Search

Trauma in the workplace can be precipitated by a number of tragedies, but death of an employee is the most common occurrence. Bereavement, mourning, and grief are common reactions. In most cases, people successfully cope with the death within two months, but some develop chronic grief, which is also referred to as complicated grief. Principles of grief counseling are outlined along with the need for employee training on trauma.

Educational handouts are becoming routine in health care, helping promote health literacy in patients and their caregivers. To be effective, handouts must be tailored to various target audiences. This article discusses several Web sites that provide accurate information for conditions commonly seen in long-term care.

Telemedicine (TM)-providing health services and information via a telecommunications device to patients or colleagues separated by distance-holds the promise of improving access to care, diagnosis and assessment, patient monitoring, treatment adherence, and positive health outcomes. TM is still evolving, and numerous obstacles must be overcome before it reaches its full potential. Major obstacles include licensure and reimbursement issues along with the development of TM care standards. While many studies have addressed TM's effectiveness, findings, although positive, are tempered because of small sample size and other methodological problems. Successful TM is clinically driven where a need is first identified and then a TM solution fulfills that clinical need.

Almost 70% of adults 60 years of age and older are overweight according to the National Health and Nutrition Examination Survey 2005-2006. While being overweight is linked to numerous comorbidities and functional impairment, few studies have addressed obesity in elders, and even fewer have addressed sarcopenic obesity. Elder obesity requires different strategies, partly because most approved weight-reduction agents and/or surgical interventions are contraindicated in older adults. Strategies and objectives for weight loss are discussed along with the consultant pharmacist's role.

Walking appears to be a simple innate ability, but it is an extraordinarily complex process involving three major afferent systems (visual, proprioception, and vestibular). Humans' unique gait is established around age seven. Velocity and step-length change with age, but the overall package we call "gait" remains stable. Age is the single most important factor in changing gait, with some normal changes expected. Gait disorders, beyond what are normal age-related changes, are common among elders. At 60 years of age, 15% of elders have gait problems, increasing to 82% for those 85 years of age and older. Abnormal gait movement can be broadly defined as hyperkinetic (too much movement) and hypokinetic (too little movement). Gait disorders are classified into lowest level (affecting one afferent system), middle level (more afferent system involvement), and highest level (characterized by planning deficits) disorders. Gait disturbances may be a manifestation of underlying conditions or may be drug-induced. To treat gait disorders appropriately, clinicians must review the patient's disease progression, medication status, and environmental conditions. Physical therapy, medication changes, and, rarely, surgery can help improve gait.

Aging is associated with physical decline, often accompanied by pathology and disability that can cause unhappiness and dissatisfaction. Despite this, many elders report a high level of satisfaction. This article discusses the anxiety associated with aging that some people experience, highlights research findings and models of aging, and pays particular attention to how elders compensate and cope with loss. Long-term care practitioners can help residents deflect negative stereotypes and improve their own attitudes about aging.

When tragic circumstances force families to focus on an individual's right to refuse treatment, society is forced to reexamine its views on life and death; these circumstances may result in legal rulings and state statutes. During media coverage of high-profile cases, reporters frequently used distinct terms like "brain dead," "persistent vegetative state," and coma interchangeably, but they are clinically different. Today, most bioethicists believe the right to refuse treatment is legally and ethically settled, but decision-making in individual circumstances often may remain less clear and emotionally charged. Even in the best situations, abatement of nutrition during the end-stage of illness continues to be difficult, often colored by religious, cultural, and racial or ethnic perspectives. Decision-making to withhold or withdraw feeding tubes for younger patients is even more difficult and raises many additional questions. Once a decision to withdraw a feeding tube is made, clinicians and the patient's loved ones need to know what to expect.

Characterized by chronic, widespread pain and heightened pain sensitivity, fibromyalgia affects up to 10 million adults. It is physically disabling and often is accompanied by chronic fatigue and psychiatric comorbidities. Individuals frequently see multiple providers before finding an answer about their condition; diagnosis is often a process of elimination. Etiology is unknown, but studies suggest fibromyalgia is a centrally mediated neurosensory disorder. Despite its recognition as an independent condition, debate continues with critics arguing fibromyalgia is a variant of other known disorders. Treatment consists of pharmacotherapy, psychotherapy, and exercise.

The transition from one's own home into institutional settings is often difficult for residents and families. Historically, dependent elders wishing to remain in their communities had few options. Seniors now have multiple aging-in-place options that support their significant lifestyle demands and allow them to live with other like-minded individuals. These include privately developed age-restricted, gated retirement communities; continuing-care retirement communities; and naturally occurring retirement communities. Housing concerns include design elements that make homes more accessible for elders and people with disabilities, but also make the home more functional for others ("universal design").

PROBLEM: We're so busy taking care of others that we rarely have time to focus on our own health needs. I've read that many companies have employee wellness programs (EWPs). Do they really work? Is this something we should consider? SOLUTION: Getting chubby? Smoking too much? Stressed? Health in decline? Dragging yourself to work even if you're too sick to be productive, EWPs can help. Today, up to 90% of employers have at least one activity promoting wellness, ranging from printed material to in-house fitness centers and one-on-one counseling. Implementing a successful wellness program, however, can be challenging, especially in health care, where almost any employee activity competes with direct patient care.

