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October 2011 • Volume 9 Number 9
Preventing falls C. Dwight Townes, MD
Diabetes Special focus
Menopause Donna Block, MD
You call it “reminding mom to take her pills.�
We call it caregiving.
You or someone you know may be a caregiver. WhatIsACaregiver.org
CONTENTS
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OCTOBER 2011 • Volume 9 Number 9
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NEWS
PEOPLE
SPECIAL FOCUS: DIABETES Systemic interventions for a systemic disease
MINNESOTA HEALTH CARE ROUNDTABLE
By Tai J. Mendenhall, PhD, LMFT, and Max Zubatsky, LAMFT
PERSPECTIVE Mark Zeigler, DC Northwestern Health Sciences University
19 24
CALENDAR Prescription drugs
T H I R T Y- S I X T H
SESSION
PATIENT TO PATIENT Shared decision-making: a case in point By John Malan
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10 QUESTIONS Eli Coleman, PhD Center for Sexual Heath, University of Minnesota Medical School
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SPECIAL FOCUS: DIABETES Eye health in childhood diabetes By Linda Chous, OD
16 20
Prediabetes ... a family affair
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ALZHEIMER’S A diagnosis of Alzheimer’s— now what? By Monica Heltemes, OTR/L
28 32
WOMEN’S HEALTH The change By Donna Block, MD
GERIATRICS A balancing act: rowing old and preventing falls among seniors By C. Dwight Townes, MD, and Amy Taylor-Greengard, PT, GCS
By Marsha Hughes, MS, RD, CDE
Improve mood to improve diabetes By Roger G. Kathol, MD; Renee Koronkowski, MD; William Meller, MD
Accountable Care Organizations Accountable to Whom? Thursday, October 13, 2011 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
Background and focus: Created as part of national health care reform, accountable care organizations (ACOs) are now part of every health care policy discussion. As defined by the 111th Congress, ACOs are organizations that include physicians, hospitals, and other health care organizations with the legal structure to receive and distribute payments to participating physicians and hospitals to provide care coordination, invest in infrastructure and redesign care processes, and reward high-quality and efficient services.
Exactly what this means is unclear, and a confusing array of levels and qualifications for ACOs has been proposed. With 2012 as a start date for Medicare reimbursement through ACOs, Congress is developing firm definitions at this time. Some say ACOs turn physicians into insurance companies; others say they are a way for physicians to take a leadership role in fixing a broken system. As health care organizations race to join, create, or redefine themselves as ACOs, they all face more questions than answers. Objectives: We will review the history, goals, and rationale behind the ACO model. We will review the latest federal guidelines defining what an ACO can be. We will discuss how the ACO will affect health insurance companies, employers, and the pharmaceutical industry. We will illustrate what must not be allowed to happen if the model is expected to succeed. We will examine who decides if ACOs are successful and how those decisions will be made. We will explore why so many people, representing very different perspectives on health care, are opposed to the idea and what can be done for it to achieve its best potential. Panelists include:
www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com
N Michael Ainslie, MD, Pediatric Endocrinology, Park Nicollet Clinic N Dave Moen, MD, President, Fairview Physician Associates N Jennifer Sorensen, Executive Director, Minnesota Home Care Association N Vernon Weckwerth, PhD, University of Minnesota School of Public Health, Health Policy and Management
ASSOCIATE EDITOR Mary Scarbrough Hunt mshunt@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com
Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address
Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.
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Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.
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OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
3
NEWS
Obama Talks Health Care Reform In Cannon Falls President Barack Obama kicked off a three-state tour in August with a town hall meeting in Cannon Falls, where he discussed mostly economic issues, including health care reform. Obama fielded two questions about health care. In the first question, he was asked about the rising cost of prescription drugs. Obama noted that the Medicare drug benefit passed by his predecessor, George W. Bush, has been helpful to seniors. But, he added, costs are continuing to rise. He said his Affordable Care Act (ACA) is helping by easing the way for generic drugs to come to market, giving a $250 rebate to every senior, and closing the “donut hole” that previously increased costs for seniors. The president was next asked about the constitutional challenge to the ACA’s individual mandate provision. An appeals
4
court in Atlanta recently ruled that the individual mandate was unconstitutional, and the issue is likely to be decided by the Supreme Court. Obama started out by listing many things in the ACA that would not be affected by the court challenge, such as insurance reforms, patient protections, and setting up insurance exchanges. However, he noted, if the individual mandate is struck down, there’s nothing to prevent people from being “free-riders,” that is, those who don’t purchase health insurance until they are sick or injured. “If an insurance company has to insure you, even if you’re sick, but you don’t have an individual mandate, then what would everybody do?” Obama asked. “They would wait until they get sick and then [they’d] buy health insurance, right?” Obama added that it would be unfair to those who have been responsible and bought insurance if the uninsured
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
got expensive care without first paying into the system. Obama noted that the individual mandate was originally a Republican idea, joking that his political opponents had developed amnesia on the issue. He said he believed the individual mandate should not be a controversial measure. “If the Supreme Court follows existing precedent, existing law, it should be upheld without a problem,” Obama said. “If the Supreme Court does not follow existing law and precedent, then we’ll have to manage that when it happens.”
Mayo Opens Facility At Mall of America Mayo Health Clinic opened a new health facility at the Mall of America in Bloomington recently. Officials say the new facility, called Create Your Mayo Health Experience, is not a clinic but will promote health and wellness, with guests invited to complete a wellness assessment, speak with
health coaches, and access resources to promote healthy living. “What differentiates this space is that it’s totally customized, allowing you to do as much or as little as you want. Whether stopping in to buy a book and leave, registering to further personalize your experience, or even meeting privately with a health experience navigator, this is truly a customized experience,” says David Hayes, MD, a cardiologist at Mayo Clinic who is leading the Mall of America project. “Create Your Mayo Clinic Health Experience is a partnership between you and Mayo Clinic to improve your health and well-being.” Mayo officials have downplayed the growing presence of the Mayo Clinic brand in the Twin Cities metro area, but the addition of the new wellness facility has drawn attention, as has Mayo’s purchase of a hospital in New Prague and an oncology clinic in Northfield.
Budget Analysis Says State Deal Hurts Poor, Elderly An analysis of the recent budget deal reached between state legislators and the Dayton administration finds that the deal could negatively impact the health of vulnerable populations such as the elderly, the disabled, and the poor. The report, released by the Minnesota Budget Project, echoes warnings voiced by health care groups when the budget bill was being debated. Those groups warned against balancing the budget on the backs of vulnerable populations. The report finds that the agreement’s $1 billion in health and human services cuts will likely have exactly that effect. The new budget increases barriers for low-income Minnesotans seeking affordable health care by increasing copayments and deductibles for public programs. It also creates a new voucher program for the MinnesotaCare program, which was designed to help some enrollees find private insurance. The report questions whether those in the MinnesotaCare program will be able to find affordable options. Other areas affected by cuts are mental health services for children and adults. Seniors and people with disabilities may find it harder to stay in their homes, the report finds. The report also sees cuts in payments to hospitals and other providers as having a negative effect. “These cuts could lead some providers to cut back on their level of services, and might force some to close their doors entirely.”
DHS Establishes Inspector General Office The Minnesota Department of Human Services (DHS) has announced it will coordinate its fraud prevention and recovery efforts under the office of
Inspector General (OIG), similar to models used by the U.S. Department of Health and Human Services and 16 other states. Officials say the reorganization will improve DHS’ fraud prevention and recovery efforts and more effectively structure staff who investigate and audit DHS programs. They add that the OIG model has traditionally had greater independence from the areas it monitors and stronger mechanisms to monitor and report abuse. “Fraud prevention and recovery is a critical part of what we do every day at DHS,” says DHS Commissioner Lucinda Jesson. “Every dollar of waste and fraud is one less dollar that goes to the people we serve. All Minnesotans deserve to know that DHS takes its role as stewards of its public dollars seriously, and will not tolerate those that misuse them.” Currently, fraud prevention and recovery efforts are located in the program areas they monitor. With the reorganization, such efforts will be consolidated into a single office and operate out of the office of the commissioner. This includes health care, child care, and food support fraud detection and recovery efforts. Jerry Kerber, current DHS licensing director, will head the OIG office as Inspector General.
CDC Data Show Teen Vaccinations Up New data from the Centers for Disease Control and Prevention (CDC) show that a greater number of teens in Minnesota are receiving recommended vaccinations, state health officials say. However, officials with Minnesota Department of Health (MDH) say Minnesota can do better, noting that the rates of vaccination during teen years are still not as high as they should be. The CDC report shows that immunization rates for the relatively new tetanus-diphtheriapertussis booster (Tdap) increased from 52 percent in 2009 News to page 6 OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
5
News from page 5 to 70.3 percent in 2010. In addition, immunization with meningococcal vaccine, which protects against a serious form of meningitis, increased from 43.9 percent to 57.0 percent. And 37.8 percent of adolescent girls had completed the three-dose series of human papilloma virus (HPV) vaccine, which prevents cervical cancer, up from 27.0 percent in the prior year. “We’re pleased that Minnesota continues to show improvement in coverage rates for these important vaccines,” says Kristen Ehresmann, director of Infectious Disease, Epidemiology, Prevention and Control for the Minnesota Department of Health. “We’re making progress, but these results also tell us we still have much work to do before we can say our young people are sufficiently protected from these diseases.” Officials note that Minnesota vaccination rates for the diseases have risen at a pace that is similar to national averages.
Franken Says Medical Loss Ratio Holds Down Costs Sen. Al Franken is touting a new report by the Government Accountability Office (GAO) that looks at the Minnesota senator’s signature contribution to the federal health care reform law: establishing a medical loss ratio (MLR) standard for health insurance plans. Medical loss ratios are generally defined as the percentage of premium dollars spent on actual health care costs, rather than on expenses such as administration or marketing. Franken authored the MLR language and has often cited Minnesota’s nonprofit health plans as examples where premium dollars are spent efficiently. In bringing MLR language to the Affordable Care Act (ACA), Franken said that setting limits on how much plans could spend on things like administration and executive salaries would save money for consumers.
