Gary M. Onik, M.D., from the Center for Safer Prostate Cancer Therapy in Orlando, Fla., treated 120 patients' prostate tumors with cryoablation under ultrasound guidance, of whom 72 were at medium to high risk of recurrence. After a mean follow-up of 3.6 years, 93 percent of patients had stable levels of prostate-specific antigen with no evidence of cancer, even in the higher risk patients. There were no local recurrences in the treated areas, potency was maintained in 85 percent of the patients who were potent before the procedure, and all patients without previous prostate surgery remained continent. Kelvin Hong, M.D., and colleagues from Johns Hopkins University in Baltimore, evaluated computed tomography-guided, percutaneous cryoablation procedures in 73 renal masses (Bosniak III-IV lesions). The researchers found that efficacy and two-year survival were near 100 percent for disease stage T1aN0M0. A second study by the same group of researchers evaluated safety. "CT-guided percutaneous cryoablation for solid renal masses has an excellent safety profile with a CTCAE>1 complication rate of 7.4 percent," Hong and colleagues conclude. "There were no treatment-related deaths."
Tuesday, March 10, 2009
More evidence that depression is hard on the heart
WASHINGTON, 10 mar 2009 – Severe depression may silently break a seemingly healthy woman's heart. Doctors have long known that depression is common after a heart attack or stroke, and worsens those people's outcomes. Monday, Columbia University researchers reported new evidence that depression can lead to heart disease in the first place.
The scientists tracked 63,000 women from the long-running Nurses' Health Study between 1992 and 2004. None had signs of heart disease when the study began, but nearly 8 percent had evidence of serious depression.
The depressed women were more than twice as likely to experience sudden cardiac death — death typically caused by an irregular heartbeat, concluded the 12-year study, published Monday in the Journal of the American College of Cardiology. They also had a smaller increased risk of death from other forms of heart disease.
The big surprise: Sudden cardiac death seemed more closely linked with antidepressant use than with the depression symptoms the women reported.
That might simply mean that women who used antidepressants were, appropriately, the most seriously depressed, cautioned lead researcher Dr. William Whang. But he said the finding merited more research.
Studies of the newer antidepressants most often used today so far haven't signaled a risk of irregular heartbeat, and some even have suggested protection, noted Dr. Redford Williams of Duke University, a specialist in how psychosocial factors affect health.
The drug question aside, Williams said the work adds to growing evidence that depression is an independent risk factor for heart disease — on top of the classic risks of high blood pressure, diabetes, high cholesterol and smoking.
The predominantly white Nurses' Health Study may underestimate it, Williams said. "If anything, the impact in African-American women is probably greater," he said, adding that it's time for the next step: A study testing whether properly treating depression lowers the risk.
Why might depression have that effect? The study found that the more severe the women's reported depression symptoms, the more likely she was to have traditional heart risk factors. Also, stresses like depression have been linked to such physical effects as a higher resting heart rate.
Perhaps a more straightforward reason: Depression can make people do a worse job taking care of themselves. Indeed, the American Heart Association last year recommended that everyone who already has heart disease be regularly screened for depression — because depressed patients may skip their medications, sit indoors instead of exercising, and eat particularly poorly.
Monday, March 09, 2009
Keep active 'for longer life'
09 mar 2009--“Men in their 50s who increase their exercise regime live more than two years longer than couch potatoes of the same age,” The Guardian reported. It said that men who do just three hours of sport or heavy gardening a week live 2.3 years longer than sedentary men, and a year longer than those who do moderate exercise.
This study followed 2,300 men around 50 years of age from the early 1970s until 2006. Men with higher levels of activity had lower overall mortality compared to less active men. Men who increased their activity from low to high also had lower mortality than the sedentary men. This research supports the idea that regular exercise and activity are beneficial. However, there are some limitations. The complex interaction of medical, psychosocial and lifestyle factors that govern lifespan cannot be encapsulated in the four, very broad, questions on physical activity that the men answered. It is not possible to assure people that simply doing the gardening in middle age will add an extra two years to their lives.
Where did the story come from?Liisa Byberg and colleagues from Uppsala University and Karolinska Institutet, Sweden, carried out this research. The work was funded by the Swedish Research Council. The study was published in the peer-reviewed British Medical Journal.
What kind of scientific study was this?This prospective cohort study investigated how physical activity in middle age affects risk of death. It also compared this effect on risk of death with that of quitting smoking. The participants were comprised of all men who were born between 1920 and 1924 and living in the municipality of Uppsala, Sweden in 1970. Of the 2,841 men who were asked, 2,322 (82%) aged 49-51 participated. Each participant completed a validated health survey, which asked the following questions:
- Do you spend most of your time reading, watching TV, going to the cinema or engaging in other, mostly sedentary, activities?
- Do you often go walking or cycling for pleasure?
- Do you engage in any active recreational sports or heavy gardening at least three hours every week?
- Do you regularly engage in hard physical training or competitive sport?
Those answering yes to question one were classed as having low activity; those answering yes to two as medium; and three and four were classed together as high activity.
The same survey was repeated when the cohort reached the average ages of 60, 70, 77 and 82, with the final survey taking place in 2006. The researchers looked at changes in physical activity between the first and second surveys and classed them as unchanged low (low or medium activity at both surveys), unchanged high (high activity at both surveys), decreased (high in survey one, low or medium in survey two), and increased (low or medium in survey one, high in survey two).
The researchers also looked at the men’s occupation, educational level and socioeconomic group from the 1970 and 1980 census; height, weight and BMI at the time of each survey; blood pressure and medications for it; cholesterol; presence of diabetes; smoking (current, former or never a smoker, and changes in habit between surveys); and alcohol consumption (abstainer, normal, or sustained alcohol dependence).
Medical and psychiatric diagnoses were detected through the national hospital discharge register, and deaths obtained through the Swedish National Population Register. Numbers diminished at each repeat survey due to death or lack of availability. At the final survey ,only 23% of those who took part in the first survey were available.
What were the results of the study?At the time of the first survey, 49% of men reported high activity, 36% reported medium activity, and 15% were sedentary. At the end of follow-up, 1,329 men, 60% of the cohort had died. By the end of the study, they had a total 61,456 collective years of follow-up.
Mortality rate was calculated to be reduced by 22% with high-compared-to-medium activity, and by 32% with high-compared-to-low activity. Absolute mortality rates per 1,000 collective years of follow-up were 27.1 for low activity, 23.6 for medium, and 18.4 for high activity. Men who increased physical activity between the first and second surveys still had a higher risk of mortality compared to those with unchanged levels of high physical activity. However, if this increase in activity was continued to the third survey, these men showed no difference in mortality from those who reported high physical activity in all surveys.
