featured speaker, Jon Katz:

Monday, August 27, 2012

Documenting and Billing for Care Plan Oversight

Home Health & Hospice

There is one service that is not face-to-face that physicians can be reimbursed for by Medicare—care plan oversight (CPO) of patients receiving home health or hospice.  Because the rules are complicated, many physicians simply don’t bill for this service.  Here we’ll try to break it down.  
To bill, CPO services must take at least 30 minutes in a calendar month. The services do not need to be provided on the same day, but the total services over the course of a month must add up to at least half an hour.  Medicare uses two HCPCS codes to pay for CPO:  G0181 is for home health, and G0182 is for hospice. 

  • Reviewing charts, reports and treatment plans
  • Reviewing diagnostic studies that weren’t associated with a face-to-face encounter
  • Phone calls with other health care professionals involved in the patient’s care who are not employees of the practice
  • Conducting team conferences
  • Discussing drug treatment and interactions (not routine prescription renewals) with a pharmacist
  • Coordinating care if physician or non-physician practitioner time is required
  • Making and implementing changes to the treatment plan
  • Renewing prescriptions
  • Talking with fellow employees at the practice
  • Travel time
  • Preparing or submitting claims
  • Talking to the patient’s family, even if discussing treatment plan changes
  • Holding informal consults with physicians who are not treating the patient
  • Working on discharge services
  • Interpreting test results at an E/M visit
  • Keep a log of the patients you provide CPO to; use this as a reminder to pull those charts at the end of the month. 
  • Keep a simple CPO log in each of these charts and document the date, total time and a brief description of the services as you provide.  Sign this documentation.
  • At month end gather the logs, total the time and bill for those for whom you provided at least 30 minutes of CPO.  Put the beginning and end dates of the month as the dates of service and be sure to put the provider number of the home health agency or hospice on the claim form.
For more information or questions, or to receive written materials about billing for care plan oversight, call Kaye Holbrook at 408.773.4359 or email your request to

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, August 20, 2012

Communicating with Residents

Be Heard Better

They are just little things, but they make a difference in reducing frustration for you and your residents.  We’re talking about techniques you can use every day to make communication smoother and more satisfying.

First let’s look at body position.  Standing over a resident who is sitting or in bed may feel threatening, especially if you are very close.  Research has shown that patients thought that their doctors stayed longer at the bedside than they actually did when the doctor sat down.  So try sitting down to appear less hurried. 

When people have hearing problems, as many older adults do, it is important to face the person directly and have your face at their eye level.  The shapes our lips make when speaking and expressions give residents a lot of clues to what we are saying.  It should go without saying that we should make sure hearing aides are in place, are turned on, and have fresh batteries.

Next we should speak slowly and clearly, enunciating our words precisely—slow down.  Older ears need more time to decipher what you are saying.  If you also have an accent, slowing down your speech will help older, hard-of-hearing adults understand you better.  It also helps to use gestures to supplement what you are saying.  For example, if you want the resident to sit in a chair, pat the chair or sit down to demonstrate what you would like.

By paying attention to the little details in our communications with the elderly, we can make the interchange more satisfactory for them and us!

This article was originally published in Pathways & Partners Newsletter - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, August 13, 2012

Heart Failure & Hospice

Patients with congestive heart failure who elect hospice live longer than those who don’t.  These were the findings of a defining 2007 study published in the Journal of Pain and Symptom Management.  Other diagnoses also experience longer prognosis with hospice, but none longer than the 81 day extension of life in heart failure.

Many factors probably contribute to the increased longevity.  Hospice care increases monitoring in the home and gives psychological, emotional and spiritual support from friendly visitors.  This holistic attention may increase the desire to live and reduce the sense of being a burden to one’s family.

Skipping the ER

Heart failure is the diagnosis most commonly associated with hospitalization.  By some estimates, patients with heart failure are readmitted at a rate of nearly 50% within six months.  For some patients, knowing that they have 24-hour access to nursing advice and visits for management of symptoms gives them a welcome alternative to the emergency room. 

Who is Appropriate?

Medicare guidelines include:
  • Patient is optimally treated with vasodilators or unable to tolerate them.
  • Patients with conditions usually treated with surgery are either ineligible or decline it.
  • Patient is Class IV on the New York Heart Association scale: unable to do any physical activity without discomfort and symptoms may be present at rest.
  • If ejection fraction is available, 20% or less is appropriate for hospice.
  • Co-morbidities play a large role in estimating prognosis.  The following co-morbidities support a prognosis of 6 months or less in conjunction with the conditions listed above:
  • Symptomatic arrhythmias resistant to treatment
  • History of cardiac arrest, resuscitation or unexplained syncope
  • Brain embolism of cardiac origin
  • Concomitant HIV disease
The extra time that hospice can give patients may be especially important to patients and families trying to find resolution and peace at the end of life.  