Under the ACA requirements, large group health insurers must spend at least 85 percent of what they collect in premiums on actual health services. Small group and individual market insurers are required to spend at least 80 percent on medical costs. The report found that in recent years, most plans spent more on non-health care costs than what the ACA requirements now allow. Health insurers told the GAO that changes in the MLR formula under ACA will have an effect on how they report their numbers in the future, and also said they will be able to report MLRs in more detail because of the changes. In surveying insurers, the GAO found that nearly all health plans said they would decrease commissions to insurance brokers as one way to adjust their MLRs to meet the new requirements. Many also said they would make changes to premiums—presumably lowering premiums charged for health insurance products.
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The report found one larger insurer that said it will consider exiting the individual market in some states because of the MLR requirements, but added that several other insurers said that the MLR requirements will not affect where they do business. After the report’s release, Franken issued a statement saying the GAO findings show that the MLR provision is bringing down health insurance costs for consumers. “This report shows that my provision is already causing insurance companies to lower premiums for consumers over excessive profits and CEO salaries,” says Franken. “Starting next year, insurance companies that fail to spend at least 80 percent of the premiums they receive on actual health care will have to refund consumers the amounts they were overcharged. Ultimately, people all over the country will receive a better value for their health care dollar.”
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The Minnesota Telephone Equipment Distribution Program can provide special telephone equipment at NO CHARGE to Minnesota residents of all ages!! The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment. To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply. The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.
PEOPLE Timothy K. Starr, PhD, has joined the University of Minnesota Masonic Cancer Center Division of Gynecologic Oncology as an assistant professor. Starr earned his PhD in molecular, cellular, developmental biology and genetics at the University of Minnesota. His research is aimed at understanding the genetic basis of cancer in order to develop individualized, targeted therapies; to identify new drug targets; and to understand the signaling pathways that cause cancer. He is currently studying genetic changes that cause ovarian, lung, and colon cancer. In addition, the Masonic Cancer Center’s Michael Verneris, MD, has received the Relentless for a Cure Award from the Minnesota chapter of the Leukemia and Lymphoma Society. The award is given “in recognition of excellence in service that has improved the quality of life of patients and families.” Affiliated Community Medical Centers added three new providers in August. Leah Schammel, DO, received her doctor of osteopathy degree from A.T. Still Leah Schammel, DO
University–Kirksville (Mo.)
College of Osteopathic Medicine, and completed her residency at Oakwood Southshore Hospital in Trenton, Mich. She will practice at the ACMC–Willmar Main Clinic. Oncologist Louay Hanna, MD, received his
Louay Hanna, MD
medical training from Damascus (Syria) University. He will be based out of the Willmar Regional Cancer Center. Meghna Mansukhani, MD, received her medical degree from Osmania Medical College, India, and completed a residency in Meghna Mansukhani, MD
family medicine and a fellowship in sleep medicine
at the Mayo School of Graduate Medical Education, Rochester. She will practice at the ACMC–Willmar Main Clinic. Timothy P. Michals, MD, MT, joined Affiliated Community Medical Centers in September. He will practice internal medicine and pediatrics at the ACMC clinic in
Timothy P. Michals, MD, MT
Marshall. Michals received his medical degree from Rosalind Franklin University of Medicine and Science, The Chicago Medical School, in North Chicago, and completed his residency at the University of Illinois College of Medicine in Peoria. Jody Giza, PA-C, has joined Lakewood Health System in Staples as a physician assistant. Giza was a physician assistant student at Lakewood Health System in 2003 and 2004. She comes to Lakewood from Minneapolis Heart Institute, where she served nearly six years as a cardiology physician assistant, first at Abbott Northwestern Hospital and most recently in Brainerd and Crosby. Giza received her master’s degree in physician assistant studies at Augsburg College in Minneapolis, and has a bachelor's degree in respiratory care. Giza is certified by the National Commission on Certification of Physician Assistants and licensed by the state as a physician assistant. She received Tobacco Treatment Specialist certification from Mayo Clinic in 2009.
OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
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PERSPECTIVE
Pillsbury House Integrative Health Clinic Partnering to provide a new model of integrative health care
T
ucked away in a neighborhood center in the Powderhorn community of Minneapolis is a little-known clinic that’s changing the way people think about health care. Every Wednesday and Saturday, students studying chiropractic, massage therapy, acupuncture and Oriental medicine, psychology, and health coaching team up with nursing and medical students to provide free integrative health care to residents of one of the poorest neighborhoods in south Minneapolis. Mark Zeigler, DC Northwestern Health Sciences University
Dr. Zeigler has been president of Northwestern Health Sciences University since 2006 and is vice president of the Association of Chiropractic Colleges. He also serves on the boards of the Academic Consortium for Complementary & Alternative Health Care, the Minnesota Campus Compact, and the Foundation for Chiropractic Progress.
The clinic sees 50 to 70 patients each week. Many patients live in the surrounding community and have no health coverage. Some are self-employed or working in jobs that have no health benefits. Still others have health insurance, but it doesn’t cover or limits natural health care treatments.
Since 2007, the Pillsbury House Integrated Health Clinic has combined complementary and alternative medicine with traditional medical care to serve the unique health needs of the neighboring A swelling patient volume prompted a 2009 community. The Pillsbury House Integrated expansion of the clinic’s physical space. Formerly Health Clinic is a collaborative effort among housed in the basement of the Pillsbury House, Northwestern Health Sciences University which also served as the center's daycare, the (NHSU); University of Minnesota’s Medical clinic now has three dedicated spaces plus a School, School of Nursing, and the Center for small office. Over time, patient growth created a Spirituality and Healing; and the Adler Graduate demand that was hard to keep up with. The team School. It is the first student-run integrated spent most of this past summer brainstorming health clinic and operates in how the clinic could enhance the Pillsbury House, located the patient experience. The The unique care at 3501 Chicago Avenue clinic now offers scheduled South in Minneapolis. model was designed appointments, instead of 100 percent walk-ins. Also, the Clinic patients are treated to benefit both the clinic added Monday evenwith a unique approach to patient and the student. ing hours for acupuncture health care that combines and massage therapy treatmedical, psychological, and natural health care treatments. Under the super- ments for patients who have already visited with vision of faculty clinicians, students collaborate a care team. to combine their skills and provide a care plan It is still not considered “mainstream” for tailored to each patient. The patients get the best providers from the allopathic and natural health of all the professions because the students aren’t care fields to join efforts in treating patients. At competing—they are there to work together to Northwestern, we are pushing the boundaries to help the patient. Best of all, the care is free and create new models of care. We are pushing for open to the public. legislation that benefits the natural care profesThe unique care model was designed to benefit both the patient and the student. A patient first visits with a student who serves as a patient advocate and documents their health history. Then the patient visits with an integrated health care unit, which can consist of a combination of one or more students from the acupuncture, chiropractic, massage therapy, psychology, nursing, or medical school. Typically around 20 students per shift staff the clinic. All of the students are volunteers, although their time at the clinic counts toward required clinical training hours. The Pillsbury Clinic provides a rich clinical learning experience, according to Michele Renee, DC, the clinic chief of staff
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and assistant professor in the School of Massage Therapy at NHSU. “For the right student it's a great opportunity.They will experience a range of patient concerns that it would take years to encounter in the typical practice. One of the goals is to maintain a strong learning component for the students, so we’re constantly trying to be innovative in our thinking.”
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
sions. We are delivering the best natural health care education to ensure a new generation of practitioners. All the students involved at the Pillsbury House Integrated Health Clinic demonstrate a willingness to learn from one another in order to better treat the patients they see.This collaboration and the partnerships that support it are a sign of progress. Patients deserve to have all treatments and health care options available to them. We hope that clinics like this will inspire others to work together to create new models of providing integrated health care.
A philosophy of caring is good. A history of it is better. Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity. That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.
www.good-sam.com
To learn more about our communities in Minnesota, call 1-888-GSS-CARE.
The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016
10 QUESTIONS
& Eli Coleman, PhD Dr. Coleman is professor, director, and chair in Sexual Health at the Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School. He has authored numerous articles and books, and has been a frequent expert consultant on sexual health issues around the world. Would you please define the term “sexual health”? At the individual level, sexual health means having self-esteem and a positive sexual identity; taking responsibility for the consequences of one’s choices and their impact on others; preventing or treating sexually transmitted diseases (STDs); having a positive, respectful approach to sexuality (free of coercion, shame, discrimination, and violence); and establishing honest communication and trust between partners. For a community, it means respect for individual differences and access to medically accurate sex ed information and sexual health care. What is the difference between “sex” and “sexuality”? People often use these terms interchangeably but there is an important distinction. “Sex” is commonly used to describe a sexual act, but it actually refers to the biology that makes one male, female, or intersex (genital ambiguity). “Sexuality” refers to an individual’s sexual identity, which encompasses one’s attractions, thoughts, fantasies, behaviors, and relationships. What can you tell our readers about maintaining sexual health? Sexuality is an important part of our lives, and each stage presents new challenges and new opportunities. Maintaining physical and mental health contributes to sexual health, and vice versa. Communicating one’s needs and desires with a partner keeps relationships alive and fulfilling. In terms of sexuality, what is “normal” and what are myths? There is a wide range of normal behavior with regard to sexual activity, frequency, and attraction. I think people would be surprised to know that sexual dysfunctions and disorders are common. However, common does not always mean normal; individuals experiencing sexual dysfunction should seek professional help. There are two common myths: First, people fear that providing sex education to young people will lead them to become sexually active. The fact is that sex education delays sexual activity, encourages responsible sexual behavior, reduces teen pregnancy and STDs, and helps individuals to establish satisfying intimate relationships. The second myth is that men and women stop being sexual at age 50 or 60, which is far from the truth.
Photo credit: Bruce Silcox
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How can we become a sexually healthier nation? Unfortunately, our society is pretty dysfunctional. The U.S. has some of the highest rates of sexual health issues (e.g., teen pregnancy) in the developed world. I am currently consulting with the Centers for Disease Control and Prevention to develop a national strategy to promote sexual health. In an effort to prevent problems before they begin, the strategy will promote effective sexuality education, provide access to integrative sexual health services, and promote sexual health research. We hope to improve the current climate so that we as a society can have mature and honest communication about sexuality.
