Health and Disability

Donna Hicks, PhD, an associate at the Weatherhead Center for International Affairs at Harvard University, has worked for over a decade in the field of international conflict resolution and has published a sentinel book called Dignity, It’s Essential Role in Resolving Conflict. Although the book is focused on a culture of dignity in the workplace, there are many parallels that are essential to health care organizations and health care professionals who strive to offer quality care.

The ten elements of dignity that Dr. Hicks outlines in her book, so relevant in a health care setting include:
1. Acceptance of every person’s individuality and identity.
2. Inclusion – making people feel they belong.
3. Safety – putting people at ease.
4. Acknowledgment -giving people full attention by listening, hearing, validating and responding to their concerns, feelings and experiences.
5. Recognition – validating others for their personal traits and talents.
6. Fairness – Treating people equally.
7. Benefit of the doubt – trusting people.
8. Understanding – believing what others think matters.
9. Independence – Encouraging people to act on their own behalf – empowerment.
10. Accountability – taking responsibility for actions.

There’s now more evidence that robust in-home care can improve health outcomes while lowering costs to the U.S. health care system. A demonstration program to increase in-home primary care for patients with chronic conditions netted $25 million in savings for Medicare in its first year, the Centers for Medicare & Medicaid Services announced Thursday.

The Independence at Home demonstration was a payment model established under the Affordable Care Act, and it involves 17 participating primary care practices. They make home visits to beneficiaries with chronic conditions, coordinate their care, and track results through quality measures. If they meet a minimum savings threshold while also meeting quality measures, they are eligible to receive incentive payments.

Non-narcotic treatments for chronic pain that work well in people, not just mice, are sorely needed. Drawing from human pain genetics, an international team led by Boston Children's Hospital demonstrates a way to break the cycle of pain hypersensitivity without the development of addiction, tolerance or side effects.

Their findings, reported June 17 in the journal Neuron, could lead to treatments for chronic pain conditions caused by nerve damage, such as diabetic peripheral neuropathy (DPN) and post-herpetic neuralgia (PHN), as well as chronic inflammation, likerheumatoid arthritis. Current treatments provide meaningful pain relief in only about 15 percent of patients.

"Most pain medications that have been tested in the past decade have failed in phase II human trials despite performing well in animal models," notes Clifford Woolf, MD, PhD, director of Boston Children's F.M. Kirby Neurobiology Center and a co-senior investigator on the study with Michael Costigan, PhD. "Here, we used human genetic findings to guide our search from the beginning."

Her team sought to identify which physicians in which settings are prescribing these drugs and found the most frequent first prescribers of opioids are emergency room physicians while general neurologists were most frequent first prescribers of barbiturates. Primary care physicians were also identified as first prescribers.

Such medications have been designated as inappropriate as first line treatment for migraine patients by the American Board of Internal Medicine's "Choosing Wisely" campaign. The campaign recommends that first medications for migraine be either non-prescription pain medications or a class of prescription drugs called triptans that are specifically for migraine.

"Taken as a whole, these data provide a useful snapshot of the wide variety of physician specialties that might benefit from additional education on the appropriate use of opioids and barbiturate-containing medications in patients with headaches," Dr. Minen said.

The study found that almost one-third of the U.S. population are informal caregivers and collectively provide about 1.2 billion hours of unpaid work weekly, the equivalent of about 30.5 million full-time care aides. But the sandwich generation comprises just 3 percent of the population, much less than researchers anticipated.

The researchers were also surprised to find that elderly people were frequently being cared for by spouses, not their adult children. About 20 percent of caregiving time spent on people 80 years or older comes from people of the same age, they found.

'The extent to which spousal care is prevalent at old ages, 70 and 80 years old, was surprising to us,' said lead author Emilio Zagheni, a UW assistant professor of sociology. 'We expected to see more caregiving by adult children of their parents.'

Older men provided slightly more spousal care than women, Zagheni said, which might be explained by men dying earlier, possibly before they need much care, and women living longer but being in poor health at older ages.

The Aging Brain Care Medical Home, a novel population health management program implemented in the homes of older adults, achieves significant health improvement for individuals with depression and also substantial stress reduction in family caregivers of dementia patients, according to a new study by investigators from the Regenstrief Institute, Indiana University Center for Aging Research and Eskenazi Health.

The researchers report at least a 50 percent reduction in symptoms in two-thirds of patients with moderately severe depressive symptoms such as feeling hopeless, feeling bad about oneself or having trouble concentrating. They also found a 50 percent reduction in stress symptoms in half of caregivers of patients with dementia.

"Depression and dementia, which typically impact other medical conditions, are difficult for primary care doctors to treat during their limited time with patients," said Regenstrief Institute investigator and IU Center for Aging Research scientist Michael LaMantia, M.D., MPH, who led the study. "The Aging Brain Care Medical Home program may be an attractive option in response to some of the challenges posed by our nation's rapidly aging population and the anticipated lack of geriatricians and primary doctors to care for them.

I recently led a journal club where we reviewed, “Use of Medications of Questionable Benefit in Advanced Dementia.”1 This cross-sectional study examined medication use by nursing home residents with advanced dementia. Medications of questionable benefit were defined as “never appropriate” medications as determined by the consensus of a group of Geriatricians.2 

Over half of nursing home residents with advanced dementia (53.9%) received at least one medication of questionable benefit. The most commonly prescribed were cholinesterase inhibitors (36.4%) and memantine hydrochloride (25.2%). Continuing these medications does not increase survival or alter the course of advanced disease, can cause side effects, and contributes to increased health care costs.

My doctor sat at his desk facing his computer as he read through my chart and got updated on the various specialists I’d seen and the tests I’d had done since my last appointment with him.

He turned around and said, “So pretty much you’ve become a professional patient.”

It’s true. I’ve seen several new specialists lately and am waiting to see a few more. This is a good thing because it means that after years of trying to politely convince my doctors that there are other things going on, I’m finally getting somewhere. I don’t yet know exactly where that somewhere is, but I’m happy to be on my way all the same and I’m thankful for the understanding and committed doctors who are helping me get there.

But it’s still hard.

The long process of recovery from the family's point of view.