Questions to Ask Patients
  • Do you have discomfort when physically active? or Does physical activity give you more discomfort?
  • Do you get short of breath when you are lying down?
  • Do you ever wake up at night feeling short of breath?
  • When you are resting in a chair do you ever feel short of breath, perspire or have chest pain?
  • Do you have any swelling?
  • Do you need help with activities like dressing, bathing, walking or eating?
Supporting Documentation
  • Cyanosis
  • Rales
  • Dusky nail beds
  • Tachycardia or bradycardia
  • Hyper- or hypotension
  • Jugular venous distension
  • Liver enlargement
  • Cachexia
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Decreased ejection fraction
  • Weight gain due to fluid retention

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, August 6, 2012

Power of Music

Music is a powerful force that can stimulate strong emotions within us.  Harnessing that power can benefit the seriously ill by improving their quality of life.  In a 3-year study Sandi Curtis, a music therapy professor at Concordia University in Montreal, Canada, divided university music therapy students and musicians in to pairs working with 371 participating terminally ill patients from 18 to 101 years old.  Participants were seen for a single music therapy sessions from 15 to 60 minutes long with the goal of enhancing pain relief, relaxation, mood and quality of life.

“Our study showed how music therapy was effective in enhancing pain relief, comfort, relaxation, mood, confidence, resilience, life quality and well-being in patients,” said Curtis.  The study was published in the journal Music and Medicine.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, July 30, 2012

Walker Safety

Walkers are valuable tools that promote mobility.  They can help when a resident has poor balance (like after some strokes) or is weak.  But incorrect use can have disastrous results.  Here are some simple guidelines for helping residents use their walkers safely.

Right Walker

First, make sure the resident has the right walker.  There should be rubber hand grips and non-skid rubber tips or wheels on the legs.  A lightweight walker allows the resident to easily lift it over bumps or stairs.  Some have wheels on the front legs if the resident has trouble lifting the walker while walking.  Sturdy wheels are a must.  Other options are hand brakes, baskets for carrying and legs that are adjustable to varying heights. If the resident has a tendency to tip backwards, the height of the walker can be adjusted down slightly to redistribute his weight.

Starting Out

When getting up from a chair, put the walker directly in front of the chair.  Then have the resident slide forward in the chair, keeping the feet directly under him.  Then have the resident use the arms of the chair to slowly stand.  The resident should grasp the walker handles firmly and move forward into the center of the walker.  When walking, watch the resident to be sure he does not put the walker too far ahead of this body.


When the resident is ready to sit down, have him back up to the chair such that he can feel the chair on the back of his legs.  If one leg is weaker than the other, have the resident put his weight on the stronger leg.  The resident should keep one hand on the walker while the other reaches for the arm of the chair.  When he has a firm grasp, he should move the other arm to the chair, then lower himself down.

Remember, to be safe using a walker:
  • the resident must take small steps
  • he should never tilt or pull on the walker when getting up from a sitting position
  • chairs should have armrests
  • walkers should be examined routinely to be sure wheels and tips are secure and not worn down. 
This article was originally published in Pathways Residential Care Journal - Issue 3.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, July 23, 2012

Advance Health Care Directives

A Gift to Families

An advance health care directive tells your family and doctor what you want done if you can’t make decisions for yourself.  Your family and doctor don’t have to guess what you would have wanted.  What would be the highest priority?  It might be to be pain free, or to not be on a ventilator, or to have everything done to keep you alive as long as possible.  This isn’t just for older people, all adults should make one.  After all, young people can be injured in accidents that leave them unable to speak.

Three Parts

An advance health care directive has three parts.  In the first part you name a person to be your agent (and alternates in case the agent is not available).  The agent can legally make health care decisions for you and is called a Durable Power of Attorney for Health Care.  In the second part, you state in detail the treatments you would want, or would not want, and under what circumstances—things like feeding tubes, ventilators and what to do if your heart and breathing stop.  In the third part you can say if you want to be an organ or tissue donor.

