Minnesota Health care News December 2011

Your Guide to Consumer Information

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December 2011 • Volume 9 Number 11

Insomnia Michel Cramer Bornemann, MD

Music therapy Katie Lindenfelser, MMus

Immunization Lynn Bahta, RN

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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DECEMBER 2011 • Volume 9 Number 11

NEWS

PEOPLE

PERSPECTIVE Maureen Kenney, MPA Amherst H. Wilder Foundation

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19 20 22

CALENDAR Holiday health and safety tips

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PRIMARY CARE Cold and flu season

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PALLIATIVE CARE Music therapy at end of life

MINNESOTA HEALTH CARE ROUNDTABLE

AGING The “Dementia Dozen”

By Marlene Graeve, RN, CHPN

T H I R T Y- S E V E N T H

SESSION

TAKE CARE Nasal congestion

By Eric Becken, MD

By Jane Kilian, MD

10 QUESTIONS Robby Bershow, MD, CAQ Fairview Sports and Orthopedic Care

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12

PUBLIC HEALTH Immunization

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SLEEP MEDICINE Insomnia

PUBLIC HEALTH Avoiding the slippery slope

By Wendy Rader, PT, and Richelle Dack, DPT

By Lynn Bahta, RN

By Michel A. Cramer Bornemann, MD, D-ABSM, FAASM

Specialty pharmacy

By Katie Lindenfelser, MMus, MT-BC

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LEGISLATIVE UPDATE Shutdowns, cuts, and stalemates

By Jesse Berg, JD, MPH

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Mary Scarbrough Hunt mshunt@mppub.com

Controlling the cost of care Thursday, April 19, 2012 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions.

The term specialty pharmacy has come to be associated with these medications.

Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers.

Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.

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

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.

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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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DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

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NEWS

Employer-based Insurance Drops In Minnesota The number of Minnesotans who do not have employer-sponsored health insurance has increased 10 percent since 2000, according to a new study by the University of Minnesota’s State Health Access Data Assistance Center (SHADAC).

The trend is greater in Minnesota than nationally, the report finds. Overall in the United States, the number of people who have employer-sponsored insurance has dropped by 8 percent in the past decade.

The report says that even with the changes brought about by health care reform, employersponsored insurance is the foundation of how health care is delivered in the U.S. The nationwide trend of lower rates of people with employer-sponsored insurance raises concerns, SHADAC officials add.

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In Minnesota, 70 percent of all residents have employer-based insurance, down from 80 percent 10 years ago. Smaller businesses saw more of a decrease in the number of companies offering insurance, with an almost 7 percent decrease. Large businesses saw only a 2 percent decrease in firms offering insurance.

“Minnesota was one of 12 states nationally that experienced a decline in employer-sponsored insurance of 10 percentage points or more. But in Minnesota we think that a key part of this story is really an economic story, says Julie Sonier, deputy director of SHADAC. “We had a pretty substantial shift in the last decade in the income distribution of our population. So we have a lot more people who are earning in the low-wage category than we did at the beginning of the decade.

People in low-wage jobs are much less likely to have access to employer insurance.“

MINNESOTA HEALTH CARE NEWS DECEMBER 2011

Competitive Bidding Alters Metro Area Insurance Landscape HealthPartners and UCare have won contracts in the seven-county metro area for public health insurance programs as part of Minnesota’s new competitive bidding process, state officials announced recently.

The move came after the Dayton administration spent several months negotiating with the private health plans that have traditionally administered public programs such as Medical Assistance or MinnesotaCare.

The Department of Human Services (DHS) announced a competitive bidding process last spring that ensured there would be winners and losers among health plans that had in recent years found public programs to be among their most profitable lines of business.

On Oct. 20, Dayton announced the results of the competitive bidding process along

with several other steps as part of his “Better Government for a Better Minnesota” campaign, which aims to streamline government and make it more efficient.

Dayton and administration officials say that the competitive bidding process will result in taxpayer savings of between $170 and $180 million this year, and with other managed care reforms, total taxpayer savings will equal $242 million over the next two years.