Men who had increased their levels of activity had a significantly reduced mortality compared to the men who had low activity levels in all surveys. This reduced mortality risk was similar to the reduction in mortality seen from stopping smoking compared to continued smoking.
What interpretations did the researchers draw from these results?The researchers conclude that an increase in physical activity in middle age is “eventually” followed by a reduction in mortality compared to sustained low levels of activity, and similar to those with sustained high levels of activity. They say that this effect is similar to that observed with smoking cessation.
This Swedish research enrolled a large group of men in the early 1970s and followed them up to the present day. The study has strengths in its size, and its use of reliable sources of data to follow-up the outcomes of all participants. The study found that men who sustained higher levels of activity throughout the study had reduced overall mortality compared to those with lower activity levels. In addition, men who increased their activity from lower levels to higher levels during follow-up also had reduced mortality compared to those with sustained low activity.This research supports the theory that regular exercise and activity contribute to a longer life. However, the news headlines have been simplistic in their interpretation. The study used four, very broad questions in order to group men into categories of physical activity. Heavy gardening was included in the third question, which was then classed as high activity. This is likely to have led to considerable variation in the men’s responses, and the possibility that some of them were incorrectly categorised. Other variables that were assessed also used very broad categories, and these are also likely to include considerable inaccuracies. Alcohol consumption, for example, was classified simply as “abstainer, normal or sustained alcohol dependence”.
The researchers also considered other possible factors that can contribute to health. However, a person’s health and lifespan are affected by a complex interplay of medical, psychological, social and lifestyle factors, which could not have been assessed in their entirety. As study members chose their own activity levels and were not randomly allocated to a certain level of activity, it is not possible to say whether other factors (e.g. medical health) affected how much activity they performed. In addition, the study only assessed men, therefore the results cannot be automatically applied to women.
It is not possible to assure people that simply doing gardening in middle age will earn them an extra two years of life. However, regular exercise, in addition to a healthy diet, is widely supported as being beneficial to a healthy life.
Links to the headlines
Middle age 'key for exercising'. BBC News, March 06 2009
Men in their 50s can add two years to their life with exercise regime, says study. The Guardian, March 06 2009
Taking up gardening in middle age can extend life by two years, research finds. The Daily Telegraph, March 06 2009
Links to the science
Byberg L, Melhus H, Gedeborg R, et al. Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort. BMJ 2009; 338:b688
Many Doctors, Many Tests, No Rhyme or Reason
09 mar 2009--I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.
He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).
Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.
This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.
Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.
And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.
Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”
Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”
His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.
“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.
But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.
“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”ESSAY; Doctor Marries Doctor: Good Medicine
09 mar 2009--Some years ago, well before I got engaged, I had a conversation with a young gastroenterologist about marriage. I was readying myself for medical school and concerned I would not meet anyone outside of medicine. I was certain I did not want to marry a doctor. ''No, marry a doctor,'' the fellow advised. ''When you get paged away during your anniversary dinner, only another doctor will understand.''
Recently, as a newly minted doctor, I got engaged to a medical student. Although we have common interests that extend far beyond medicine, most of my friends focus on the fact that we will both be doctors. Like the gastroenterologist, some think being in the same demanding field will help our marriage. Others think I was bound to marry a doctor, given my schedule, but wonder how we will find time to spend together. A few wink and joke about our future income.
Like me, many young doctors today are marrying other doctors. That was not the case fairly recently, when the vast majority of doctors were men and dual-doctor marriages were rare. Male doctors tended to have stay-at-home wives who took care of children and supported their husbands and their careers. About 50 percent of female doctors, on the other hand, have always married other doctors. Today, when women account for almost 50 percent of medical students and about 20 percent of all doctors, the number of these marriages is rising rapidly. Soon, perhaps half of all young doctors will be married to other doctors.
A recent study in The Annals of Internal Medicine set out to discover what these marriages were like. A group of researchers surveyed 1,208 doctors, comparing the 26 percent in dual-doctor marriages with the rest in ''mixed marriages.'' The researchers looked at three areas: number of hours worked and annual income, number of children and child-rearing arrangements, and perceptions of family and work.
Over all, they found that dual-doctor marriages were relatively happy and stable. Compared with other physicians, doctors in dual-doctor marriages reported greater satisfaction in discussing and sharing work interests with their spouses, more involvement in child rearing by both partners and a higher family income.
Dr. Robert Campagna, a 37-year-old cardiologist at New York Presbyterian Hospital who recently married an internist, said he believed that there were many advantages to marrying another doctor. ''Sarah and I speak the same language, we belong to the same clique,'' he said recently. ''I don't have to go home and say, 'I started a dopamine drip on a patient today. Oh, and by the way, dopamine is a drug we use to . . .''
The survey also found that dual-doctor marriages were traditional in many ways, particularly in the area of family. Compared with other female doctors, for example, women in dual-doctor marriages spent more time rearing children, more often arranged their work schedules to fulfill family responsibilities, worked fewer hours and earned less money.
However, neither men nor women in dual-doctor families said they felt less successful than other physicians in achieving their career or child-rearing goals.
Dr. Shari Midoneck, an infectious disease specialist at New York Presbyterian who is married to a gastroenterologist, agreed that most women in dual-doctor marriages bore the brunt of child rearing. ''The onus is on me to make sure that there's food in the house, that the kids are ready for school, that their homework is done,'' she said. ''My mother was there for us every night cooking dinner. She went on all our field trips. So I want to be there for my kids.''
Dr. Midoneck works in a practice with other women, most of whom have children, which helps her maintain flexibility in her work. ''I never miss anything with my kids,'' she said. ''If I need time off, I just take it.''
Dr. Campagna, venturing an explanation for some of the survey's results, said: ''Medicine is not a radical profession. Many women in the field tend to have traditional outlooks on their nonprofessional lives.''
But medicine has been changing and continues to change, particularly in regard to the work ethic. Doctors, both male and female, work fewer hours, and life style and family time are top considerations for medical students choosing specialties.
Still, medicine remains inflexible in many respects, especially with regard to women. For example, most residency programs do not have formal maternity leave policies, though most female residents are in their childbearing years. Medical schools still do not make proper allowance for female (or male) academics who want to hop off the tenure track to have children. A recent survey found that female academics believe having children is a hindrance to career advancement, though those with children had no regrets.