Today's prisons are vastly overcrowded and ill prepared for the fastest growing segment of the inmate population: those 50 years of age and older. Collectively, such inmates present with age-related illnesses earlier, and often their conditions are more complex than similar nonincarcerated people. Prisons focus on discipline and order; as a result, they have had to adapt to the health care needs of aging inmates, especially those with physical impairments. While some prisons have created special units for older inmates, demand for such units outpaces supply. Medication errors are common as is medication nonadherence. Continuity of care is compromised both within the system and at the point of community release. Regardless, the prison setting offers many opportunities for pharmacists to expand their practices in ways that are rewarding.

Kidney stones are among the more common and painful urological disorders, affecting approximately 10% of Americans. While most stones pass spontaneously, obstructions result in renal colic, often requiring aggressive management of pain. If obstructions persist, extracorporeal shockwave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy may be required for a stone's removal. Recurrence rates are high, and prevention includes increased fluid intake, dietary restrictions, and the use of pharmacotherapy. Stone recurrence increases with age, underscoring the importance of prevention for those 60 years of age and older.

Approximately 134,000 amputations occur annually in the United States, resulting mostly from peripheral vascular disease. The risk of amputation increases with age, peaking among those 85 years of age and older. As a lifesaving and life-defining procedure, amputations result in physical and emotional changes affecting quality of life. Phantom pain is problematic for many patients, and agents approved by the Food and Drug Administration for phantom pain are nonexistent. Pharmacists should be knowledgeable about weight-based dosing as well as patient education guidelines.

While skin tears are common among the elderly in general, and residents of long-term care facilities in particular, there has been limited research into their treatment. Many facilities voluntarily track skin tears, and some states require facilities to report these events. Risk factors include age, xerosis (abnormal eye, skin, or mouth dryness), need for help in activities of daily living, presence of senile purpura, visual impairment, and poor nutrition. Plans to prevent skin tears that employ skin sleeves, padded side rails, gentle skin cleansers, moisturizing lotions, as well as staff education, can decrease by half the number of skin tears incurred in a long-term care facility. Although the treatment process seems simple, it is time consuming and can be painful for the patient. Residents with dementia or agitation often try to remove bulky dressings used to cover skin tears. Dressing changes may injure the fragile wound via skin stripping.

Each year as many as 90,000 patients die from facility-acquired infections. Data indicate up to 70% of acquired infections are antibiotic resistant. Hands are the most common routes for transmission of infections. Efforts to improve hand hygiene involve more than the duration of hand washing--they should address disinfectants used, fingernail cleanliness, jewelry worn, and shirtsleeve length. Several low-cost interventions help minimize the spread of infections; alcohol-based handrubs are especially effective. Organizational improvement programs should address hand hygiene compliance.

Essential tremor (ET), traditionally considered benign, is a serious neurologic condition with life-altering repercussions. Its involuntary, rhythmic oscillations involve alternating, irregular, or simultaneous contractions of agonist and antagonist muscles. It is the most common of the 20 known tremor disorders and often confused with Parkinson's disease. Numerous drugs can aggravate ET, and alcohol consumption may alleviate it. Its etiology is unknown. Proven drug treatments are currently limited to propranolol and primidone. This article reviews ET with examples from history to demonstrate points.

Optimism is linked to positive health outcomes, although its mechanism is largely unknown. Evidence supports two independent types of optimism: dispositional optimism, which is similar to other personality traits, and explanatory optimism, which affects an individual's interpretation of success and failure. Generally, individuals scoring high on optimism have better health outcomes, and when confronted with life-threatening illnesses, cope with the illness in a healthier manner. Cognitive behavioral therapy offers one potential intervention that may increase a person's level of optimism, with a corresponding increase in health outcomes.

The number of hip fractures increases substantially with age, and they often become life threatening. Fractures can increase postsurgical incidences of deep venous thrombosis, delirium, persistent pain, wounds, and urinary tract infections. The one-year mortality from hip fractures is 20%, but prophylaxis interventions improve outcomes. Rehabilitation is patient-specific and focuses on maximizing functional status and minimizing future risks. Ongoing medication review and assessment are important components in preventing fractures.

Inadvertent puncture during use, disassembly, or disposal of needles or sharp devices (called collectively, "sharps") creates risk beyond a simple puncture. Sharps injury has always been a risk for health care workers, but emergence of certain blood-borne pathogens has intensified the need to act. Three- hepatitis B, hepatitis C, and HIV-are of utmost concern because they can cause significant morbidity or death. The incidence of sharps injury remains unacceptably high. Injury analysis at long-term care facilities and at the national level reveals several trends that can be used to shape policy and select interventions. Policy, practice, and training need to address new devices engineered to prevent sharps injuries, sharps disposal containers, and prophylaxis after percutaneous injury.

PROBLEM Our facility encourages family involvement, but some families are rude, intrusive, or disruptive. Occasionally, this derails staff-family relationships. How can we turn this around? SOLUTION Family vigilance at its most intense can become disruptive. Understanding the dynamics of family vigilance is key. Knowing, anticipating, and preventing its pitfalls make family involvement an asset.