Earlier in October, Metropolitan Health Plan had confirmed that it was losing 16,000 of 20,000 enrollees because of the competitive bidding process, and it appears that other changes in enrollments will take place as well. State officials say that only HealthPartners and UCare will be awarded contracts in all seven metro area counties. Medica will still be able to offer its public plans in Hennepin County, and officials say DHS is in final negotiations with Blue Cross and Blue Shield of Minnesota over programs in Ramsey and Dakota

Counties.

Enrollees in state health plans will still have insurance, but in many counties will see fewer options, and in some cases will have to switch plans.

Report Questions Effectiveness of Flu Vaccine With flu season well underway, state officials continue to stress vaccination as the best way to protect public health, even as a new study says current vaccines are not as effective as previously thought.

In Minnesota, the first official case of flu was reported on Oct. 13. Officials with Minnesota Department of Health (MDH) say the first case was caused by the A (H3) strain of the influenza virus, which appears to be covered by this year’s vaccine.

“Identifying influenza in the laboratory helps us know which strains are circulating and tells us how well this year’s vaccine will protect people from influenza and its complications,” says Kristen Ehresmann, director of the Infectious Disease Epidemiology Prevention and Control division at MDH. “The first case also serves as a reminder that vaccination is the best way to protect yourself and others against influenza and the best time to get vaccinated is now.”

However, a new report by the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota finds that flu vaccines are less effective than previously thought. The study says that current flu vaccines are effective on average about 60 percent of the time, rather than the 70 percent to 90 percent effectiveness that had been reported in the past. The CIDRAP study also found little evidence exists that flu vaccines are effective among seniors, who are among the most vulnerable populations.

Officials say that while vaccination is still the best protection against the flu, the new report

underlines the need for better vaccine formulas to be developed in the near future.

U of M Report Suggests Earlier Cancer Screenings A new finding by University of Minnesota surgeons is raising questions about the most appropriate age for screening for colorectal cancer.

The American Cancer Society currently recommends that Americans age 50 or older be screened for colorectal cancer. But the U of M study, published in the journal Cancer, found a rise in rectal cancer in people age 40 and younger.

The U of M researchers, using the largest cancer database in the United States, found that signet cell histology, a unique type of cancer cell, was almost five times more prevalent in those under age 40 with rectal cancer than in older patients. “The prev-alence of signet cell histology in patients under age 40 was statistically significant at 4.63 percent versus 0.78 percent in patients over 40,” says lead investigator Patrick Tawadros, MD, PhD. “While rectal cancer remains fairly uncommon in patients under 40, the rising trend, combined with our novel finding that signet cell histology is found at a rate of almost one in 20 in this population, is cause for attention,“ Tawadros says. “Clinicians need to be aware of this condition and carefully assess patients who present with any symptoms or signs that may be suggestive of rectal cancer.“

Two Task Forces To Lead Efforts on Health Care Reforms Gov. Mark Dayton has created two new task forces to lead health care reform efforts in Minnesota.

The governor says his Vision for Health Care Reform task force will develop an action plan for reforming how the state delivers

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News to page 6 DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

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News from page 5 and pays for health care. The governor is also establishing a task force to help set up health insurance exchanges in the state.

“Minnesota historically has led the nation and the world in the quality of our health care systems and the healthiness of our residents,“ said Dayton.

“Minnesota also has been a leader in reforms that have expanded access to quality health care for all Minnesotans. We must continue to innovate, and there is real urgency to our mission. Health care costs are rising at an unsustainable rate, undermining the budgets of Minnesota families, businesses, and our state and federal government budgets. The status quo is not good enough; we need to find new ways to delivering better quality health care at a lower price.“ The new groups join a long list of task forces and advisory committees that a succession of governors have created to deal with health care issues. Dayton,

like his predecessors Tim Pawlenty and Jesse Ventura, has been primarily concerned with health care costs and their impact on the state’s budget deficits.

Although some of these efforts have resulted in significant reform legislation, such as the current efforts to create health care homes and enact payment reforms, the effect on state deficits has been negligible so far.