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
“
”
Maintaining physical and mental health contributes to sexual health.
How did the Center for Sexual Health get started? In 1970, the Program in Human Sexuality was founded at the University of Minnesota Medical School to conduct research and provide education in the area of sexuality. In 1973, we began to offer services at our new clinic, the Center for Sexual Health. Since then, we have provided thousands of individuals and families with psychological and medical care for a myriad of sexual concerns. What are the most common reasons people come to the clinic? Common issues for women are low sexual desire, sexual pain, and lack of orgasm. For men, the issues are erectile dysfunction, rapid ejaculation, and low sexual desire. For couples, the most common issue is desire discrepancy. Sexual dysfunction impacts relationships; likewise, relationship problems negatively impact sexual relationships. We treat both. Another common problem is impulsive/compulsive sexual behavior, i.e., out-of-control behavior that causes distress and interferes with social and occupational functioning. The clinic offers transgender services; what does this mean? The transgender community is diverse, with specific health care needs. We provide care for all of these individuals including people who identify as transgender, transsexual, crossdresser, bi-gender, and gender queer. We offer physical health care (including medication and feminizing or masculinizing hormones); psychological, physical, and psychiatric evaluations; and psychotherapy (individual, group, couple, and family). We work with the families of children and ado-
lescents who are gender non-conforming, meaning that they express their gender differently than the societal expectations for their biological sex. We also work with a team at the U of M’s Disorders of Sex Development clinic to provide psychological services to families who have children with intersex conditions (genital ambiguity). What unique sexual health issues do individuals with same-sex orientations face? While the social climate in the U.S. has improved, individuals who are gay, lesbian, or bisexual (GLB) still encounter prejudice and discrimination. These barriers make it challenging for individuals to feel good about themselves or their sexuality, which impacts the development of healthy, loving relationships. This population experiences higher rates of depression, suicide, chemical dependency, and STDs. Many of the challenges that GLB individuals face are not unique, though; they have the same needs and desires as anyone. Tell us about some of the research you do. I am trying to better understand impulsive/compulsive sexual behavior. Often characterized in the media as “sexual addiction,” this is a highly debated and misunderstood clinical phenomenon. I am trying to better conceptualize the problem, develop an assessment tool, and improve treatments. I maintain an interest in HIV prevention, sexual offender treatment, and sexual identity development. I have also been conducting research in various areas of the world where gender variance is not nearly as stigmatized as it is in the U.S.
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OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
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DIABETES
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however, do not detect a number of eye health problems. Children with diabetes are in special need of an annual comprehensive eye exam, because eye conditions are more common for those with juvenile (type 1) diabetes. The eye disease primarily related to all types of diabetes is retinopathy, but cataracts and glaucoma can also occur. Type 1 diabetes is usually diagnosed before age 20 and is caused by a decreased production of insulin, which the body needs to turn blood sugar (glucose) into energy. Too little insulin means high blood glucose levels, which can harm organs including the kidney and eyes. Insulin supplementation is needed. By Linda Chous, OD Type 2 diabetes in the past was confined to adulthood, but is now rapidly increasing in children and adolescents in the U.S. due to the epidemic of childhood obesity. In type 2 diabetes, the body produces insulin but is unable to use it. In these cases,
ision problems affect 20 percent of school age children, yet parents often underestimate the importance of comprehensive eye exams. Typical vision screenings in schools measure visual acuity from a distance of 20 feet. These screenings,
Eye health in childhood diabetes Protecting vision for life
Eye health to page 15
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MINNESOTA HEALTH CARE NEWS OCTOBER 2011
FOR TYPE 2 DIABETES
Victoza® helped me take my blood sugar down…
and changed how I manage my type 2 diabetes. Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells. While not a weight-loss product, Victoza® may help you lose some weight. And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.
Model is used for illustrative purposes only.
Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children. Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,
If you’re ready for a change, talk to your doctor about Victoza® today.
or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis. Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.
Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies. Please see Brief Summary of Important Patient Information on next page. If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088. Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011
To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).
Non-insulin • Once-daily
• Serious low blood sugar (hypoglycemia) may occur when Victoza® is used with other diabetes medications called sulfonylureas. This risk can be reduced by lowering the dose of the sulfonylurea.
Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you. WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body. What is Victoza® used for? • Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • Victoza® should not be used as the first choice of medicine for treating diabetes. • Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas). Therefore, it should be used with care in these patients. • Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®
• It is not known if Victoza® is safe and effective when used with insulin. Who should not use Victoza®? • Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®
• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. • Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes). What are the side effects of Victoza®? • Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer. • The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea. • Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials. • This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®. What should I know about taking Victoza® with other medications? • Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time. Can Victoza® be used in children? • Victoza® has not been studied in people below 18 years of age. Can Victoza® be used in people with kidney or liver problems? • Victoza® should be used with caution in these types of people. Still have questions?
What is the most important information I should know about Victoza®? • In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer. • In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.
This is only a summary of important information. Ask your doctor for more complete product information, or • call 1-877-4VICTOZA (1-877-484-2869) • visit victoza.com Victoza® is a registered trademark of Novo Nordisk A/S. Date of Issue: May 2011 Version 3 ©2011 Novo Nordisk 140517-R3 June 2011
Eye health from page 12
blood sugar may be managed by diet and lifestyle changes, but often oral medication or insulin therapy is also needed. Symptoms of diabetes Parents should be aware of the following symptoms, especially if they occur together:
Eye conditions are more common for those with juvenile (type 1) diabetes.
• Blurred vision or alternating blurred and clear vision • Extreme hunger followed by weight loss • Fatigue • Frequent urination Both children and adults with diabetes may experience temporary changes in vision, even throughout the span of one day. Blurry vision can be an indication of high glucose levels, because the lens inside the eye swells when blood sugar increases, causing temporary nearsightedness. When glucose levels return to normal, the lens returns to normal and so does vision. If a child’s blood sugar levels are high, the child will appear to be more nearsighted. Diabetic retinopathy Diabetic retinopathy is a potentially blinding condition in which blood vessels of the retina, the “camera film” in the back of the eye, become damaged from high blood sugar levels associated with diabetes and damaged blood vessels leak fluids into the retina. As a result, weaker blood vessels form, which can hemorrhage, causing vision loss. Diabetic retinopathy is not related to age but to the length of time one has had diabetes, and the severity is closely related to how well blood glucose has been controlled. During the early stages of retinopathy, however, there may be no symptoms. Five years after initial diagnosis of type 1 diabetes, there may be signs of retinopathy. Ten years after the initial diagnosis, more than half of diabetics will have some amount of retinopathy. Fifteen years on, nearly all type 1 diabetics will have some amount of retinopathy, a quarter of whom will develop proliferative retinopathy, the most serious form.
loss can be reduced by 50 to 60 percent. Vision problems that may signal the onset of diabetes Although retinopathy often does not occur until diabetes is advanced, other vision problems may arise earlier that could be associated with uncontrolled blood sugar. Examples are: • Fluctuating vision. Both children and adults with diabetes may experience temporary vision changes, causing temporary nearsightedness. When glucose levels return to normal, the lens returns to normal and so does vision. If a child’s blood sugar levels are high, the child will be more nearsighted. • Intermittent blurry vision. This is not always a sign of diabetes, but the only way to know for sure is to have a comprehensive eye exam. • Floaters. Dark, floating spots can be caused by serious eye conditions. Although they are sometimes normal, they can also be caused by leaking blood vessels, and may require laser treatment to stop the leaking. The only way to know if the floating spots are normal or not is to have a dilated eye exam. If a child with diabetes mentions seeing black spots or “floaters,” schedule an appointment with an eye specialist right away. Eye health to page 34
Stages of retinopathy Mild proliferative retinopathy is the earliest stage, in which microaneurysms (small balloon-like swellings in the retina’s blood vessel walls) occur. Moderate, nonproliferative retinopathy is the stage at which some blood vessels in the retina are blocked, which signals the body to grow new ones. Proliferative retinopathy is the stage at which new, abnormally fragile blood vessels develop and leak, possibly causing severe vision loss or even blindness. Macula edema may also occur. It is a swelling of the macula, the area of the retina responsible for our most central, accurate vision. Edema, or swelling, causes blurry, distorted vision. Because almost everyone with type 1 diabetes will eventually develop some level of retinopathy, it is vitally important that one develop a healthy lifestyle, control blood sugar, and get regular eye exams. If diabetes is controlled and signs of retinopathy are discovered early, permanent vision loss can be prevented and severe vision OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
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DIABETES slow to realize that his lifestyle has brought on hidden dangers. Over the years, he has been gaining weight, and in fact can be described as obese. In addition, he has a family history of diabetes: His father and uncle were diagnosed when they were in their 70s. Anthony, now overweight and inactive, can be classified—as can an epidemic-sized group of other Minnesotans—as someone who may have prediabetes.
Prediabetes … a family affair By Marsha Hughes, MS, RD, CDE
M
eet Anthony, who has lived in Minnesota his entire life. He is 57 years old, married, and has three grown children. He has a sedentary job in an office. His job often requires him to work long days, which has resulted in little time for exercise and meals skipped or eaten on the run from take-out restaurants. While he has enjoyed a prosperous life, he has been
What is prediabetes?
Prediabetes is a condition in which one’s blood sugar level is higher than normal, but not yet high enough to be classified as type 2 diabetes. Nevertheless, it is still a dangerous condition, because without intervention, prediabetes is likely to become type 2 diabetes. Anthony, by most measures, has less than 10 years to address his condition. He is probably unaware that long-term damage, especially to his heart and circulatory system, may already be occurring. Is prediabetes dangerous?
If Anthony has prediabetes, he will have a greater risk of heart disease and stroke. In addition, prediabetes will also increase his
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If you are under 65 with a disability and your income is below $1,362 there is help for you! ® Call the Disability Linkage Line at 1-866-333-2466 to learn about Medicare Savings Programs and Extra Help that may pay Medicare out of pocket costs.