The system will change with time, as more women assume positions of power, but the increasing number of dual-doctor marriages is also bound to hasten the change. The sentiments and sympathies of the men who now run most teaching hospitals will change when more of them go home every night to their doctor wives. Instituting flexible work schedules in academic medicine and on-site child care will become more of a priority when these issues hit closer to home. The system is bound to become more flexible, reflecting the current reality of the profession instead of the outdated reality of the past, benefiting men and women alike.
#1. It’s “I Before E”
And It’s Alignment Before Empowerment
The empowerment of patients has the potential to improve treatment adherence and healthcare in general but only if that empowerment is accomplished in the context of a therapeutic alliance with the goals and values of patients, clinicians, and the system though which care is provided in alignment.
The empowerment of patients without such alignment endangers rather than enhances healthcare on both the individual and systemic level.
For example, members of a jazz band may discover hitherto untapped power and evocativeness from a composition when they are empowered to improvise and take responsibility for their performance rather than play as automatons. On the other hand, fourth graders in a beginners orchestra may have implicitly agreed to play from the same sheet music and follow the lead of the same conductor, but it requires only a few moments of observation to grasp that such nascent musicians, however desirous they may be to please the audience or how enthusiastically they approach the task at hand, lack the maturity of temperament and conceptual capacity necessary to operate independently without an ensuing cacophony.
Senge’s warning, although written about business administration, is equally valid in this situation,
Empowering the individual when there is a relatively lower level of alignment worsens the chaos
#2. Love Is Not Enough: Neither Are Good Intentions
If I Only Had a Brain
~ Wizard of Oz
A desire to cooperate on the part of all those involved in a given case — patients, clinicians, and healthcare administration — is a good starting point, but effective implementation of treatment requires knowledge and skills as well as motivation. Further, healthcare situations are dynamic; all parties involved must continuously update their ability to cooperate. The best healthcare will occur when patients, clinicians, and healthcare administrators learn fast and apply what they learn most expeditiously. Accelerating this process is a key responsibility of healthcare professionals.
#3. A Desire For Health & Motivation To Comply With Treatment
Are Not Identical
Let all men, if they can manage it, contrive to be healthy!
~ Thomas Carlyle
Even patients who desperately want to be healthy can vary remarkably in their willingness and capacity to adhere to the prescribed treatment.
It is a mistake to assume that patients will necessarily follow treatment instructions because they want to get well or because they are fearful of the negative outcome of their disorders, even if those consequences are catastrophic.
The goal is to help the patient connect his or her desire for health, as defined by the patient, with a course of treatment that is most likely to be beneficial, also as defined by the patient.
#4. Oneupsmanship Or Compliance-Enhancement: Choose One
More often than not, the first clinician to see the patient for a given ailment is actually providing a second opinion. It is the rare patient who does not arrive at a doctor’s appointment without forming an idea about what his or her symptoms portend. The source of the patient’s self-diagnosis may have been the New England Journal of Medicine, the Miracle_Snake_Oil.com web site, the 90-second personal health feature (inevitably called “To Your Health”) produced as a school project by the local TV station’s 19 year old intern, the overheard fragment of a conversation between two psychiatrists at a party, or my Aunt Hazel from Broken Arrow, Oklahoma. Even if the ideas are inaccurate — make that especially if the ideas are inaccurate — the failure to ask about and listen to these ideas is dangerous. That the clinician renders the correct diagnosis when he interrupts the patient’s prolonged account of recurrent dizziness, fluctuating appetite, and intermittent left knee pain does not insure the patient’s agreement, respect, gratitude, or compliance.
#5. “Complianceadherenceconcordance” Just Doesn’t Scan;
Let’s Call It Compliance Until Something Better Comes Along
Now look, Colonel Bat Guano – If that is really your name
~ from Dr. Strangelove
They certainly give very strange names to diseases
~ Plato
And to compliance
~ Showalter
Even though I’m a doctor, I just can’t go along with “medical compliance” as an ideal term for whatever it is we’re talking about. I’ve also had it with “patient compliance.” “Cooperation” doesn’t quite work with me. And while “adherence” has its adherents, it does not seem something I could stick with. As for “concordance,” which carries the official sanction of the Royal Pharmaceutical Society of Great Britain, it just doesn’t lend itself to puns.
Pragmatically, whatever distinctions once may have existed between the connotations of “compliance” and “adherence” have likely been washed out by the pervasive use of these and their congeners as synonyms in the preponderance of the medical literature. The argument can legitimately be made that such semantic quibbles may now produce more distraction than insight into the clinician-patient relationship. Lacking compelling advantages favoring the use of any of the suggested terms and the institutionalized encoding of “medical compliance,” “patient compliance,” and “medication compliance” into the medical literature and databases, it makes sense — until something better comes along — to continue using this familiar phrase to designate the healthcare behaviors of individuals responding to medical recommendations and, unless specified otherwise, assume that “adherence,” “compliance,” and “concordance” refer to the same phenomenon.
My own hunch is that eventually, the issue of compliance/adherence will be properly subsumed by a focus on treatment implementation and execution.
For what it’s worth, my preference is to get behind “alignment” under the premise is that we are striving not so much to persuade, coerce, or trick patients into doing what their doctors prescribe as to align clinicians, patients, payers, and anyone else involved in healthcare so that everyone is working in concert. An easy example of alignment’s advantages is the case in which a patient does not adhere to the prescribed treatment plan but does communicate that decision and his or her reasons to the clinicians. That is not “compliance” (at least by a strict definition), but it seems different from and exponentially preferable to the case in which the patient not only does not follow the treatment plan but also misleads the clinician into thinking he or she is doing so. Assuming the patient was not just perversely turning down all options, he or she and the clinicians could be in “alignment” although the patient is not in “compliance.” The other important connotation is that “alignment” obviates the assumption, essential to “compliance,” that patients are either obedient or disobedient to the dictates of the clinician; rather, “alignment” allows for a less one-sided involvement of the clinicians and patients. Nonetheless, “alignment,” used in this sense, would not be recognized by the medical community.
#6. There is no universal antidote for noncompliance
AKA The Universal Truth About Universal Panaceas
It’s the rare coach of a team sport who even claims to treat all his or her players the same; teachers acknowledge the need to individualize education as much as possible; and, perhaps most telling, marketers espouse as their ultimate goal a sales message personalized for a specific potential customer. Yet, the medical literature dealing with patient compliance often expresses perplexity, frustration, and, on occasion, amazement that a given intervention (whether that intervention is patient education, cues & reminders, free medical services, easy access to services… ) improves compliance among some but not all patients.