Choosing an Agent

The person you choose as an agent must be 18 years old, and someone who knows you well and who will honor your wishes, even if they are different from yours.  A husband or wife is not automatically recognized as a patient’s spokesperson in California.  The agent may be a family member, a friend, or even an attorney, but caregivers in a facility cannot be agents for residents.  Agents may choose a doctor, hospital, skilled facility or hospice for you.  The agent may also accept or refuse treatments on your behalf, and consent to organ donation.

Making it Legal

An advance health care directive does not need to be prepared by an attorney, but it must be signed and dated in front of two witnesses (who are not the agent or alternate) or it can be notarized.   There is no official, standard form.  One web site where you can get advance directives in several languages is

When complete, you should make sure your doctor, loved ones and agent all have copies.  The original should be kept in a safe place and a copy should go with you to the hospital.  Experts recommend that an advance directive be updated at least every 10 years, in the event of a divorce, or if the agent is unable to act.  The directive is valid forever unless you revoke it or state in the directive the date on which you want it to expire.

This article was originally published in Pathways Residential Care Journal - Issue 3.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, July 16, 2012

Do Your Patients Get Enough Sleep?

Many Don't

Nearly 41 million American workers—that’s 30% of the labor force—get 6 hours of sleep or less each night, according to the CDC.  They are putting themselves and those around them at risk. 

This data is from the National Health Interview Survey done in 2010 and was published in the April 27, 2012 issue of CDC’s Morbidity and Mortality Weekly Report.

“Not surprisingly, workers who work the night shift are more likely to not get enough sleep,” said Dr. Sara Luckhaupt, lead author.  Others include people with more than one job or working more than 40 hours a week; widows and divorced people; those with a high school education; and African-Americans.

Short sleep duration is linked to:
  • Car accidents (CDC estimates 20% of crashes)
  • Weight gain
  • Heart attack, stroke, falls
  • Depression, substance abuse, irritability
  • Poor attention, work absenteeism
Nearly 70% of those working night shifts in transportation and warehousing are sleep-deprived, the study said.  Although inadequate sleep was most common to workers on night (44%) and rotating (32%) shifts, 29% of people who regularly work day shift averaged 6 hours or less.  Working nights and sleeping during the day, in particular, disrupts the natural sleep cycle, called circadian rhythm, Luckhaupt said.

The National Sleep Foundation recommends 7-9 hours of sleep nightly for healthy adults.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Monday, July 9, 2012

Reasons to Get Online & On Your Feet

Agile Minds

We have known that mental activity staves off cognitive impairment, and the same is known about exercise.  But is it even more effective if seniors do both?  It looks like the answer is yes.

Research involving seniors ages 70 to 93 demonstrated that any amount of moderate exercise in conjunction with using a computer during the previous year resulted in a 64% less likelihood of mild cognitive impairment compared with those who reported neither activity.

According to lead researcher, Yonas Ged, MD, of the Mayo Clinic in Scottsdale, AZ, there was a significant additive effect when both exercise and the computer were employed.  Geda and colleagues examined data from the Mayo Clinic Study of Aging, an ongoing population-based study of individuals living in Olmsted County, Minn. The analysis included 926 men and women who did not have dementia.  The researchers controlled for age, sex, education, medical co-morbidity, and depression.

Among seniors who had normal cognition, 36% reported getting any moderate exercise and using a computer in the previous year.  Among those with mild cognitive impairment, only 18.3% reported both exercise and computer use.

The study was reported in the May, 2012 issue of Mayo Clinic Proceedings and was supported by grants from the NIH and numerous foundations.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at

Tuesday, July 3, 2012

Acupuncture for COPD

It's Effective

Dyspnea during exercise can be debilitating.  This fact coupled with earlier findings that acupuncture has been shown to reduce dyspnea in cancer patients led a team of Japanese scientists to explore whether it would also help people with COPD.  They found that, in fact, it does help.

Researchers at Kyoto University conducted a randomized study of 68 patients who were taking standard medications for COPD in various stages.  They were randomly assigned to have actual acupuncture or a placebo treatment in which needles did not penetrate the skin.  Patients received treatment once a week for 12 weeks.

Results showed a statistically significant improvement in dyspnea ratings.  As their dyspnea subsided, patients also demonstrated in tests that they were able to tolerate exercise better and increase the distances they were able to walk.

The study was led by Masao Suzuki, PhD, and published in the Archives of Internal Medicine.

More information is available at: Suzuki M, et al “A randomized, placebo-controlled trial of acupuncture in patients with chronic obstructive pulmonary disease (COPD): the COPD-acupuncture trial (CAT)” Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.1233.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at