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chance for developing other health problems. Glucose levels in the prediabetes range mean a greater likelihood of cardiovascular disease and retinopathy, an eye disease that can result in blindness. So prediabetes is a warning sign to
Prediabetes tests Blood glucose (sugar) test
Prediabetes blood sugar level
Normal blood sugar level
Fasting blood glucose
100 mg/dl to 125 mg/dl
Less than 100 mg/dl
2-hour oral glucose tolerance
140 mg/dl to 199 mg/dl
Less than 140 mg/dl
Hemoglobin A1c
5.7% to 6.4%
Less than 5.7%
If you have blood sugar levels higher than those shown above, you should contact your doctor to talk about diabetes. (Source: Diabetes Care, January 2011)
take action.
How does Anthony know if he has prediabetes?
Prediabetes usually has no symptoms, so it is very important for Anthony to see his doctor to discuss his risk. He should ask to have simple blood tests done to determine if he is in the prediabetes category. There are three common types of tests Anthony’s doctor can use to determine whether he has prediabetes (see sidebar above). If any of Anthony’s blood sugar levels are in the prediabetes range, he will join an estimated 21 million Americans diagnosed as having prediabetes, also known as impaired glucose tolerance. According to a recent report by the U.S. Centers for Disease Control and Prevention (CDC), 25 percent of Americans have prediabetes. A separate CDC survey found that 46 percent of those between the ages of 40 and 74 also have prediabetes. Most troubling, however, it that 96 percent of these adults are like Anthony— they don’t even know if they have prediabetes.
Eating more home-cooked meals and not skipping meals can also help meet the above-mentioned goals. These healthy lifestyle changes will have a positive impact on the health of Anthony’s family, who all may be at risk for prediabetes. What else can Anthony do?
Anthony needs to be physically active every day, several times a day. The type of activity is not important; it can be as simple as walking. Anthony might try getting up from his desk every hour and walking for 5 minutes. This daily routine is an easy way to help control his condition. The ideal is 30 minutes of activity each day. Prediabetes ... a family affair to page 18
If Anthony does have prediabetes, does he need treatment?
It’s critically important for Anthony to address his condition and take steps to delay or prevent diabetes. The key is to maintain blood sugar levels in a healthy, normal range. In order to do this, Anthony will need to make lifestyle changes, which include eating healthier foods, increasing daily activity, losing weight, and maintaining these changes over the long term. Every little bit helps; losing even a small amount of weight and increasing exercise will have a positive effect.
Prediabetes is a warning sign to take action.
What are the healthy food choices Anthony can make?
The American Dietetic Association and the American Diabetes Association recommend some
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fairly simple things, such as: • Limit fat intake—no more than 45 to 55 grams per day. • Eat foods high in fiber—at least 35 grams each day. • Eat about the same amount of carbohydrates at each meal, and limit carbohydrates from sweet beverages and desserts. This helps maintain steady blood sugar levels. • Choose fruit instead of fruit juice. Fresh fruits contain more fiber and usually less sugar. • Eat more home-cooked meals and do not skip meals.
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OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
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Prediabetes ... a family affair from page 17
Who else is at risk?
Anthony should learn as much as he can about his family history of diabetes, so he can help himself and other members of his family. This means sharing what he knows with his children, his siblings, and their children about their shared genetic risk. In addition, if any of the women in Anthony’s family had gestational diabetes (i.e., during pregnancy), they should know that they have an increased risk American Diabetes Association of developing diabetes. www.diabetes.org/pre-diabetes.jsp People who are Native National Diabetes Education American, African AmerProgram ican, Asian, or Hispanic are www.YourDiabetesInfo.org at even greater risk. American Dietetic Association Evidence that lifestyle changes work
www.eatright.org Centers for Disease Control and Prevention www.cdc.gov/diabetes/ consumer/prevent.htm
Research shows that lifestyle changes can actually delay or prevent diabetes. In 2002, the Diabetes Prevention Program (DPP)—a landmark study sponsored by the National Institutes of Health—found that 30 minutes of physical activity five days a week (150 minutes per week) combined with a 7 percent reduction in body weight led to a 58 percent reduction in a person’s risk for getting diabetes. As a result of these findings, federal agencies established the National Diabetes Prevention Program to establish programs across the country to promote the DPP’s findings. These group programs help people with prediabetes make the lifestyle changes needed to reduce their risk of developing diabetes. Programs such as these are being offered in Minnesota: • “I Can Prevent Diabetes” is sponsored by the Minnesota Department of Health. For more statewide programs being offered, go to www.icanpreventdiabetes.org. • YMCA Diabetes Prevention Program. For more information, call 612-465-0545 or go to https://www.ymcatwincities.org/ health__fitness/wellness_programs/diabetes_prevention/ Additional resources
If you have been diagnosed with prediabetes or diabetes, medical nutrition therapy (MNT) can help. Many insurance plans now cover MNT for those diagnosed with prediabetes. Ask your doctor for a referral to a registered dietitian. You can also attend a group diabetes prevention program at your local health clinic, YMCA, or other community organization.
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MINNESOTA HEALTH CARE NEWS OCTOBER 2011
Marsha Hughes, MS, RD, CDE, is the director of Diabetes Care at HealthEast in St. Paul. She has been a registered dietitian and certified diabetes educator for more than 20 years. She is also president of the St. Paul Diabetes Lion’s Club, which serves those in the community with diabetes.
October Calendar Oct. 3–Nov. 14
Cancer Education and Support Series In adult groups, parents will review skills to help them lead their families through the cancer experience and beyond. Special programs help children ages 5 to 18 develop the necessary life skills to confront and manage the daily fear, stress, and uncertainty that come from living with a parent or grandparent with cancer. To register, contact jhaines@mnangel.org. Mondays, Oct. 3, 10, 17, 24, Nov. 7, and 14, 6–8 p.m., Angel Foundation, 700 S. 3rd St., Ste. 106W, Minneapolis
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Aging Well Expo Aging Well Expo features more than 25 health and wellness exhibitors, health talks, a variety of screenings (eye, hearing, BMI, blood pressure), consultations (legal, Medicare, caregiving, veterans’ benefits, and pharmaceutical), a technology room, flu and pneumonia shots, lunch, massage, and door prizes. Free and open to all. Call 651-298-5493 with any questions. Tuesday, Oct. 11, 10:30 a.m.–1:30 p.m, West 7th Community Center, 265 Oneida St., St. Paul Benefit for Crisis Nursery Harvesting Hope is a memorable evening of fine wine, fabulous food, and exciting live and silent auctions hosted by Greater Minneapolis Crisis Nursery. Proceeds directly benefit children at risk of abuse or neglect and help strengthen vulnerable families in crisis. Tickets are $75 and can be purchased by calling 763-226-2061 or visiting www.crisisnursery.org. Friday, Oct. 14, 6:30–9:30 p.m., Marriott Southwest, 5801 Opus Pkwy., Minnetonka Twin Cities Ataxia Support Group This group meets on the third Saturday of every month. Family and friends of afflicted individuals are always welcome. For more information, contact Lenore Healey Schultz at schultz.lenore @yahoo.com or at 612724-3784 between 10 a.m. and 4 p.m. Saturday, Oct. 15, 10 a.m.–noon, Presbyterian Nursing Home, 1910 W. County Rd. D, Roseville
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Stroke Recovery Lecture: Mental Practice Stroke survivors and their care partners are invited to learn more about recovery and life after a stroke. This lecture focuses on using imagination to unlock stroke recovery potential. For more information, call Sue Newman at 612-863-4996. Tuesday, Oct. 18, 2–3:30 p.m., United Hospital, 333 N. Smith Ave., Bentson Family Conference Rm., St. Paul
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ALS Family Caregiver Support Group This new group offers caregivers education about ALS. Come and receive support to overcome the challenges of caring for a family member with the disease. Meetings are held the third Wednesday of the month. Registration is necessary to access parking. Contact Jennifer Myhre, LICSW, at 1-888672-0484 or jennifer@alsmn.org. Wednesday, Oct. 19, 7–8 p.m., ALS Association Chapter Office, Union Plaza Bldg., 333 Washington Ave. N., Ste. 105, Minneapolis
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Fibromyalgia Support Group You can manage your symptoms of fibromyalgia or chronic fatigue. The meetings offer a variety of self-care topics through speakers or open forums, shared personal experiences and coping strategies, informational handouts, and a lending library. A social worker is available for questions at 651-351-2364. Monday, Oct. 24, 6:30–8 p.m., Courage Center St. Croix, 1460 Curve Crest Blvd., Conference Rm. A, Stillwater
Educate Before You Medicate: Talk About Prescriptions! According to the National Council on Patient Information and Education, two out of three doctor visits end with a prescription being written. More people are also using medicines that do not require a doctor's prescription, called over-thecounter (OTC) medicines. Since 1990, sales of OTC medicines have increased by more than 60 percent. Acetaminophen is found in more than 600 different medicines—both prescription and OTC pain relievers, fever reducers, and sleep aids as well as cough, cold, and allergy medicines—so it is important your doctor knows about all the medicines you take. When used as directed, acetaminophen is safe and effective. However, taking more acetaminophen than directed can lead to liver damage and even death. You can take too much if you take more than the labeled dose of one acetaminophen medicine, or if you take an OTC medicine containing acetaminophen with a prescription medicine that also contains acetaminophen. To prevent acetaminophen overdose, read labels and recognize when your medicines contain acetaminophen. The active ingredients in OTC medicines are clearly listed on the label, but always ask your health care provider whether your prescriptions contain acetaminophen. For more information about taking medications safely and appropriately, visit www.talkaboutrx.org. Please consult a licensed health care professional with questions or concerns about your medication and/or condition.
www.talkaboutrx.org
Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to 612-728-8601 or email them to jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.