That different patients react in different ways to healthcare recommendations and compliance-enhancing efforts is a concept that hardly rises to the level of a profundity but must, it seems, be evangelized.
#7. “Better patient education” is the answer — but only if the question is “What is the only response made to correct noncompliance in 90+% of cases?”
This is a specific case of Mencken’s observation,
— And Wrong
There is no indication that patient education is uniformly the appropriate corrective reaction to noncompliance; there is evidence that patient education, regardless of how well structured the teaching process and how motivated the client, is unsuccessful in achieving compliance in a significant portion of cases.
More information does not necessarily result in more compliance. It is a difficult intuitive leap, for example, to concur with the bureaucratic a priori rationale that providing a patient a three-page listing of a medication’s adverse effects (instead of a one-page list of a subset of those adverse effects) will result in that patient taking the medication more faithfully.
Educating the patient without first determining if education will solve the problem for that patient in that situation is no more rational than automatically prescribing antibiotics to every patient complaining of coughing and a sore throat.
#8. Compliance Enhancement Can Be A Win-Win-Win Game
While there may be, despite the unremitting efforts of pharmaceutical detail reps, no free lunch, compliance enhancement may be the source of that equally elusive goal, the Win-Win outcome. In fact, compliance enhancement may be the sole example, other than casino and lottery ads, of the Win-Win-Win game.
Looking Out For #1, #2, and #3
Improved compliance tends to result in happier
- Clinicians: who can count on treatment plans being implemented as written
- Administrators: who savor the lower costs
- Patients: who avoid unnecessary delays in recovery, relapses & side-effects
#9. Once You’ve Seen One Noncompliant Patient,
You’ve Seen One Noncompliant Patient
The extent to and manner in which Patient X, in a specific set of circumstances,2 adheres to a prescribed treatment can be extrapolated and generalized to accurately characterize — the extent to and manner in which Patient X, in that specific set of circumstances, adheres to that prescribed treatment.
Compliance is the result of a complex collection of cognitive, emotional, physiological, and cultural factors, some of which are obvious, others which are subtle, and many of which may be in conflict. Compliance not only varies from patient to patient but the same patient may respond differently to the demands of different treatment regimens and in response to various disorders. Further, Patient X’s compliance behavior vis-Ã -vis the same disorder and treatment may vary under different circumstances; patient X’s adherence to the same treatment for the same disorder may, for example, be different at ages 5, 15, 35, 55, and 85.
Past compliance behavior for a specific patient may be somewhat predictive of that patient’s future compliance, but the power and reliability of such predictions are not impressive even if the circumstances are similar. Generalizing beyond a specific patient to a group of patients has proven a sucker’s bet for clinicians.
#10. Complacency about compliance leads to treatment failure
If you know that 75% or more of your patients follow your treatment recommendations, one of the following explanations holds:
- You are charismatic, empathic, and knowledgeable — and incredibly lucky. If enough poker players try drawing to an inside straight enough times, someone — somewhere — sometime — does eventually end up with that hand. So, sure, it’s possible that 75% of your patients are compliant. If you’re this lucky, however, let’s you and me go buy some lottery tickets.
- You are incredibly charismatic, empathic, and knowledgeable but are no luckier than the rest of us schmucks. You also sustain a charmingly naive confidence in human nature despite evidence to the contrary, tend to invest heavily in Franklin Mint commemorative plates depicting the official fungus of each state, continue to expect the check that (you have been assured) is in the mail, and believe for every drop of rain that falls, a flower grows.
A reasonable rule of thumb is that 50% of patients do not comply with treatment recommendations.
The Six Habits of Highly Respectful Physicians
09 mar 2009--Recently, I asked a colleague about the quality of care her hospitalized mother was getting. “Well, you can at least have a conversation with her doctor,” she replied. Clearly this was a big relief.
High-level skills like reflectiveness and empathy are an important part of medical education these days. That is all to the good, of course. But as I noted last May in an article in The New England Journal of Medicine, medical schools may be underemphasizing a much simpler virtue: good manners.
In the article, I described a common-sense method for spreading clinical courtesy that I call “etiquette-based medicine,” and I proposed a simple six-step checklist for doctors to follow when meeting a hospitalized patient for the first time:
• Ask permission to enter the room; wait for an answer.
• Introduce yourself; show your ID badge.
• Shake hands.
• Sit down. Smile if appropriate.
• Explain your role on the health care team.
• Ask how the patient feels about being in the hospital.
Do doctors really need to be told to do such obvious things? Unfortunately, anyone who has spent time in the hospital as a patient or a physician knows how haphazardly such actions are performed, and as Samuel Johnson wrote, “Man needs more to be reminded than instructed.”
There is a useful analogy here to raising children. The British physician D. W. Winnicott coined the term “good enough mother” in part to help mothers who were overly anxious about their parenting skills. Rather than worry about trying to be perfect (whatever that meant), he urged them to relax, trust their intuition and realize that their children needed a mother who was caring, alert and reliable — in other words, good enough.
Similarly, when medical schools try to turn out ideal doctors, they can miss the opportunity to help them be good enough: perhaps not perfectly attuned to the patient, but at least respectful and professional. An etiquette-based approach can promote such behavior.
Etiquette-based medicine rests on the fact that patients derive comfort from specific actions — as opposed to attitudes or feelings — that are independent of the doctor’s emotional investment in the patient. My doctor may be tired, preoccupied or not that interested in me as a person; but I should still expect him or her to treat me with the kind of attentiveness and respect I recently received from a “genius” at the local Apple store.
The “genius” was skillful, efficient and professional, and solved my problem quickly without feeling my pain (which had been considerable). I don’t necessarily want or need to have an exceptional healer, but I would like to have good service. Patients should command at least the same regard from their doctors.
Does this mean surrendering medicine’s nobler values in the service of mere client satisfaction? Not at all. Consider one more analogy: A developing country may make a major investment in M.R.I. machines, an essential element of up-to-date medicine. But that money will be misspent if the country lacks enough antibiotics and doctors to prescribe them.