The ongoing rollout of the federal Affordable Care Act (ACA) gives new impetus to reform efforts, however. States face deadlines to conform to ACAmandated measures such as health insurance exchanges, which all states are required to implement by 2014.

Dayton’s preliminary efforts to move forward with an insurance exchange for Minnesota have met with resistance by the Republican-controlled legislature, but the Oct. 31 announcement signaled that the administration is determined to continue the process of setting up the health insurance exchanges.

Administration officials say the new task forces will allow the state to work with a wide range of stakeholders in finding consensus on health care reform. “In Minnesota, we have a strong history of working across party lines with advocates, health plans, and providers, all collaborating to pass groundbreaking health reforms,“ says Department of Human Services Commissioner Lucinda Jesson. “Governor Dayton created these task forces to bring together the best minds in health care to continue in that grand tradition.“

Guidelines for Kids Could Help Identify Mental Health Issues Mayo Clinic researchers, in collaboration with a wide range of mental health groups, have created a new set of guidelines to help identify mental health disorders in young people.

Studies show that up to 75 percent of young people with

mental health disorders are not diagnosed and do not receive needed care. The Mayo project surveyed more than 6,000 parents and children about mental health services and created guidelines to help identify symptoms of mental health disorders in young people.

The language that mental health providers use can be confusing, says Peter Jensen, MD, who led the Mayo research team.

He adds that researchers have concluded that they need to communicate better to families the warning signs of mental illness.

“We had to get out of the mental health jargon and into the very best terms that would communicate with families,” Jensen says.

The new tool includes a list of action signs in simple, nonstigmatizing language to lead young people and their families to seek help if they are experiencing symptoms of mental health disorders.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2011

PEOPLE Jackie Boucher, project director for Hearts Beat Back: The Heart of New Ulm Project, was awarded the Excellence in Practice–Management Practice Award from the American Dietetic Association in September at the 2011 Food & Nutrition Conference & Expo in San Diego, Calif. The award recognizes an outstanding registered dietitian who has demonstrated excellence and leadership in this specific

Public Health Certificate in Clinical Research

area of practice. Boucher is also vice president for education at the Minneapolis Heart Institute Foundation. The New Ulm (Minn.) project is a 10-year initiative to significantly reduce and eventually eliminate heart attack deaths among residents. Boucher also oversees both professional education and community education at the foundation.

The award cited Boucher’s “exceptional professionalism, innovation, creativity and leadership in her career as a registered dietitian.”

Twin Cities Orthopedics has added five new orthopedic surgeons to its medical staff. Jason Barry,

The University of Minnesota School of Public Health offers a program for people who work with research clinical applications on human beings but who do not have an advanced degree in clinical research.

MD, is a sports medicine fellowship-trained orthopeJason Barry, MD

Coursework is conveniently offered online and the program can be completed in six terms.

dic surgeon who special-

izes in total joints, fracture care, and general orthopedics. His special interests include ACL reconstruction and arthroscopy of the shoulder, knee, and hip. He will see patients at the Coon

Scott Holthusen, MD

Rapids, Fridley, and Shoreview locations. Scott Holthusen, MD, is a

www.sph.umn.edu/programs/certificate/cr

fellowship-trained foot and ankle specialist. He will see patients at the Chaska and Waconia locations. Allan Hunt, MD, specializes in sports medicine and treats athletes of all ages.

His areas of expertise include arthroscopic shoulder reconstruction and adult shoulder, knee, and hip reconstruction. He will see patients at the Edina and Plymouth locations.

Daniel Marek, MD, is a fellowship-trained hand

Do your legs hurt when you walk?

Does it go away when you rest?

Or, have you been diagnosed with PAD?

surgeon who treats condiAllan Hunt, MD

tions of the hand, wrist,

and elbow in both adults and children. He will see patients at the Chaska, Glencoe, and Waconia locations. Corey Wulf, MD, specializes in sports medicine, multi-ligament knee reconstruction, cartilage trans-

Leg Pain Study

Daniel Marek, MD

plant, and general orthopedics. He will see

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

patients at the Edina and Eden Prairie locations.