America's leading source of health information online OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
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DIABETES
Improve mood to improve diabetes: Three patients’ journeys By Roger G. Kathol, MD;, Renee Koronkowski, MD; and William Meller, MD
C
armelita, Judy, and Keisha had been casual friends since their children became inseparable friends their first day of kindergarten more than 15 years ago. The mothers made small talk at potlucks, sports events, and class outings. It was not until they ran into each other at a diabetes “refresher” class more than 10 years after their diagnoses that they formed a deeper connection; it was then that they realized they were all battling non-insulin-dependent (type 2) diabetes mellitus. Their health histories were remarkably similar. All three women were overweight, had a family history of diabetes, and had been warned about their risk for developing diabetes when they had high blood sugar levels during pregnancy. By the age of 30, each woman had become insulinresistant. Their doctors had instructed them about diet, exercise, and medication. They all experienced intermittent episodes of depression, however, which affected how well they were able to participate in their own diabetes care. None knew the personal approach the other two had taken as they attempted to control their diabetes. By their mid-40s, success for each was very different. They were about to learn from each other just how important effective depression treatment is in maintaining health and preventing diabetic complications.
Carmelita
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MINNESOTA HEALTH CARE NEWS OCTOBER 2011
Carmelita should have had the most difficulty controlling her blood sugars, but she was actually the most fortunate because of the lessons she had learned watching her mother fight diabetes. Her mother had suffered and died from the ravages of diabetes. As Carmelita participated in her mother’s care, she saw how important personal involvement in her own treatment would be if she got the illness. Over the course of 20 years, she had watched her mother experience near-blindness, kidney failure, heart disease, and numerous infections. By the time her mother turned 48, she had been in and out of the hospital with foot and leg infections, was on dialysis, and then had a stroke and died. It was while Carmelita watched her mother—who also experienced bouts of moderate to severe depression—try to comply with her doctors’ recommendations that she recognized how mood affected her mother’s overall health. When her mood was good, she was conscientious about eating healthy foods, taking her medications, exercising, and dealing with diabetic complications. When her mother was depressed—which was often, since she did not know that depression control related to diabetes control—she did not adhere to her doctors’ recommendations and would lie in bed feeling helpless about controlling her diabetes. Despite encouragement, she refused therapy and resisted taking antidepressant medication. Carmelita had three energetic children who needed their mother, so she refused to follow in her mother’s footsteps. She knew how important her emotional state was in managing her own diabetes. In the 14 years since her doctor first noted her elevated blood sugars, he had also monitored her
mood and had prescribed antidepressant medication for the several episodes of moderate to severe depression Carmelita experienced. Adding this component of care probably saved her life. With the support of her doctor, Carmelita conscientiously followed the diet recommended, exercised, took her medications—including an antidepressant—and didn’t smoke. Despite her genetic risk of a poor outcome, she was now in her early 50s and still had normal blood pressure, no skin infections, minimal visual impairment, and only slightly impaired kidney function.
Judy had not considered the possible correlation between depression and poor diabetes control until her psychiatrist pointed it out.
Judy Judy also had a family history of type 2 diabetes, but the role model in her life, her father, did not have significant complications. He did not suffer from depression and followed the recommendations of his physician. While he experienced minor complications related to high blood sugars, he was still living a full life at age 72. Judy was not so lucky. She had trouble controlling her blood sugars almost from the very beginning. This was due in large part to not following her doctors’ recommendations and to her untreated depression. She was frustrated, overwhelmed, and angry about having diabetes. Feeling depressed sapped her energy and her willingness to try. It was during a hospitalization to amputate a gangrenous toe that she had a life-changing psychiatric consultation. Judy had not considered the possible correlation between depression and poor diabetes control until her psychiatrist pointed it out. The consultation was a result of Judy’s indecision about going through with the amputation, and her frustration concerning the outcome. For the first time, she tried psychotherapy and an antidepressant. This change in her approach to diabetes care occurred five years ago. Since that time, Judy's depressive symptoms have been under control. In addition, she has arrested the progression of diabetic eye complications, slowed the loss of sensation in her legs and feet, and has had no more skin ulcers or infections. She was also told her “a-1-c� had dropped from 10.3 to 7.8. Though she did not know what that really meant, she did know that her doctor was pleased. (Hemoglobin A1c is a blood test that estimates average blood sugar levels over months; nondiabetic patients have levels of about 6.)
Message About 30 percent of those battling diabetes experience depression. Whether it is a reaction to the challenges of dealing with diabetes or with a complication of the disease, effective treatment is imperative. Without treatment, it is quite likely that the diabetes will be poorly controlled and the patient will develop more complications, experience more impairment, and have a shortened life. Family members and friends should support depression treatment. Roger G. Kathol, MD, is an adjunct professor of internal medicine and psychiatry at the University of Minnesota and founding president of Cartesian Solutions Inc., a health care consulting company. Renee Koronkowski, MD, is a board-certified adult psychiatrist and practices at Fairview Lakes Medical Center in Wyoming, Minn. She also serves on the Minnesota Psychiatric Society Ethics Committee. William Meller, MD, is an associate clinical professor of psychiatry at the University of Minnesota and works at Fairview Riverside. He also serves as president of the Itasca Brain and Behavior Association.
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Keisha Many of Keisha’s family members had suffered from diabetes and its complications, including depression. Unfortunately, they did not “believe in� depression or in the value of psychotherapy, so they suffered the consequences. Up until shortly before the time of the diabetes refresher course, Keisha followed her family’s approach: She did her best to follow treatment recommendations but avoided depression screens, denied an association between depression and poor diabetes outcome, and �saved face� with her family by not “having� to be treated for depression. Keisha enrolled in the diabetic refresher class at the urging of her physician and was happy to see familiar faces. She appreciated the review of basic diabetes control techniques from specialists, but was truly grateful for her friends Carmelita and Judy, who shared their stories about how paying more attention to and treating their depression had led to better health, a greater sense of well-being, and more fulfilling lives with their families. Keisha felt ready to accept that her depression was affecting her health and its treatment.
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DIABETES
DIABETES
Systemic interventions for a systemic disease Tai J. Mendenhall, PhD, LMFT, and Max Zubatsky, MA, LAMFT
D
iabetes is one of the most widespread chronic diseases in the United States, with current prevalence estimates exceeding 7 percent of the general population. More than 2,500 new cases are diagnosed each day in this country, with current approximations of those afflicted at over 25 million people. And it’s getting worse. Linked strongly to Americans’ rising global consumption of highfat and carbohydrate-rich diets, sedentary lifestyles, and epidemic-rates of obesity, the Centers for Disease Control maintains that this six-fold increase since the 1950s is still going up. One in every three Americans—30 percent of us—may develop type 2 diabetes by 2050. Those afflicted with this disease also endure a number of other serious and related health problems, such as cardiovascular disease (which is the most common cause of death and disability in the U.S.), eye disease
and blindness, kidney failure, nerve disease, and sexual dysfunctions. And while diabetes is a chronic illness that crosses all cultural, ethnic, and racial groups, considerable disparities in health status exist: Hispanics and African Americans are two to four times more likely, and American Indians three to 10 times more likely, to be diagnosed than Caucasians.
The family context Diabetes is often called a “family disease” because it affects more people than just the person who is diagnosed. As the patient changes longstanding habits in several areas, significant others in the same household will have to do the same. Disease management requires careful attention to diet, and some (nondiabetic) family members may resent having to change what they can and cannot eat. Family incomes may become strained as they pay for healthier foods (which tend to be more
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MINNESOTA HEALTH CARE NEWS OCTOBER 2011
expensive), and the costs of additional insurance copays, doctor visits, and blood testing supplies can add up. Because it is easier for patients (or anyone, really) to exercise if they have someone to exercise with, family members are encouraged to take part—but often reluctantly. Children without diabetes can sometimes feel jealous of their diabetic siblings as the latter get more attention from parents and other family members. Patients with diabetes—children and adults—may feel that others’ attempts to be supportive are actually harassing or nagging. Research shows, however, that patients do better when their families take an active part in helping them manage their disease. Many say that diabetes management—that is, discussing diet, cooking, exercising, going to physician visits together, etc.—actually brings them closer together.
The importance of systemic interventions Recognizing diabetes as a “family disease” pushes us to think systemically, and to thereby be sensitive to how one part influences other parts within any larger unit. Indeed, the health of a diagnosed patient depends on how the connections within that person’s family and social system affect—and are affected by— Diabetes is multiple areas of his or her life. And while it would be far easier for health often called care providers to just work strictly a “family with a patient on his/her medications disease” because or diet, research has shown that attending to co-existing facets of it affects more patients’ lives yields better outcomes. people than just Medical treatment for diabetes the person who should be personalized to each patient, depending on overall health and the is diagnosed. presence or absence of diabetes-related conditions and other ailments. The main things to focus on are controlling blood sugar (through insulin supplementation and other medications) and making lifestyle changes in diet and physical activity. Administering drugs to lower blood pressure and bad cholesterol is also common. Different types of individual therapy can help address the various issues a patient must deal with, such as talking with a diabetes educator, nutritionist, and/or therapist about health behaviors (meal planning, exercise, regular blood sugar testing, and record-keeping) and the common feelings of depression, anxiety, and stress associated with living with a chronic illness. Couples therapy generally involves patients and their spouses or partners meeting with a mental health provider and diabetes treatment team to recognize and validate stressors related to disease management, to learn more about it together, and to build a sense of co-ownership and teamwork. Family therapy applies similar techniques, but includes children, siblings, parents, and anyone else closely associated with (and affected by) the patient. For example, professionals can help families work through challenges related to an adolescent’s developmentally appropriate desire for independence vis-à-vis a parent’s desire to be involved in care. Social and community interventions also provide opportunities for patients and family members to connect with other patients and their families to learn from others who have “been there.” For example, spouses can share with other spouses how they have achieved a
balance between being supportive and being a “nag.” Likewise, experienced patients can share with new patients how they were able to adjust their diets and stick with those changes.