By the same token, trying to cultivate deeper human sensibility in doctors will be an inefficient use of scarce educational resources if those doctors cannot make the time to sit down, introduce themselves and make eye contact with their patients. Training good enough doctors should be like fluoridating the water supply or vaccinating children: uncomplicated, routine, relatively inexpensive — but with widespread and long-lasting benefits.Sunday, March 08, 2009
Benefits of increased physical activity similar to stopping smoking
Liisa Byberg, Ph.D., of Uppsala University in Uppsala, Sweden, and colleagues conducted a study of 2,205 men who were aged 50 years from 1970 to 1973 and who were followed up at 60, 70, 77 and 82 years. In groups with low, medium and high levels of physical activity, the absolute mortality rate was 27.1, 23.6 and 18.4 per 1,000 person-years, respectively, the investigators found. Men who increased their level of exercise between the ages of 50 and 60 did not have a lower mortality rate for the first five years, but after 10 years their risk of dying was the same as that of men who had been in the high physical activity group all along, the researchers report. "An increase in physical activity has the same impact on lowering mortality rate in the long term as smoking cessation. Thus, efforts for promotion of physical activity, even among middle-aged and older men, are important," the authors write. "The effects in other age groups and in women need to be studied. Mechanisms and reasons for an active choice to change physical activity are not fully understood."
Regardless of annual running distance they have lower prevalence of high cholesterol
Paul T. Williams, Ph.D., of Lawrence Berkeley Laboratory, Donner Laboratory in Berkeley, Calif., conducted a study of 62,284 male and 45,040 female participants in the National Runners' Health Study, who gave information on their self-reported medication use, running mileage, age, diet and alcohol intake. Among men, those who ran 0.2 to 0.8 marathons a year were 13 percent less likely to be taking antihypertensive medication compared to non-marathon runners, and were 22 percent and 67 percent less likely to be taking LDL-cholesterol-lowering medications and anti-diabetic medications, respectively, Williams found. In women, there was an association between marathon running and lower use of LDL-cholesterol-lowering and anti-diabetic medication, but this association disappeared when the annual running distance was taken into consideration, the researcher reports. "Among all runners (marathoners and non-marathoners combined), prevalence in the use of all three medications decreased in association with the length of the longest usual run, independent of total annual mileage," Williams writes. "This may be due to the inclusion of longer training runs in preparation for marathons or to genetic or other innate differences between marathon and non-marathon runners."
Frank A.J.L. Scheer, Ph.D., of Brigham and Women's Hospital in Boston, and colleagues analyzed data from 10 healthy men and women aged 19 to 41 who underwent a 10-day laboratory study in which they lived in individual suites and ate and slept according to a 28-hour "day" without time cues. They ate four meals of equal calories during each day. When subjects' eating and sleeping times were misaligned from normal, leptin was 17 percent lower, glucose and insulin were 6 and 22 percent higher, respectively, mean arterial pressure was 3 percent higher, sleep efficiency was reduced by 20 percent, and the daily cortisol rhythm was completely reversed, the researchers report. "Approximately 8.6 million Americans perform shift work, which is associated with increased risk of obesity, diabetes and cardiovascular disease," the authors write. The effects of the circadian misalignment on glucose, leptin, sleep efficiency and other factors "may provide a mechanism underlying the increased risk for obesity, hypertension and diabetes in shift workers."
Blood flow changes in specific regions suggests pathological progression to Alzheimer's disease
Weiying Dai, Ph.D., of Harvard Medical School in Boston, and colleagues performed CASL MRI on 104 control individuals and patients with mild cognitive impairment or Alzheimer's disease. Contiguous axial section images were generated to compare the regional cerebral blood flow. Compared with control individuals, decreased blood flow in the posterior cingulate gyrus with extension to the medial precuneus was noted among patients with either mild cognitive impairment or Alzheimer's disease, the researchers report. Alzheimer's disease patients also displayed decreased blood flow in the left inferior parietal, left lateral frontal, left superior temporal and left orbitofrontal cortices, the investigators found. Increases in right anterior cingulate gyrus blood flow was observed in Alzheimer's disease patients, while mild cognitive impairment patients showed increases in the left hippocampus and right amygdala. "Decreases in blood flow (and by implication, decreases in brain function) were observed both subcortically and cortically in patients with early Alzheimer's disease," the authors write. "We found increases in regional cerebral blood flow in portions of the limbic system, which suggests some form of compensatory mechanism during the early expression of the clinical syndrome, especially during the mild cognitive impairment stage."
William Dale, M.D., Ph.D., of the University of Chicago, and colleagues analyzed data from 67 patients (average age 68) with biochemical recurrence of prostate cancer. Patients reported on their anxiety at presentation and at follow-up visits until they began androgen deprivation therapy (ADT). In multivariate analysis, elevated anxiety over the prostate cancer -- as measured with the Memorial Anxiety Scale for Prostate Cancer -- was the strongest predictor of early initiation of ADT, the researchers report. In addition, those with elevated scores started ADT an average of 11 months after presentation, compared with 24.9 months for those with lower anxiety, the report indicates. "If it is true that anxious patients who experience biochemical recurrence are starting on ADT nearly 14 months earlier, for reasons unrelated to clinical factors, would this be important for their care?" the authors write. "ADT has known toxicities, many of which are especially concerning for older men, who are vulnerable to osteoporosis, fatigue, muscle loss and falls. The impact of ADT may be quite long lived, and an additional year on ADT for asymptomatic individuals is of concern, especially because anxiety could be a modifiable intervention target."
Saturday, March 07, 2009
Giving doctors the complete picture
New Regenstrief clinical support tool significantly improves communication between doctors
INDIANAPOLIS, 07 mar 2009 – During the course of a hospitalization, patients are seen by a variety of specialists in addition to the physician who has primary responsibility for their care. However, faulty communication, inappropriate timing, inadequate details, illegibility, lost paperwork or other problems may keep the specialists' recommendations from being evaluated and implemented.
An award-winning study by Martin Were, M.D., of the Regenstrief Institute and colleagues reports on the success of a physician decision-support tool they developed to overcome these barriers and to complement physician-to-physician communication processes already in place. The computer tool facilitated convenient flow of information, providing both the specialists and the patient's primary-care physician with detailed information on the patient and the advice sought at the right time and place. They found that when using the new computer tool, medical recommendations from geriatrics consultants were implemented 30 percent more frequently than when it was not used.
"Consulted specialists might not have the full clinical or most current picture of the patient. For example, they might not know all medications the patient is taking, the patient's allergies, or the most current results of tests ordered by others. The decision-support system provided by our computer tool eliminated these problems. We alerted the specialist when a drug he was contemplating prescribing conflicted with another medication the patient was taking. Automatic electronic notification of the exact specialist recommendations eliminated the need for the patient's primary doctor to leaf through a thick medical file to see the specialist's recommendations and the details of these recommendations. The tool also lets the specialists know if their recommendations have been implemented by the patient's primary doctor. All these benefits can be very important for patient safety," said Dr. Were, who is an internist.