When groups of people relocate from their homelands to other nations, especially if the movement is involuntary, minority populations are created in the countries that receive them. The issues related to these diaspora and diasporic communities--any groups that have been dispersed outside their traditional homelands--are financial, social, historical, political, or religious. In health care, issues include heritable diseases, cultural barriers, patients' health care beliefs, and unique disease presentations. In long-term care, many residents and health care providers have relocated to the United States from other countries.

PROBLEM: In the long-term care facilities where I work, I've noticed certain ways health care providers converse with residents, and I am starting to pick up these speech patterns myself. Are these language changes helpful, or are they communication hazards? SOLUTION: Although most people pick up on the special language caregivers often use with long-term care residents and elders in general, few question its appropriateness until they are old enough to be subjected to it. Since the late 1980s, however, researchers have been examining this vernacular. It has acquired a number of names, such as "secondary baby talk" or "overaccommodative speech," but the tag used most often is "elderspeak."

More than 70% of nursing home residents spend at least part of their day in wheelchairs. Ideally, each resident would be fitted for his or her own wheelchair. A well-fitted chair can improve mobility, safety, and comfort. Wheelchairs that are ill fitting, however, can cause or exacerbate medical problems. These include posture-related complications like poor breathing or dysphagia, falls, pressure sores, and several other conditions. Pharmacists who are involved with quality improvement activities can make wheelchair use and selection a priority, improving care for wheelchair-bound residents.

Numerous market factors have converged to create a need for change in the drug development process. Public scrutiny, high failure rates for investigational agents, and concern about the use of animals in research, are just a few. In response, some changes in this process are being made. Microdosing--administering very small, radiolabeled doses of investigational agents to humans--is one change that has the potential to save time and money. It is used to elucidate the pharmacokinetic profile of agents. Not all experts agree that it will live up to its promise, but the potential is great.

Vertigo is a common balance deregulation symptom among elders. Its etiology may be peripheral vestibular disease or a central vestibular disorder. Symptom onset, severity, and duration are distinguishing characteristics. The majority of peripheral vestibular disorders include benign paroxysmal positional vertigo, vestibular neuronitis, Meniere's disease, and perilymph fistula. Medication regimen review is necessary to identify possible drug-induced etiology. Treatment options include pharmacotherapy, canalith repositioning procedures, surgery, vestibular rehabilitation therapy, and dietary interventions.

Long-term care facilities have tracked resident data for decades. Using those data, researchers have been able to identify and track trends. Resident demographics, facility information, and types of deficiencies uncovered by state surveys are three types of data of interest to consultant pharmacists. Examining trends can provide clues about areas where improved training, greater scrutiny, or targeted interventions may next be needed.

Clinicians use the word disinhibition and its derivatives to describe a resident's behavior. Up to 30% of people with dementia may manifest behavioral disinhibition; sexual disinhibition is also a problem, but less frequently. Several causal relationships have been hypothesized, with frontal lobe deterioration among the best documented. Lobar lesions or trauma, seizure activity, cerebellar dysfunction, and drugs have been implicated as well. Behavioral disinhibition creates clinical challenges in the long-term care facility, and to date, no drug treatment has been approved for this indication. Behavioral interventions are the strategies of first choice. Reports of drug treatment are limited to case reports and very small studies.

Although rare, spontaneous remissions or remarkable recoveries occur and are sometimes documented in the medical literature. In the past, researchers who examined remarkable recoveries were able to identify some components of cellular healing. Modern day examination could identify previously unknown interventions or keys to self-healing. Today's researchers suspect that physiological and psychological factors may be involved.

PROBLEM: One of my older colleague's work is steadily declining, and sometimes her judgment seems "off," and she is easily distracted. Alcohol and drugs are most certainly not the problem nor is this a disability that is protected by the Americans with Disabilities Act, requiring accommodation. I want to help, but I'm not sure what to do. Any suggestions? SOLUTION: Deteriorating performance often is associated with difficulty with perception, memory, task perseverance, and reasoning skills-in other words, cognitive impairment. It's observant of you to note that alcohol/drugs are not an issue. Most people associate declining performance with alcohol or drug abuse for good reason; more often than not, employee assistance programs (EAPs) find alcoholism and drug abuse when employees are referred to them, and in fact, EAPs were initially developed with alcohol-related problems in mind. EAPs now offer help in many more situations, including situations like this. Language: en

Chronobiology focuses on variations in biological rhythms across time. This article describes biologic cycles, particularly circadian cycles and their underlying neuroanatomy. Metabolic rhythms are reviewed and their impact on disease and symptom variation discussed. Clinical and chronopharmacological implications and diagnostic applications are presented, highlighting chronotherapy's perspective.

Medical applications (apps) for smart phones have grown in popularity, with minimal oversight by regulatory agencies. A few Web-based resources exist that evaluate apps using peer review or certification standards. Eight clinical apps are presented along with brief explanations of each. Many users believe apps improve patient care and clinical decision-making, but until additional research is conducted, these assertions remain untested assumptions.