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 www.pathwayshealth.org/publications.

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 www.pathwayshealth.org/publications.

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 www.pathwayshealth.org/publications.

Managing Agitation in People with Dementia

Agitation in dementia has many possible causes.  It can be a result of degeneration of the nervous system which may lessen a person’s ability to cope.  Another huge factor is that the resident is unable to communicate a need.

Six Triggers
Researchers have identified six main causes of agitation in dementia.  As caregivers, it is our job to do the detective work to find out what the cause might be.  We need to imagine ourselves in his or her shoes to help figure out the trigger.  If at first you don’t succeed…be persistent, keep digging!  And always consider a combination of factors.

Fatigue: Most of us tend to be more irritable when tired and people with dementia are no exception.  Did the resident get enough sleep last night?  Has he had more activity than usual today?  You can ask, “Would you like to rest now?” 

Change: People with dementia usually like routine—everything done the same way, at the same time, every day.  What’s different today?  Think of anything new: maybe a new caregiver, clothes, holiday decorations or a change in lunch time or bath time.

Perception of loss: If the resident is reliving a loss such as the death of a loved one, empathy followed by distraction may work to divert the person’s attention.  If the loss is the perception that something has been taken, help the resident to look for it.  If the loss centers around money, it may help the resident if the family will bring in some loose change to keep in the resident’s pocket so he can be reassured that he has his money or his wallet.

Stimulus levels: Consider the environment.  What is going on around the resident?  Some people react negatively when there is too much noise, too many people or too much activity.  Others may tolerate this normally, but react badly when they are more tired.  This might be a time to walk the resident to a quiet area or his or her room where they have a chance to feel calmer.

Is it possible the resident is under-stimulated?  Could he be bored or restless?   Perhaps he or she needs physical activity such as a walk outside.  Could she be lonely?  You can ask family members to make a video of themselves doing routine activities for the resident to watch when she misses them.

Excessive demands: With dementia comes the loss of the ability to process multiple thoughts at one time.  People with dementia can’t multi-task or multi-think.  So we need to be careful in our communications that we only make one brief request of them at a time.  Saying “Brush your teeth, then you can get into your pajamas and ready for bed” may simply be too many concepts.  You may be more successful breaking it into bite-sized chunks: “Now it’s time to brush your teeth.”  When that is accomplished: “Now it’s time to put on your pajamas.”

Physical stressors: Rule out pain: it could be a headache, a pebble in the shoe, a stomach ache, a urinary tract infection or clothes that are too tight.  Look for signs of injury: red spots or bruises, limping, a bump on the head or holding a body part.  Look for signs of infections such as a rash, redness, runny nose or strong smelling urine.  Could the resident feel cold or hot and unable to tell you?  Is he or she uncomfortable due to wet briefs?

Communication

One of the greatest frustrations of having dementia is not being able to clearly communicate your wants and needs.  But we can do a lot to facilitate better communication.  First we need to make sure the resident is ready to communicate: are his glasses clean?  Is her hearing aide in, turned on and does it have a good battery?

Now the resident may be ready to communicate, but are YOU?  You should identify yourself every day, sometimes more than once a day.  Don’t assume the resident will remember you just because he knew you last week. 

Key Principles

It is essential that you know what the person’s limitations are.  If he or she has had a stroke it is important to know what parts of speech and thinking were affected.  Sometimes a stroke leaves the person unable to understand speech, other times he understands but cannot get the right words out.

Remember that agitation is a symptom that means something else is wrong.  It is the job of caregivers to figure out what the real cause is.  So when the resident is agitated, put on your detective hat and see if you can’t solve the mystery at the bottom of the behavior.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Need More Friends? Maybe Not

“Friending” current and former patients on Facebook is probably not a good idea; in fact it’s not a good idea at all.  This is the advice the British Medical Association is handing out to physicians.