The study, entitled "Using Computerized Provider Order Entry and Clinical Decision Support to Improve Referring Physicians' Implementation of Consultants' Medical Recommendations," earned Dr. Were the American Medical Informatics Association's 2008 prize for Best Student Paper and is published in the March/April 2009 issue of Journal of the American Medical Informatics Association.
Dr. Were developed the physician support tool during his fellowship in medical informatics at the Regenstrief Institute under the mentorship of Michael Weiner, M.D., IU School of Medicine associate professor of medicine and a Regenstrief Institute research scientist.
"Although medical specialists provide critical advice about diagnosis and treatment, up to half of their recommendations are not implemented," said Dr. Weiner. "This work, based at Wishard Health Services, showed that electronic facilitation of consultants' recommendations is not only valued by physicians but can markedly improve the chance that the recommendations will be followed."
According to Dr. Were and Dr. Weiner, use of the new clinical support tool may save health-care dollars by decreasing delays in care, improving patient safety, and prioritizing specialty treatment. The next step is to see how big a difference implementation of the system makes in patients' outcomes, duration of hospitalization and costs of care.
Regenstrief Institute medical informatics research scientists comprise one of the largest medical informatics physician brain trusts in the United States.
In addition to Drs. Were and Weiner, co-authors of the study are Greg Abernathy, M.D., of the Regenstrief Institute, Siu L. Hui, Ph.D., of the IU School of Medicine and the Regenstrief Institute, and Carol Kempf, R. N., of the IU School of Medicine and the Roudebush VA Center of Excellence for Implementing Evidence Based Practice.
The study was funded by the National Institute on Aging. Dr. Were was supported by the National Library of Medicine.
New Tel Aviv University research links diabetes to cognitive deterioration
Blindness, renal failure, stroke and heart disease are potential complications of type 2 diabetes, which currently afflicts more than 15 million Americans. Now research from Tel Aviv University has found more worrying news ― type 2 diabetes can be a risk factor accelerating cognitive decline and dementia.
07 mar 2009--Dr. Tali Cukierman-Yaffe, a physician and researcher from TAU's Sackler School of Medicine, found that people with diabetes were 1.5 more likely to experience cognitive decline, and 1.6 more likely to suffer from dementia than people without diabetes. Her recent publication in the journal Diabetes Care suggests that higher-than-average levels of blood glucose (blood sugar) may have a role in this relationship.
Her work is part of the ongoing Memory in Diabetes (MIND) project, a sub-study of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.
First Step Towards New Treatments
"Our results send an important message to the public," says Dr. Cukierman-Yaffe. "We have shown conclusively that there is a relationship between diabetes and cognitive dysfunction. This should be known by diabetics and their doctors. Knowledge is the first step towards action.
"Intact thinking is essential for managing the disease," Dr. Cukierman-Yaffe adds.
Clinicians today work with the patient to prevent complications of diabetes. Early detection of visual problems, for example, can be treated with laser surgery if diagnosed early enough, and blindness can be avoided in some cases.
"Today, diabetes cannot be cured. We can however delay or prevent many of its complications," says Dr. Cukierman-Yaffe. "Diagnosing cognitive dysfunction at a pre-clinical stage is the first step in finding new treatment options."
A New Association with Poor Cognitive Performance
Dr. Cukierman-Yaffe's work opens a new opportunity for researchers to better understand the cognitive risks associated with diabetes and dysglycemia. She points out that diabetes, unlike other chronic disease states, is a complex disease to manage and one that requires intact cognition in the patient. As the mind starts deteriorating, so does the patient's ability to treat the diabetes effectively. Disease management can then spiral out of control.
Findings in her recent study show that in people with type 2 diabetes, higher levels of haemoglobin A1C (a measure of average blood glucose) are significantly associated with poorer performance on three cognitive tasks which require memory, speed and ability to manage multiple tasks at the same time. A higher A1C level was also associated with a lower score on a test of global cognitive function.
The results of the study suggest that lowering A1C levels could slow the accelerated rate of cognitive decline experienced by people with diabetes. However prospective studies and clinical trials are needed in order to prove this. The ongoing ACCORD-MIND study, in which study patients are followed over time and are tested three times during the trial will test the hypothesis that lowering A1C could result in improved cognitive function.
Dr. Cukierman-Yaffe also works at the Gertner Institute for Epidemiology & Health Policy Research, Endocrinology Unit at the Chaim Sheba Medical Center at Tel Hashomer Hospital. She is affiliated with the Population Health Research Institute (PHRI) at McMaster University in Canada.
American Friends of Tel Aviv University (www.aftau.org) supports Israel's leading and most comprehensive center of higher learning. In independent rankings, TAU's innovations and discoveries are cited more often by the global scientific community than all but 20 other universities worldwide.
Internationally recognized for the scope and groundbreaking nature of its research programs, Tel Aviv University consistently produces work with profound implications for the future.
After a few drinks, older adults more impaired than they think
GAINESVILLE, Fla., 07 mar 2009— Older, active people who have a drink or two might be more impaired afterward than they think, according to a report today from a University of Florida research group in the Journal of Studies on Alcohol and Drugs.
Although people 50 or older in the study metabolized alcohol similar to how younger people did, they performed worse on special tests after having moderate amounts of alcohol and did not always realize when they were impaired. Soon after having alcohol, older adults also took on average five seconds longer to complete a test than their counterparts who did not have a drink.
"That doesn't sound like much, but five seconds is a big difference if you're in a car and need to apply the brakes," said lead author Sara Jo Nixon, Ph.D., a psychiatry professor at UF's McKnight Brain Institute. "It can mean the difference between a wreck, and not-a-wreck."
In 2007, an estimated 12,998 people were killed in crashes involving alcohol-impaired drivers, according to the National Highway Traffic Safety Administration.
"We still have a tremendous overhead in the United States of terrible tragedy with drinking and driving," said Edith Vioni Sullivan, Ph.D., a professor of psychiatry and behavioral sciences at the Stanford University School of Medicine. "We usually hear about the deaths; we seldom hear about the serious accidents that put people into nursing homes and hospitals for the rest of their lives."
More than half of adults older than 55 drink socially, according to a 2008 report from the Substance Abuse and Mental Health Services Administration. But few studies have focused on the short-term effects of social drinking among older adults. Previous research mainly investigated consumption of large amounts of alcohol at one time, and generally in young people. But results from studies of younger adults might not be applicable to older people because of age-related declines in cognitive skills, as well as changes in how alcohol is metabolized and removed from the body.
Nixon's group aimed to expand understanding of the effects over time of moderate levels of alcohol consumption in healthy, active older adults.