March of Dimes has

To see if you qualify, contact the EXERT Research Team at

named Sarah Gutknecht, RN, MSN, CPNP, the 2011

612-624-7614

Distinguished Nurse of the Year. Gutknecht is a pediCorey Wulf, MD

or email EXERT@umn.edu or visit EXERTstudy.org

atric orthopedic nurse who

cares for children with special needs at Gillette Children’s Specialty Healthcare and Shriners Hospital for Children–Twin Cities. In addition,

Sarah Gutknecht, RN, MSN, CPNP

Gutknecht has cared for children around the world through her volunteer work in patient care, teaching, and leadership positions.

In addition, March of Dimes celebrated Nurse of the Year winners in 14 other categories. Nominations were submitted by patients, their

EXERTstudy.org

families, and health care professionals statewide.

DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

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PERSPECTIVE

You or someone you know may be a caregiver Why caregivers should self-identify

D

Maureen Kenney, MPA Amherst H. Wilder Foundation

Maureen Kenney, MPA, serves as the caregiver services manager at the Amherst H. Wilder Foundation in St. Paul. Prior to assuming this role, Kenney held leadership positions in a variety of nonprofit organizations serving lowincome families, elders, and persons with disabilities.

Kenney holds a master of public affairs degree from the Humphrey School of Public Affairs at the University of Minnesota.

o you pick up groceries for your parents, remind your spouse to take his or her medication, or mow the lawn for an older neighbor? If the answer is “yes,” then you are a caregiver.

or begins showing signs of memory loss—and overnight you find yourself cast in a new role. In addition to being a daughter, husband, partner, or friend, you are now also providing care, navigating systems, and advocating for their needs.

You’ve probably heard the word “caregiver” before, but if you are like most people, thought it could not apply to you. On the contrary: A caregiver is anyone—family member, friend, or neighbor—who provides ongoing care for an older or disabled adult. Caregiving can be as extensive as providing round-the-clock care for a loved one, or as simple as picking up groceries for a neighbor.

What should you do first? How do you prepare yourself to take on this new role with confidence?

In Minnesota, over 90 percent of all long-term care for elders is provided by family members and close friends. These caregivers make it possible for older and disabled adults to remain in their homes and communities.

1) Acknowledge the changes that your new role as caregiver will require. This is often harder than it sounds. We have longstanding relationships with our loved ones, relationships with their own habits, rituals, and expectations. When circumstances require us to take on the role of caregiver, these relationships don’t end, but they do evolve. Embracing rather than avoiding this new role will encourage you to get the information and support you need to provide confident care to your loved one.

Why identify as a caregiver?

According to AARP, only 19 percent of family members and friends who are actively caring for a loved one identify as caregivers. Family members 2) Build your support team. People feel valued think of themselves as husbands and wives, and included when you ask them for help. Not everyone is equipped to help daughters, or sons—but not with every type of task, of as caregivers. Because they course, but it’s usually possiaren’t even aware they have Identifying as a ble to find a task for everyone taken on the role of caregivcaregiver is the first and who offers support. Don’t set er, they are often unaware of most important step. ... impossibly high expectations the resources that exist to for yourself or let others do support them.

There is a world so, either—make it clear that Identifying as a caregiver is of resources available. you don’t intend to be a the first and often the most superhero. You want and will important step a person can need help. And keep in mind take in this important role. Numerous studies that your support team goes beyond friends and have shown that if you don’t know you are a carefamily—it also includes health care professionals, giver, you won’t seek support. Once you recognize community service organizations, and individuals that you are playing the role of caregiver, you will you may hire. discover there is a world of information and resources available.Taking advantage of them can increase your confidence as a caregiver and can help create the future you want for your loved one, while ensuring that you have the resources you need to remain healthy and active.

Being a caregiver to an aging or disabled loved one is one of the most meaningful and important roles one can play, so identify today—check out whatisacaregiver.org for more information on caregiver services and supports.

I’m a caregiver—now what?

Becoming a caregiver often happens suddenly.