In the BMA’s social media guide they state that “because of the power imbalance that can exist in any doctor-patient relationship,” it’s important to establish a professional boundary. They state that it can be difficult to maintain those boundaries with all the personal information available on Facebook.

The BMA suggests physicians politely decline friend requests.  They write:

“Given the greater accessibility of personal information, entering into informal relationships with patients on sites like Facebook can increase the likelihood of inappropriate boundary transgressions, particularly where previously there existed only a professional relationship between a doctor and patient.

“Difficult ethical issues can arise if, for example, doctors become party to information about their patients that is not disclosed as part of a clinical consultation. The BMA recommends that doctors and medical students who receive friend requests from current or former patients should politely refuse and explain to the patient the reasons why it would be inappropriate for them to accept the request.”

For instance, what if you were to see a picture posted of your patient in a bar drinking a beer.  You know that with his medical condition he should strictly avoid alcohol.  Do you bring this up at his next visit, or let it go because he did not share this with you himself?

The BMA guidance 1) suggests that physicians adopt conservative privacy settings on their online profiles, 2) warns doctors to respect patient confidentiality, and 3) advises they declare conflict of interest.

The social media policy of the American Medical Association does not come right out and say physicians should not “friend” patients, but says they should “maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.”  It also suggests doctors “should consider separating personal and professional content online.”   

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

What You Say Without Speaking

It’s estimated that up to 93% of all communication exchanges are nonverbal.  That means facial expressions, gestures and the way we stand all say something—of which we are often unaware.

For nearly 20 years medical schools have been required to teach communication skills, mainly due to research that links physician-patient communication with patient satisfaction and health care outcomes.  They offer everything from courses on lectures, video recording and self-assessments.

But, writes New York Times columnist Pauline Chen, few schools offer courses on facial expressions and body language, “despite a growing body of research suggesting that nonverbal communication may be as important as verbal communication. Important nonverbal cues in physician-patient interactions can include subtle body gestures, body positions, eye contact, facial expressions, and touch.”

One of the most powerful tools we have is eye contact, and how much we are willing to give to patients.  It tells patients they are being listened to (a great satisfier in patient interactions).  Do you nod to let them know they have your full attention, or does it look like you are a million miles away while they tell their story?

A recent study in the Journal of General Internal Medicine (JGIM) found that black physicians used positive nonverbal cues better than white physicians, although they sometimes gave contradictory nonverbal signals.  A 1994 study had shown that women physicians tend to give male patients conflicting nonverbal cues, like smiling while speaking in an anxious tone of voice.

Experts suggest physicians note their body language: Do you cross your arms, look away or make notes while the patient is speaking?  Or do you look engaged, touch the patient’s hand, and appear unrushed? Experts say nothing is more powerful than imagining yourself in the patient’s place to put things in perspective.  

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Not All Physicians Honest with Patients

A 2009 survey of 1,891 practicing physicians from across the US aimed to find out how many of them adhered strictly to the Charter on Medical Professionalism endorsed by 100+ professional groups around the world and the US Accreditation Council for Graduate Medical Education.  It requires openness and honesty in physician communications with patients.

A large majority agreed completely that physicians should fully inform patients about risks and benefits of interventions.  They also agreed that they should never disclose confidential information to unauthorized people.

• But about 1 in 3 did not completely agree with telling patients about serious medical errors.
• Nearly 1 in 5 did not completely agree that physicians should never tell a patient something untrue.
• Almost 2 of 5 did not completely agree that they should disclose to patients their financial relationships with drug and device companies.
• More than 1 in 10 said they had told patients something that was not true during the previous year.

The authors of the research represent Harvard Medical School, the Mongan Institute for Health Policy, University of Massachusetts and other august bodies.  They stated that, “Our findings raise concerns that some patients might not receive complete and accurate information from their physicians, and doubts about whether patient-centered care is broadly possible without more widespread physician endorsement of the core communication principles of openness and honesty with patients.”  

Source:  http://content.healthaffairs.org/content/31/2/383.abstract

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.