"You want to know how long does it take for them to become sober enough to engage in potentially dangerous activity such as driving," Sullivan said.
The study involved 68 nonsmokers — one group aged 50 to 74 and a comparison group aged 25 to 35 — who had at least one drink a month. Within each group, some individuals were given alcohol while others were given a placebo beverage that did not elevate their breath alcohol levels. The groups were carefully matched by gender, body mass index, history of alcohol consumption and other demographic characteristics.
When a person consumes alcohol, concentration in the blood builds to a peak, then dissipates. During the first phase of the metabolic process, alcohol has a stimulating effect. During the second phase, there is a sedative or depressive effect.
During each phase — at 25 minutes and 75 minutes after alcohol consumption, respectively — participants were given tests that required them to draw lines connecting numbered and lettered dots on a paper, in chronological order, without lifting the pen from the paper. They were timed and evaluated for how many errors they made. The first test involved numbers, while the second involved alternating between numbers and letters. Those tests give clues about a person's mental processing related to movement, and about the ability to mentally shift from one problem-solving strategy to another. The researchers also asked participants to rate on 10-point scales how intoxicated they felt, and how much they thought the alcohol impaired their performance.
Older adults who had alcohol took longer to complete the tasks than younger adults who had alcohol. But there was no such age difference between the older and younger groups that had not had alcohol. The researchers found that even though blood alcohol levels for participants in both groups rose at a similar rate right after drinking and reached the same peak, the older adults did worse on tests. That suggested the performance gap seen after moderate amounts of alcohol was not because of age-related differences in how the body processes the substance, but because of other factors influencing how alcohol affected the individuals.
In the test portion during the "stimulating" alcohol phase, older adults who had alcohol were slower than those who had not had any. In contrast, alcohol seemed to give the younger group a performance boost during that phase.
"People shouldn't take it to mean that younger people can drink with impunity," Sullivan said.
During that same post-drinking phase, when the older adults were impaired, they didn't think they were. And in the second phase — an hour and 15 minutes after having alcohol — older adults thought their performance was impaired, even when it wasn't.
"An older person might say 'Really, I feel all right, I'm sure I can drive,'" Sullivan said. "But the study shows that you can't always take someone at their word."
So what advice would Nixon give to active, older adults?
"If you have a couple of drinks at dinner, sit around, have dessert — don't drive for a while."
The researchers didn't evaluate the role of interactions between alcohol and prescription and other medicines.
They hope to conduct studies with larger numbers of people, more age groups and a wider range of alcohol intake levels. Future studies in which subjects take multiple, more difficult tests; the same individual is observed under different circumstances; and differences between the sexes are evaluated might shed more light on alcohol effects in older active adults.
Hazardous conditions in the home health-care setting may put frail and elderly at risk
07 mar 2009-- – A large-scale study conducted at Columbia University's Mailman School of Public Health has identified the type and frequency of hazardous conditions found in the home healthcare (HHC) setting. An anonymous survey of over 700 home healthcare RNs employed in New York City provided the most complete assessment of homecare hazardous household conditions to date. The most common hazardous conditions found in households were environmental and physical hazards, including animal hair, cigarette smoke, excessive dust, and mold/dampness. Physical hazards, such as loose rugs, were also common. The paper, "Household-Related Hazardous Conditions with Implications for Patient Safety in the Home Health Care Sector," was published in the December 2008 issue of the Journal of Patient Safety.
"Although HHC is the fastest growing sector in the health care industry, data are particularly sparse with respect to patient and provider safety in this setting," says Robyn Gershon, DrPH, professor of clinical Sociomedical Sciences at the Mailman School of Public Health and principal investigator. "Of special concern is the fact that nearly 70% of homecare patients in the U.S. are 65 years or older. Frail and elderly HHC patients may be particularly vulnerable to unsafe conditions." Environmental and physical hazards were three times more likely to be associated with households located in inner-city urban communities compared with other types of communities. The research team also collected extensive data on violence and the threat of violence in the household. Nearly 40% of RNs reported feeling threatened by their clients' neighborhoods and 9% reported the presence of guns in their clients' homes.
"Another important finding from this study was the observation of unsanitary conditions in the household, which could increase the risk of infectious disease," noted Dr. Gershon. Vermin (predominantly rodents, cockroaches, and bedbugs) were noted in over 40% of households. "Poor housekeeping was not uncommon," Dr. Gershon stated, "and may be related to the fact that increasing numbers of elderly patients live alone, and are too frail to perform routine household cleaning."
Importantly, the findings suggest that unsafe conditions in the households of homecare patients could present a risk of injury and illness in both homecare patients as well as the homecare workers who provide them with necessary care.
More than 735 RNs responded to a 96-item questionnaire. Information was also based on qualitative data collected during in-depth interviews, focus groups and cognitive interviews, to assess safety hazards found by RNs in their patients' households. Roughly 44% of RNs' patients resided in urban areas, generally in single-family homes or apartments.
Dr. Gershon believes that organizational characteristics of the RN's agency could increase the risk of adverse events in the HHC setting. While a large majority of RNs (91%) did report receiving infection control training, few RNs reported that they were provided with sharps containers (14%), safety needles and syringes (9%), safety butterfly needles (23%), or safety lancets (26%). Reports of understaffing (37%) were also relatively common.
Dr. Gershon commented, "Some of the household hazards identified in our study might be remedied with relatively simple interventions; for example, HHC workers may use hand gels and creams between treating patients because of the unsanitary conditions of patients' sinks. Other hazards, such as the presence of mice and other vermin, might be more difficult to address, as they generally require the assistance of building managers, contractors, or other outside assistance to remedy. However, because RNs frequently provide patient/family education, they could similarly provide information on achieving and maintaining a clean and safe household."
"Given that 20% of the U.S. population will be over 65 years old by the year 2030, keeping our older population healthy and free from injury is critical," says Linda Fried, MD, MPH, dean of the Mailman School of Public Health. "Research such as Dr. Gershon's is key to help us assess the prevalence of risk factors in the home healthcare setting and the interventions necessary to promote the health, safety, and well-being of older adults – especially frail older adults," added Dr. Fried, an epidemiologist and geriatrician whose career has been dedicated to the science of healthy aging.
The study was funded by the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health.
Older adults control emotions more easily than young adults
Study shows that while regulating a feeling of disgust, older adults perform memory-intensive tasks better than young adults
07 mar 2009--With age comes the ability to better regulate emotions in order to not disrupt performance on a memory-intensive task, according to a study published in the March issue of the journal Psychology and Aging.