Your loved one has a stroke, falls and breaks a hip,

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Below are some simple suggestions that will go a long way in equipping you for success as a caregiver:

MINNESOTA HEALTH CARE NEWS DECEMBER 2011

3) Get organized. Gathering key documents, medical information, and contact lists early on will enable you to be prepared when decisions need to be made or emergencies arise. It’s likely that you or someone on your support team will need to be as familiar with your loved one’s financial, medical, and legal affairs as you are of your own.

Taking these first steps can help you move forward confidently in your new role as a caregiver.

For more information, visit wilder.org or contact Wilder Caregiver Services at 651-280-CARE or caregiver@wilder.org.

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10 QUESTIONS

& Robby Bershow, MD, CAQ Dr. Bershow is a primary care sports medicine physician at Fairview Sports and Orthopedic Care in both Eden Prairie and Burnsville. He is a diplomate of the American Board of Family Medicine and has a Certificate of Added Qualification in Sports Medicine.

What is sports medicine? “Sports medicine� is a broad term covering a wide range of practices, with the overall goal of preventing, managing, and rehabilitating injuries. In general, it refers to the care of muscle, bone, and joint conditions, as well as a variety of medical issues related to those areas. The sports medicine team consists of primary care doctors, surgeons, physical therapists, sports psychologists, athletic trainers, radiologists, and nutritionists, among others.

The American Board of Medical Specialties recognizes sports medicine under several different areas of practice. What can you tell us about this?

Doctors in this field fall into one of two main categories: primary care sports medicine and orthopedic sports medicine. Providers with a primary care background evaluate and provide nonsurgical treatment of musculoskeletal problems. Typical activities include casting fractured bones, doing joint injections, and helping people manage symptoms. When an operation is required, patients are referred to an orthopedic sports medicine doctor.

Is special training or certification required to practice sports medicine? While any doctor can care for sports injuries, there is a special certification process for both primary care and orthopedic sports medicine specialists. After medical school, primary care sports medicine doctors usually complete a residency in family medicine, but that residency can be in pediatrics, internal medicine, emergency medicine, or other specialties as well.

Following residency, they complete an additional one- to two-year fellowship program and then must pass a comprehensive board examination to receive a Certificate of Added Qualification (CAQ) in sports medicine. Those who wish to become surgeons complete an orthopedic residency, then a one- to two-year surgical fellowship program to specialize in sports medicine or on a specific joint. If your doctor is specially trained in sports medicine, you can be sure that you will get the best possible care for your problem.

What kind of patients do you see? People often think sports medicine is primarily for competitive athletes, which is not always the case. It is true that sports doctors provide sideline medical coverage for sporting events and enjoy caring for athletes at all levels of ability, from Little League through college and into masters-level competitions. However, we also see a large number of patients who are just starting to be active or who can’t participate in activities they enjoy because of arthritis, overuse injuries, or other conditions. Sports medicine doctors can also provide exercise prescriptions, or counseling on how being active fits in with chronic medical issues like obesity or diabetes. We like to think that every person is an athlete on some level, and that our goal is to maximize his or her potential.

Photo credit: Bruce Silcox

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What are some examples of the types of treatments you most commonly prescribe? Every problem is different, but there are some basic principles that apply to most injuries. With the exception of some types of bone fractures and overuse conditions, almost all do better if we can work to restore normal motion and to strengthen the muscles that control how the joints function. Physical therapy focuses on these areas and therefore

MINNESOTA HEALTH CARE NEWS DECEMBER 2011

“

”

Every day, new research is helping us get patients back in the game sooner.

plays a major role of many our treatment plans. Sometimes we will prescribe oral medications to control pain or relieve inflammation, and frequently we will perform injections (such as cortisone shots) in target areas that are not responding well to other therapies.

How much of sports medicine involves prevention?

Prevention is an extremely important part of wellness. This is true for all medicine, and sports medicine is no exception. It’s much easier to keep someone healthy by heading problems off at the pass than to heal an injury after the fact. Much of what we do focuses on familiarizing patients with how their bodies work so they can set appropriate goals for starting, resuming, or maximizing activity.