Tips for diabetes caregivers The impact of diabetes affects not only the patient’s quality of life, but that of the primary caregiver as well. Caregivers can help improve the overall health of patients in the following ways: • Attend and participate in doctor appointments. • Develop awareness of routine/schedule around the management of indicated medications. • Take part in counseling appointments. • Seek additional education through workshops or local support groups, etc. • Exercise together. • Adjust and monitor one’s own diet to help the patient eat better— i.e., do it together as a team. Navigating a complex health care system is a challenge for many families. Improving the health of an individual with chronic illness, especially in the case of diabetes, depends greatly on the sustainability of support by the family and on the health care provider’s willingness to include families in effectively managing this disease. Tai J. Mendenhall, PhD, LMFT, is a faculty member in the University of Minnesota Medical School’s Department of Family Medicine and Community Health and an associate director of the university’s Citizen Professional Center. Max Zubatsky, MA, LAMFT, is a doctoral student in the U of M’s Department of Family Social Science (Marriage and Family Therapy Program) and a behavioral health intern at Broadway Family Medicine Clinic.
Leg Pain Study Do your legs hurt when you walk? Does it go away when you rest? Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health
To see if you qualify, contact the EXERT Research Team at
612-624-7614 or email EXERT@umn.edu or visit EXERTstudy.org
EXERTstudy.org OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
23
PAT I E N T T O PAT I E N T (65 percent) in another. My cardiologist wanted to insert stents, but I had reservations, primarily because I know they can close up again and, even if they worked perfectly, would require me to be on a blood thinner for the rest of my life. He was not at all open to talking about alternatives. He started me on Lipitor for my cholesterol and lisinopril for my blood pressure. And that was it. If I wanted his input or help, we’d be talking stents. Some years back, I had discovered I had borderline high blood pressure. I went to the bookstore (as my wife says I always do when I’m scared) and looked around. Dean Ornish’s book “Dr. Ornish’s Program for Reversing Heart Disease” caught my eye, and his holistic approach, which involves a very low-fat diet, exercise, and stress management, was very much to my liking. Unfortunately, I did not take my condition seriously enough to follow through. Now that I had had a much sterner warning, I went back to the book with renewed commitment. But my doctor said the diet was too diffiWary cardiologist, cult, that I wouldn’t be able to stay with it. leery patient work it out He also implied that—despite favorable reports in journals including JAMA and By John Malan Circulation, among others—he doubted Ornish’s claim that adherence to the diet could reverse blockage in the arteries. Then, demonstrating just how little he understood of what I was saying, the doctor suggested that I was in denial. I disagreed vehemently, saying I believed I could die at any minute. He looked at the angiogram and said, “No, I don’t think so.” Neither of the arteries with major blockage was the so-called widow-maker.
Shared decision-making: a case in point
I
n September 2009 I felt an ache and pressure in my chest one evening as I walked home from work. Over the next couple of weeks it recurred with mild exertion. At first I thought it might be indigestion or the remnants of a bad case of bronchitis. When it didn’t go away, I went to see my primary care doctor, who diagnosed my chest pain as angina caused by insufficient oxygen to my heart, and sent me to a cardiologist. A stress test and an EKG showed that, not yet 60, I had had two nontransmural infarcts. I knew that an infarct was a heart attack, but I did not know what nontransmural meant. I learned it means that the damage to the heart muscle did not go all the way through the wall of the heart. “Mild” heart attacks, in other words. Next I had an angiogram that showed significant blockage (99 percent and 85 percent) in two major arteries and lesser blockage
Seeking direction
Catering by Seward Co-op
The next two weeks were very hard. My wife wanted me to do whatever needed to be done as quickly as possible; if that meant getting stents, then that’s what I should do. I, on the other hand, saw stents as a last-ditch measure. One night it came to a head: We could not go on without some sense of direction. Suddenly we remembered that a friend from church was married to a cardiologist. I called her and she put her husband on the phone. He spent the next 30 minutes talking to me. He prescribed metoprolol, a beta blocker that lowers blood pressure and reduces the heart’s metabolic needs, and nitroglycerin, in case I experienced chest pain that didn’t go away, and told me to call his office for an appointment. His compassion that night was a godsend. He gave me another stress test. This time I did pretty well, with no angina. He reassured me that my heart was stable and that I could follow the Ornish program if I wished while staying on the prescriptions, which I was happy to do. Differing views
Then something unexpected happened. Within a couple of weeks of completing the stress test without pain, I began to have serious angina just walking. My new cardiologist’s nurse had told me how to
24
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
use the nitroglycerin: As soon as I felt chest pain, I was to rest and breathe deeply for five minutes. If the pain did not stop, I was to put a nitro tablet under my tongue and wait five more minutes. If the pain continued, I was to do it again. If I got to the third tablet, I was to get to the emergency room. I never had to take the first tablet, and because of that I never thought to report this development to my doctor. Over the next two months I maintained the Ornish diet, did yoga, meditated, and gradually began exercising on a stationary bicycle, carefully maintaining my level of effort so that I experienced only mild angina that quickly went away when I stopped to rest. Gradually, the amount of exercise I could tolerate increased. When I eventually told the cardiologist about all this, he seemed disappointed that I hadn’t called. The reason, I explained, is that I had read that the heart responds to angina by developing new arteries, called collaterals, that grow around the blockage into the area that is not getting enough blood flow: In short, the heart heals itself. He offered me a new pill that would suppress angina and allow me to be more active. I asked him if this would prevent my heart from knowing it needed to develop collaterals and he said it would. Thus, taking the medication would relieve my symptoms—but thwart the heart’s natural ability to heal itself. No thanks, I said.
Could I improve my heart’s health through lifestyle changes? Or was the best I could hope for to manage the symptoms of a sick heart?
The central question
While my relationship with this cardiologist was much more supportive and open than with my first cardiologist, we still struggled with a fundamental question: Could I improve my heart’s health through lifestyle changes? Or was the best I could hope for to manage the symptoms of a sick heart by relying on traditional medicine? For me, the necessary changes in my way of life were not onerous. We had eaten a largely vegetarian diet for years. The biggest difference in the Ornish diet was the limit on fats—only 27 grams per day, of which only nine may be saturated. I lost 20 pounds in the first month or so and have never put it back on. Bill Clinton has recently done likewise, I hear. I have a sweet tooth and I was afraid I would not be allowed to satisfy it, but there are many recipes for low-fat desserts that use fruit and other complex sugars that the diet allows. My other weakness is for things salty and crunchy. I have had to accept some loss there, though there are some crackers with low fat and sodium that I have found are quite good when dipped in salsa. My total cholesterol in January 2010 was 108, well within the desirable range. We checked it again in December and it was still 108. The only concern was that my HDL, the “good” cholesterol, was too low. I am addressing that with Omega 3 supplements. (Omega 3 is a naturally occurring lipid that increases HDL.)
major compromises. So things have gone well. I am exercising four or five times a week now and rarely experience any angina. I continue to believe that I might be farther along if I had a cardiologist who supported the complete Ornish program, which includes group sessions in which patients can talk with each other and a caregiver about their struggles and receive emotional support and encouragement, as well as a greater willingness to discontinue meds when it is safe to do so. I plan to visit an Ornish-friendly cardiologist in Chicago before year’s end. If you find yourself in a similar situation someday, where your doctor insists on a traditional approach in spite of solid clinical research that supports a less invasive, less pharmaceutically oriented approach, do not give up! Get another opinion, show your doctor the studies that support your preferred approach, engage him or her in a respectful and assertive discussion of the options. And if he or she refuses to listen and to take you seriously, run, don’t walk, to another doctor. John Malan has a desk job in Springfield, Ill., where he is known to the local medical community as a wellread, engaged patient with a strong desire to know what’s going on and a strong will to live.
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A workable compromise—for now
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OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
25
ALZHEIMER’S
A
ccording to the Alzheimer’s Association 2011 Facts and Figures report, there were 94,000 cases of Alzheimer’s disease in Minnesota in 2010 for people 65 and older. The number of caregivers was 237,441. Those numbers have already increased and by 2025, the cases are expected to rise to 110,000. As an occupational therapist, I have spent 15 years working in the Twin Cities with some of these people and have been privileged to provide help along their journey. I started a company, MindStart– Activities for Persons with Memory Loss, to provide games, puzzles, and more to persons with dementia. This is but one resource, however; there are many others as well. My experience has been that caregivers especially are thirsty for more knowledge about the disease, its everyday implications, and how to manage it. Often, they are not aware of resources that may be available to them.
Difficult to accept diagnosis
A diagnosis of
Alzheimer’s
–now what? By Monica Heltemes, OTR/L
In the next issue.. • Evaluating Medicare plans • Naturopathic medicine • Chronic venous insufficiency 26
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
After a diagnosis of Alzheimer’s or other form of dementia, the person, family members, and friends are usually in shock and feel overwhelmed. They may not have the mental energy to pursue looking into resources or may be in denial. This often occurs in people with dementia. Family and friends may also be in denial, and/or they may not fully recognize the memory and cognitive problems. Either way, they are not likely to pursue resources. In some cases, the person with dementia and family may choose not to reveal the dementia until later, so may not think to look into resources. Last, Alzheimer’s disease does not get the same attention and media coverage as other medical conditions, such as cancer, so knowledge of or access to resources may be more limited.
Alzheimer's care more complicated
Why is knowledge of resources so important? Because unlike many other medical conditions, Alzheimer’s has no cure and can last for many years. Caregiving tasks become more and more consuming as the person with Alzheimer’s declines. In addition, care for someone with Alzheimer’s often involves a different type of care—it is not like helping a person with a physical problem, for example, helping someone with a broken arm put on a shirt. Instead, care techniques for a person with Alzheimer’s may be repeating directions they have forgotten, reminding them to brush their teeth, reassuring them when they are worried, or redirecting them when they are lost. Caregivers need to be taught these dementia-specific care techniques, because knowing what approach to use does not come intuitively. Moreover, Alzheimer’s and other dementias do not progress at the same rate from person to person. There is a saying: “When you have met one person with Alzheimer's disease, you've met one person with Alzheimer's disease.” So it’s difficult to give one particular recommendation for care; there is no one formula. It will be up to the individual and family to determine what works or not in a particular environment. This is why knowledge of resources is so important. Knowing where to get help is especially important in trying to deal with difficult reactions or emotions—often labeled “behaviors”—of the person with dementia. They may wander or have periods of agitation, aggression, and paranoia due to the brain changes that are occurring. These conditions can be very disconcerting for the caregiver and difficult to manage. Often, caregivers are at a loss for what to do.