The research study found that regulating emotions – such as reducing negative emotions or inhibiting unwanted thoughts – is a resource-demanding process that disrupts the ability of young adults to simultaneously or subsequently perform tasks.
"This study is among the first to demonstrate that the costs of emotion regulation vary across age groups," said Fredda Blanchard-Fields, chair of Georgia Tech's School of Psychology and the study's lead author.
The study – which included 72 young adults who were 20 to 30 years old and 72 adults who were 60 to 75 years old – was funded by the National Institutes of Health. It was conducted by Blanchard-Fields and Susanne Scheibe, a former postdoctoral fellow at Georgia Tech currently at Stanford University.
For the investigation, three-fourths of the participants watched a two-minute Fear Factor television clip depicting a woman eating something revolting in order to win money. The video was intended to induce a feeling of disgust in the participants. The remaining participants comprising the control group watched a two-minute clip of two men talking about a woman's dress and subsequently sharing a beer in silence that was not intended to induce emotions.
After watching one of the videos, each participant played a computer memory game. For the task, a number – between zero and nine – appeared on a computer screen and each participant had to determine whether that number matched the number that appeared on the screen two numbers earlier. Twenty-two trials were presented before the task concluded and a combined performance score was computed.
"To compare the effect that a person's emotion regulation strategies had on his or her performance at the working memory task, the participants who watched the disgust-inducing film were divided into three groups and given different emotion-regulatory instructions," explained Blanchard-Fields.
One group was told to change their negative reaction to the disgusting television clip into positive feelings as quickly as possible and another group was advised to maintain the intensity of their negative reaction to the video and to not change their feelings in any way. A third group received no instructions. The control group that watched the neutral video of the men drinking beer also received no instructions. The volunteers then completed two additional memory games.
The study showed that all of the participants performed better at the working memory task after watching the clip than before, likely due to the learning process. However, after being told to turn their disgust into positive feelings, the young adults performed significantly worse than the older adults in the memory task. Older adults who were given the same instructions continued to improve at the memory task.
"Negative emotions can be toxic and disrupt one's balance in life, so the ability of older adults to regulate negative emotions serves to enhance their quality of life," noted Blanchard-Fields. "Older adults are so efficient at dealing with their emotions that it doesn't cost them any decrease in performance, which is a really positive thing."
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The trial also showed that having feelings of disgust by themselves did not have an effect on performance, as the participants in the control group and the no-instruction group performed similarly in the computer tasks. It also showed that maintaining feelings of disgust that were already present did not disrupt performance in the computer tasks in either age group.
To ensure that feelings of disgust were induced by the film clip, participants reported the extent to which they felt each of eight emotions – disgusted, sad, frustrated, distressed, angry, happy, content and interested – at the beginning of the study, after watching a clip and after each computer task. Watching the Fear Factor video produced elevated disgust ratings in all participants.
After watching the video clip and completing two computer tasks, the group that was told to turn their disgust into positive feelings and the control group both felt the same level of disgust as they did before watching the video. The no-instruction group returned to their baseline level after three computer tasks, and the group asked to maintain their feelings of disgust still had significantly elevated disgust ratings at the final emotion assessment.
"This study tested participants' abilities to perform a computer memory task after watching a clip that induced disgust, but additional research should be conducted to determine whether the present findings apply to all types of cognitive tasks or to all types of negative emotions," explained Blanchard-Fields. For example, sadness is an emotion that is highly relevant to old age and therefore may be harder for older adults to regulate than disgust.
Future studies should also be conducted to determine exactly how older adults achieved the same emotion-regulatory goal with less cognitive effort.
"The amount of resources necessary for older adults to maintain or regain emotional well-being, while performing well at other tasks might be less because they have a wealth of past experience in regulating their emotions – they've been doing it for a long time," said Blanchard-Fields. "On the other hand, younger adults don't tend to regulate their emotions, so it takes effort, which draws away resources so that they don't perform as well on tasks."
The project described was supported by Grant No. R01AG015019 from the National Institute on Aging (NIA). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIA or the National Institutes of Health.
Friday, March 06, 2009
Older adults more impaired by social drinking
Older adults may be more affected by a couple of glasses of wine than their younger counterparts are -- yet they are less likely to be aware of it, a new study suggests.
06 mar 2009--The findings, published in the March issue of the Journal of Studies on Alcohol and Drugs, suggest that older adults should be particularly careful about driving after social drinking.
"How many times have you asked someone, 'Are you OK to drive?'" said senior researcher Sara Jo Nixon, Ph.D., of the University of Florida Gainesville. The problem, according to Nixon, is that there is a "disassociation" between people's perceptions of their abilities after a few drinks and their actual capabilities.
And this may be particularly true of older adults, Nixon and her colleagues found.
For their study, the researchers recruited 42 adults between the ages of 50 and 74, and 26 adults ages 25 to 35. Participants were randomly assigned to drink either a moderate amount of alcohol or a nonalcoholic "placebo" beverage. Each person in the alcohol group was given enough to achieve the same blood alcohol level.
Next, all participants completed the so-called Trail Making Test, which requires takers to connect numbered and lettered dots, in order, as quickly as possibly. It gauges visual-motor coordination, planning and the ability to move from one thought to the next.
They took the test twice, 25 minutes and 75 minutes after drinking.
In general, the researchers found, older adults in the alcohol group performed more poorly on the first test than their younger counterparts did -- an age gap not seen in the placebo group. Yet, when asked how they subjectively felt, the older drinkers thought they were less impaired.
The extra effects of alcohol on seniors are subtle, Nixon pointed out, but could become important behind the wheel of a car.
Her advice to older social drinkers: "Sit around for a while and let the alcohol metabolize. Don't drink and run -- stay and have dessert."
It's not clear why the same blood level of alcohol would affect older and younger adults differently. But it does not seem to be a difference in alcohol metabolism, Nixon said. Instead, she explained, alcohol may affect the brain of older adults differently.
Nixon also pointed out that the study looked only at the immediate effects of alcohol and does not speak to the potential long-term effects of social drinking on brain function. Many studies have suggested that moderate drinking -- such as a glass of wine each day -- may have long-term health benefits, including a lower risk of heart disease.
The Journal of Studies on Alcohol and Drugs is the oldest alcohol/addiction research journal published in the United States today (formerly the Journal of Studies on Alcohol [1975-2006] and the Quarterly Journal of Studies on Alcohol [1940-1974]). It is a not-for-profit journal based at the Center of Alcohol Studies at Rutgers, The State University of New Jersey, Piscataway, NJ. The journal is online at www.jsad.com.