What are the most important things a person can do to prevent an injury? The most important part of preventing injury is being active on a regular basis. The more we sit around, the harder time we have getting moving again—deconditioning can lead to problems with balance, strength, and flexibility, any of which can lead to injury. I always tell patients to listen to what their bodies tell them: Knowing where their limitations are today can help them set goals for tomorrow, and their physician is always there to help figure out what is too much and what is not enough.

How would a patient know to see a sports medicine physician? Frequently patients come to see us soon after an injury, or some time later if they feel they are not improving. Often a patient

is referred to us by the primary physician, who feels that the patient may benefit from a more thorough sports medicine evaluation. Some of the more common problems we see are arthritis, low back pain or neck pain, concussions, broken bones, overuse injuries (such as tennis elbow or runner’s knee), and other joint problems.

What advice can you offer to limit winter sports injuries?

Given how much Minnesotans like to play outside all year, we see plenty of sports injuries from the first snowfall to the last of the spring melt. The vast majority of winter injuries, though, are accidents: people getting hurt in car accidents, falling off ladders, slipping on the ice. Having good footwear and maintaining good visibility make a huge difference. Taking extra time getting from point A to point B and being willing to ask for help when needed are probably the two best pieces of advice for preventing these injuries.

What do you see as the future for sports medicine? This is an exciting time to be in sports medicine; every day, new research is helping us get patients back in the game sooner, with innovative surgical techniques, therapies, and types of injections. Even more importantly, we are learning just how crucial exercise is to health and wellness, and how much work there is to be done in helping people become more active. The future of health care involves rethinking how we can work with patients to treat the whole person, and I see sports medicine playing an integral role in that evolution.

Your quality of life deserves our quality of care.

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11

PUBLIC HEALTH

Immunization

Protect all children by protecting your child

By Lynn Bahta, RN

V

accinating our children never used to be in question. I remember taking my 2-month-old to the doctor for his first set of shots. I cried right along with him, but knew I had done what was needed to keep my son healthy. Now, 20 years later, other parents have decided to delay or even forgo immunizing their children altogether. Is that really a good idea? How did we get to this point?

The reasons include: • Low rate of some diseases. When we no longer see a disease and its severe effects, we no longer fear it, forgetting that vaccines made this possible.

• Concern about the number of vaccinations. Parents ask: “Are there too many vaccines?” Or “Are babies too young?”

• Inaccurate information from the Internet. As parents, we want to be informed advocates for our children, but there is so much information on the web, unfortunately, that is inaccurate. So any information you use to make decisions should reference its sources—which should be authoritative sources, such as leading

research institutions or peer-reviewed scientific journals. Read several sources, too, before forming an opinion that will affect the health of your child.

“Isn’t the risk of disease low?”

Not low enough to forgo vaccination. Diseases preventable by vaccination are closer than we realize thanks to international travel.

Four different times in 2011, travelers brought measles into Minnesota from abroad. Minnesota’s immunization rate hovers between 70 and 75 percent, and few parents exempt their children from vaccination, but clusters of unvaccinated children are increasing within our communities. Diseases seek and often find the vulnerable—i.e., the unvaccinated. This past spring, an unvaccinated traveler brought the measles to Minnesota and it spread to 18 children—the first measles contagion in over a decade. Unless a disease is eradicated, as smallpox was, we need to stay vigilant and keep vaccinating.

“Is it risky to vaccinate my baby?”

No—not vaccinating your child is actually risky. Last August, a 1-year-old in Dakota County became so sick from measles that he almost died. His mother wants every parent to know how important it is to vaccinate your child against measles and other serious diseases.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2011

Minnesota Department of Health (MDH) Immunization Program 651-201-5503 or 1-800-657-3970 or http://www.health.state.mn.us/divs/idepc/immunize/safety/index.html

For further reading: Stringent government monitoring Vaccines must be licensed by the Federal Drug Administration and therefore must undergo rigorous clinical trials to prove that they are effective and safe. Even after approval, vaccines are continuously monitored for effectiveness and safety.