Things that help Fortunately, approaches such as therapeutic activities and environmental changes have been successful in limiting these behaviors. Removing clutter and limiting noise can help provide a calm, structured environment. The Tailored Activity Program, a researched approach devised at Thomas Jefferson University in Philadelphia, showed that engaging a person in activities matching their capability level and interests led to less agitation and resistance. I started MindStart to capitalize on the abilities the person with Alzheimer’s still has through use of items such as games and puzzles, and to provide caregivers with tools that are quick and easy to use. The adaptations needed for the person with Alzheimer’s are built into the design of the items, so they are helpful at any stage of dementia and can help with everyday life. (See the sidebar for a list of resources.)
Resource list Alzheimer’s Association, MN-ND Offers education programs, support groups, 24/7 phone help line, care consultations, and online communities. www.alz.org/mnnd/index.asp 952-830-0512 Alzheimer’s Reading Room An online blog with informative articles, managed by an editor whose mother has Alzheimer’s. www.alzheimersreadingroom.com Memory Café A new fellowship group for persons with early memory loss and their caregivers. www.tinyurl.com/3erorhd MindStart–Activities for Persons with Memory Loss Offers games, word searches, puzzles, etc., designed specifically for persons with dementia. New products are added periodically. www.mind-start.com 612-868-5831 Minneapolis Institute of Arts and Walker Art Center Offer tour programs for people with memory loss. www.alz.org/mnnd/in_my_community_56774.asp (MIA): 612-870-3140 (Walker): 612-375-7574 Minnesota Adult Day Service Association Programs offer health, social, and other support services for persons with physical or cognitive deficits; also offers caregiver respite. www.madsa.org 763–464–2698
Caregivers also need care
Senior Linkage Line Caregiving can take a physical and emotional toll; the Free statewide phone information and assistance service: 1-800-333-2433. Online database of statewide caregiver may not even realize that the caregiving tasks community resources: www.minnesotahelp.info are becoming more and more consuming. Knowledge and use of resources provide an outlet for stress and a way to find support from others, and also help caregivers recognize stress and keep it in check. If stress becomes too great, the caregiver can find services or care homes to help. According to the Fisher Center for Alzheimer’s Research Foundation, “Support and education for caregivers and family members is … crucial to the best care of people with Alzheimer's.” This is not only to benefit the person with dementia, but also to protect the well-being of the caregivThere’s a huge difference in the kind of home care you can receive from someone er. There are many types who really understands what your life is like as a senior. Your concerns and need for independence. Someone who like you, has a little living under his or her belt. of resources available, Our caring, compassionate seniors are there to help. We offer the services you such as community and need to stay in your own home, living independently. church programs; virtual • Companion Care • Respite for caregivers and in-person support • Housekeeping Services • Doctors appointments groups; books and other print information; and websites and other • Meal preparation/cooking • Transportation and more Internet resources such as chat rooms, blogs, and Facebook groups. To borrow another saying, it truly does “take a village” to manage Alzheimer’s and other forms of dementia.
Knowledge and use of resources provide an outlet for stress, a way to find support from others, and help for caregivers.
Call us today, it’s like getting a little help from your friends®
Monica Heltemes, OTR/L, is a registered occupational therapist and owner of MindStart–Activities for Persons with Memory Loss, which designs and produces activity items specifically for people with memory loss.
Mpls. area: 763-694-0765 • St. Paul area: 651-274-4285 www.seniorshelpingseniors.com © 2011 Seniors Helping Seniors. Each office is independently owned and operated. All trademarks are registered trademarks of Corporate Mutual Resources Inc. Not all services are available in all areas.
OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
27
ENDOCRINOLOGY
J “The Change” by Donna Block, MD
ust when many women have launched their semi-independent children into the world and their parents become semi-dependent, they find themselves on the brink of “the change” known as menopause. “The change”—or any change, for that matter—is frequently met with fear of the unknown. As many women approach the end of their fertility, they begin to take stock of inevitable body changes as well as how they are viewed by their partners, their workplace, and society. It is important for all women to understand what is happening to their bodies during this exciting time so they are empowered to take better care of themselves.
Perimenopause and menopause About five to 10 years before menopause, the ovaries reduce production of the hormones estrogen and progesterone. This phase is called perimenopause. Women may notice a few “warning signs” such as trouble sleeping, rageful moods, spotting a few days before their period, or one day of such heavy bleeding that they can barely leave the house. Eventually, the cycles might get closer together or can occur at unpredictable moments. These changes occur when the ovaries, with their limited number of eggs, are not able to respond to the brain’s command to produce the appropriate amounts of estradiol (estrogen) and proges-
WHO’S A BIGGER BASEBALL FAN, YOU OR ME? You’ll find that people with Down syndrome have a passion for knowledge and learning that can rival anyone you’ve met before. To learn more about the rewards of knowing or raising someone with Down syndrome, contact your local Down syndrome organization. Or visit www.dsamn.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:
(651) 603-0720 • (800) 511-3696 28
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
©2007 National Down Syndrome Congress
For most women, menopause will occur at about the same age as it did for their mothers, and symptoms will be similar.
terone. Because these female hormone levels fluctuate daily, random testing for menopause is not reliable. Women can still become pregnant during perimenopause, too, so adherence to a reliable contraceptive is vital. Menopause is defined as the absence of menstrual periods for at least one year, and marks the end of fertility. The average age at which menopause arrives is 50½ to 51, but anytime after age 40 is considered normal. At this transition, the ovaries are no longer able to respond to the stimulating hormones from the brain. When they stop producing estrogen and progesterone, the menstrual cycles stop, so any irregular or heavy bleeding should be evaluated by a physician. For most women, menopause will occur at about the same age as it did for their mothers, and symptoms will be similar. Other factors such as smoking (and perhaps other unplanned events such as chemotherapy or surgery) can also affect the timing of menopause.
Weight and body changes Most women bemoan the change in body shape and weight gain that often occur around the advent of menopause, caused by one’s metabolism crawling to a halt. This isn’t inevitable, however; regular exercise can speed up the metabolism. Exercise coupled with a healthy diet can help maintain weight and muscle tone. More women die from heart disease than from any cancer, so maintaining a healthy weight and exercising is crucial anyway, because they reduce the risk of heart disease, diabetes, and cancer. Physical activity also strengthens the muscles that support the bones, reducing the incidence of falls and broken bones.
Libido changes Since menopause means a reduction in estrogen, the vagina can become drier and intercourse thus more painful. A good over-thecounter lubricant can help. Adding an estrogen supplement to the vagina on a regular schedule helps prolong its elasticity and moisture content. The skin will also start to lose elasticity at this time. Sexual desire and response can also be affected by medicines used to treat heart disease, diabetes, and high blood pressure. Many women think that after menopause they no longer need worry about contraception, but they should continue to use precautions because they can be exposed to sexually transmitted infections, especially in a new relationship.
Vaginal and bladder changes The low amount of estrogen in the vagina can also increase the number of bladder infections or contribute to urinary problems such as needing to void more frequently. Use of a topical vaginal estrogen supplement (e.g., cream or lotion) can improve these symptoms, and pelvic exercises can help prevent pelvic floor problems such as incontinence. Always discuss any issues with your gynecologist, since excellent treatment options are available.
Hot flashes and sleep changes Some of the most common symptoms of menopause (other than irregular cycles) are “hot flashes” or “night sweats.” They usually start as a rush of heat from within that travels up to the head, coupled with anxiety or heart palpitations and sweating. Night sweating often occurs around 3:00 a.m., the time when the body’s hormone levels are at their lowest. Sleep deprivation can contribute to increased anxiety, decreased concentration, and mood swings or even low-grade depression. Treatment for these symptoms might consist of hormone replacement therapy (HRT), an antidepressant, or a dietary/herbal supplement. For some women, alcohol, spicy foods, coffee, humidity, and stress can trigger hot flashes. Whether or not to use HRT or any supplement is a discussion for women and their physician, because treatment varies from person to person. If women have questions about bioidentical hormones obtained via the Internet or about other advertisements, they should discuss them with their physician before using them. “The change” to page 30
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29
“The change” from page 29
Bone and postural changes Most women also lose height during this transition. Once in menopause, women will experience most bone loss within the first five years. Daily exercise, calcium, and vitamin D will help prevent dangerous bone loss as well as some of the accompanying postural changes. A woman’s physician will monitor bone loss and can treat osteoporosis should it arise. Family history can contribute to the development of osteoporosis, as can smoking and thyroid disease.
Mood changes and more Many of us find that our emotional “filters” have become diminished during both perimenopause and menopause. We can become rageful in a split second, lash out, then wonder what has inhabited our bodies. Mood swings can be treated with relaxation exercises, medication, and change in lifestyle such as drinking less caffeine, increasing exercise, and reducing stress. Thankfully, this phenomenon doesn’t last forever.
(e.g., pap smears) or a colonoscopy are recommended, as well as vaccinations such as tetanus, pertussis, shingles, flu and pneumonia. The Mayo Foundation for Medical Education and Research recommends that menopausal women maintain a healthy weight, eat heart-healthy foods, reduce the amount of salt in the diet, exercise most days of the week, limit or avoid alcohol, and stop smoking. “The Change” is a physical and emotional transition that opens a door to opportunity—the chance for women to finally take stock and take care of themselves. They can reflect on the past, process what they have learned from the bumps along the way, and apply the wisdom acquired from these life lessons to define their future adventures. It can be a very exciting time. Donna Block, MD, is founder of Clinic Sofia, an ob-gyn clinic based in Edina. She has been an ob-gyn physician since 1987 and is board-certified by the American College of Obstetricians and Gynecologists.
Maintaining health Once menopause occurs, heredity often plays a role in any health issues that might surface, such as high blood pressure, high cholesterol, diabetes, and so on. Your health will require higher maintenance during this period. The American College of Obstetricians and Gynecologists recommends that women get regular health exams with annual mammograms and physical examinations, in addition to adopting a healthier lifestyle. Each woman’s current health and family history will determine when additional lab testing
Once menopause occurs, heredity often plays a role in any health issues.
Minnesota
Health Care Consumer September survey results... Association
Percentage of total responses
60 50 40
30.4%
30 20
15.2%
10 Yes
Don’t know
19.6%
20 10
Always
6.5% Usually
28.3%
20
15.2% 10.9%
10 4.3%
Sometimes
Rarely
Never
MINNESOTA HEALTH CARE NEWS OCTOBER 2011
0
2.2% Always
Usually
Sometimes
Rarely
52.2%
40 30
10.9%
60 Percentage of total responses
26.1%
15 10
5. Do you understand what kind of care your insurance company covers?
41.3% Percentage of total responses
Percentage of total responses
30
4.3%
30
No
23.9%
20
0
50 43.5%
40
30.4%
25
5
4. Would knowing the cost of care have an impact on your decisions to utilize care?
50
32.6%
30
0
0
35
54.3% Percentage of total responses
Each month members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions about topics that affect our health care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the September survey.
3. How often is your doctor able to provide accurate answers to questions about the cost of your care?
2. During primary care office visits, how often do you ask about the costs of proposed care (i.e., lab tests, medications, referrals, etc.)?
1. Has recent federal health care reform made changes in your preventive health care benefits?
Always
Usually
Sometimes
Rarely
Never
50 40 30 20
26.1% 15.2%
10 0
6.5% 0.0% Always
Usually
Sometimes
Rarely
Never
Never
Minnesota
Health Care Consumer Association
Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.
SM
Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.
www.mnhcca.org
Join now.
“A way for you to make a difference� OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
31
G E R I AT R I C S
A balancing act: growing old and preventing falls among seniors by C. Dwight Townes, MD, and Amy Taylor-Greengard, PT, GCS
Growing old isn’t for the faint of heart. A body that once ran marathons, gardened for hours, and wrestled with children can slowly begin to creak, crack, and pull with age. What once was a quick stroll around Lake Calhoun can turn into an obstacle course of uneven pavement, low-hanging tree branches, and scattered rocks. Each obstacle can turn a simple stroll into a life-threatening stumble or fall. Although the potential to fall increases with age, there are a variety of ways to prepare for and prevent falls. From a simple fitness plan to a physician’s visit to review balance-related disorders, seniors can be proactive in preventing a fall from occurring. Falls common among seniors The senior population in Minnesota is growing fast. The Minnesota Department of Health anticipates that by 2030, the population of Minnesotans age 65 and older will have grown from 12 percent to 23 percent. Unfortunately, the Centers for Disease Control and Prevention (CDCP) is also reporting that nationally “each year one out of three
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adults over the age 65 falls. Among those aged 65 and older, falls are the leading cause of injury death.” In addition, the Minnesota Safety Council reports that “in 2000 the Hennepin County Community Health Department released a study which found that falls were the leading cause of injury hospitalization (76 percent) and death (67 percent) among seniors age 65 and older. The Hennepin County senior injury death rate was among the highest in the nation.” Falls, according to the CDCP, are also “the most common cause of nonfatal injuries and hospital admissions for trauma. In active people over the age of 65 who fall and break a hip, more than half never return to their previous level of activity.” These statistics do not bode well for those approaching old age. Fortunately, seniors and their family members can be proactive about their care and learn ways to prevent falls from occurring. Learning more about fall prevention and balance-related disorders can be the difference between getting up and walking away from a fall or a hospital admission for a life-threatening injury. What causes a fall?
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There are many reasons why people fall and why seniors are more prone than other age groups. Decreased coordination, joint flexibility, and nerve impulse speed, combined with blood pressure changes, muscle weakness, and increasingly poor vision all contribute to the increased risk of a fall, but are part of the aging process. So whether due to medical disorders, medication side effects, or obstacles in the home, a fall can occur anytime, anywhere.
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Disorders that impair balance Balance and movement disorders can be difficult to diagnose and treat. The challenge lies in the fact that balance disorders do not represent a single disease, but can be caused by a combination of disorders. A person’s balance requires the cooperation of the sensory, motor control, and central nervous systems in order to work correctly. If any one of these systems is impaired, the body is at risk for a fall. Vertigo, Parkinson’s, Alzheimer’s, cerebrovascular accident (stroke), osteoarthritis, diabetic neuropathy, and Ménière’s disease are just some of the disorders that can greatly affect a person’s
The Hennepin County Community Health Department released a study which found that falls were the leading cause of injury hospitalization (76 percent) and death (67 percent) among seniors age 65 and older. mobility and balance. Sometimes even a simple ear infection or abscessed tooth can affect balance. Drug interactions Many medications can cause problems with balance. Some have side effects that include dizziness and confusion. The more medications a person takes, the more likely drug interactions will occur that can increase the risk of falling. These include over-the-counter (OTC) medications such as pain relievers, vitamins, and nutritional supplements. High blood pressure medications—common among seniors—can often make a person feel dizzy or lightheaded upon standing or rising from bed. This is due to what is known as orthostatic hypotension. Staying healthy Many balance problems are treatable by fitness plans, medication, or surgery, if necessary. A physical therapist or physician can assess where a person’s balance problem lies, then suggest a plan that focuses on strengthening the muscles in a weak knee, for example, or suggest taking a class like yoga or Pilates, both of which improve balance. Take time to visit your doctor or a physical therapist to discuss any concerns about medication, balance, or overall health. Sometimes a simple change in medication or a new pair of glasses can make all the difference.
accidents happen just from being in the wrong place at the wrong time. The weather may change from rain to snow quickly, especially in Minnesota, and if an individual is caught outdoors without boots, walking can be hazardous. Walking on snow or ice—especially when wearing dress shoes with smooth soles—is always precarious. Instead of walking down a steep driveway to get the mail in the winter, ask if there is someone who drives by daily who could bring it to your doorstep. Plan accordingly Even though we cannot predict what life brings, we do have the power to anticipate potential mishaps and plan accordingly. Seniors have the power to be—and should be—proactive. Maybe that means a new fitness plan that focuses on increasing muscle strength, moving a piece of furniture from one area to another, or simply bringing along a cane for a walk around the lake. No matter which option one chooses, seniors must take an active role in preventing falls. C. Dwight Townes, MD, is the medical director at Saint Therese and has been providing quality care to seniors since 1976. He is also a board member of the Minnesota Medical Directors Association. Amy TaylorGreengard, PT, GCS, is the director of Rehabilitation and Fitness Services at Saint Therese.
Environment Indoors and out, the home environment can be an obstacle course. Consider the interior of your home. Do you have steps? From the garage to the house, or from upstairs to downstairs, seniors—or anyone, for that matter—can miscalculate a step and slip. What about a door threshold or irregular floor surface? Or a loose rug? All of these can cause a fall. The same is true for outdoors. Stairs from the deck or patio or uneven ground (holes or hills, etc.) can cause a fall. It is not possible to prevent all falls from happening. What a person can do is look around the home for potential pitfalls then try to prevent them by making a few simple changes, such as rearranging furniture, carrying a cane, or obtaining new medication. The Minnesota Safety Council offers a Fall Prevention Checklist on its website. On the list are suggestions for each room in the home: where to place handrails or guardrails, for example, reposition a rug, or increase lighting in certain areas. Other suggestions are to move commonly used items onto countertops or into cupboards that are easy to reach, or to use a cordless phone to prevent rushing for the phone when it rings. Even the smallest change can make a big difference.
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Uncontrollable factors Even if a senior is not tripped up by a rug, doesn’t have a balancerelated disorder, and is in perfect health, falls can still occur—some OCTOBER 2011 MINNESOTA HEALTH CARE NEWS
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Eye health from page 15
• Vision loss. This can also be associated with diabetes, if caused by macula edema. Since the macula is the most sensitive part of the retina and is responsible for clear vision, swelling in this area can cause difficulty with reading or even face recognition. If this happens, the child should see an eye doctor right away.
once a good blood sugar level has been established. Celiac testing is performed at four-year intervals. • Flu shots are important for diabetics, as for anyone with a chronic illness. Keys to preventing retinopathy
Controlling a child’s blood sugar level can be challenging. Parents must be involved in managing their child’s diabetes, by educating Other things to monitor beside blood sugar themselves and by modeling a healthy lifestyle. Children learn by • Height and weight, to assess normal development. example, so healthy eating habits and regular exercise should be • A hemoglobin A1C blood test should be performed every three integrated into a family plan. The child can be encouraged to months. It is the definitive test to determine if the glucose levels in develop other daily habits such as monitoring their own blood the blood have been maintained properly. If the A1C test result is sugar, keeping an insulin dose diary, recording carhigh, the treatment plan is adjusted. bohydrate intake as well as physical activity, and • Kidney function must be checked annually for following the instructions given by the health care diabetic children beginning at the age of 10 team. With integrated team care—care from the Almost because of the diabetes-kidney disease association. eye doctor, pediatrician/endocrinologist, diabetes everyone • Blood pressure is checked because type 2 diabetes educator, and the family—today’s diabetic child no is associated with hypertension and the developlonger needs to expect serious long-term complicawith type 1 ment of heart disease. tions such as cardiac, kidney, or vision disorders. diabetes will • Cholesterol and triglyceride levels are checked Comprehensive eye and health care form the founupon diabetes diagnosis for those at age of puberdation for a lifetime of healthy vision. eventually ty or older because high levels are associated with Linda Chous, OD, is active in the American Optometric heart disease. Younger children should be tested if develop some Association and is past president of the Minnesota there is a family history of heart disease. A norOptometric Association. She is chief eye health officer at level of mal test should be repeated at five-year intervals. UnitedHealthcare and maintains a pediatric practice • Tests for thyroid and celiac disease are important at diagnosis. The thyroid should be tested again
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MINNESOTA HEALTH CARE NEWS OCTOBER 2011
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