While vaccine reactions can occur, most are quite mild, such as a slightly swollen or sore injection site, temporary fever, or tiredness. Occasionally, a child might develop a fever that triggers a seizure, but the child usually recovers on its own. A severe allergic reaction to a vaccine is rare, as are serious side effects. Continuous safety monitoring shows that the benefits of vaccination far outweigh any

This website contains a variety of reliable resources and a link for ordering immunization materials. Many materials are available in other languages, including Hmong, Russian, Somali, Spanish, and Vietnamese.

Centers for Disease Control (CDC) National Center for Immunization http://www.cdc.gov/vaccines/ CDC Immunization Information Hotline 1-800-CDC-INFO or 1-800-232-4636 (TTY 1-800-232-6348). In English and Spanish.

American Academy of Pediatrics Immunization Initiatives http://www.aap.org/immunization/

risk.

“How do infants handle all these vaccines?”

An infant is born with an immune system that needs to be challenged in order to do its job. Infants are exposed to thousands of foreign proteins called antigens on a daily basis. So vaccines actually help the immune system mature. To put things in perspective, an ear infection poses a bigger challenge to an infant’s immune system than the eight vaccines it receives at the two-month checkup.

It is a myth that spacing out vaccinations is safer. Vaccines are recommended at certain ages for a reason—to protect babies from serious diseases as soon as their bodies can cope. Delaying vaccination just means that the child gets more injections later, which is more stressful physically. One mother described her attempt to spread out the vaccines as useless; she got further behind in the schedule and her baby still had mild reactions—and actually more

often than it would have had it been vaccinated on schedule. The child’s younger sibling is now getting vaccinated on time.

“What about all those concerns I hear in the news?”

Simply hearing or reading about a vaccine concern does not make it true. One of the most pervasive myths over the past decade is that vaccines cause autism. This was started by a British doctor who suggested in his 1998 study that the MMR vaccine might cause autism.

His study had several flaws, however; the study included only 12 children, data were falsified, and the doctor benefited personally from the study, which was a conflict of interest. Because of the latter, 10 of the 13 authors removed their names from the study. In the end, the doctor lost his medical license for violating medical ethics.

More importantly, no researcher since then has been able to validate the original findings; repeated studies have shown that there is no Immunization to page 34

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EOE

13

SLEEP MEDICINE

Insomnia

By Michel A. Cramer Bornemann, MD, D-ABSM, FAASM

Insomnia is the second most common complaint doctors hear from their patients, affecting 10 to 20 percent of all adults in the United States. Insomnia is defined not only by a perceived decrease in total sleep time, but also by the difficulty in initiating and maintaining sleep and by the consequent negative impact upon overall quality of sleep. Though many people focus on nighttime sleep complaints, the degree of clinical intervention is often determined by insomnia’s impact on daytime functioning.

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In the past, it was believed that psychiatric or psychological problems caused insomnia. This is not usually the case.

In the past, it was believed that psychiatric or psychological problems caused insomnia. This is not usually the case.

The majority of those with insomnia do not have significant psychiatric disease, although insomnia, if left untreated, may lead to problems such as depression or substance abuse. The relationship between insomnia and psychiatric conditions goes both ways: Depression may worsen insomnia, and insomnia may worsen depression.

Many patients with insomnia complain of nonrestorative sleep.

That is, they do not sleep long enough or well enough to feel rested upon awakening, despite having set aside plenty of time to sleep.

(Sleep deprivation due to lack of time for sleep is not insomnia.)

People with significant insomnia may feel compromised in many areas: emotional, cognitive, and physical. Symptoms may include irritability, lack of focus, and headaches. Severe insomnia has also been associated with increased absenteeism and in decreased productivity in the workplace. Interestingly, bouts of inappropriately falling asleep during the day are extremely rare, as insomniacs tend to be in an activated state, which contributes to the perpetuation of their condition.

Insomnia may be treated using behavioral methods, medication, or both concurrently.

Medications for insomnia Medications for treatment of insomnia fall into three categories: 1. “Natural” remedies

uted to a unique side effect of the drug or to the sheer number of prescriptions (given its popularity), or to misuse by the patient or inadequate information from the prescribing physician. Regardless of the situation, care must taken with these medications, as—unlike other potential side effects—these may become both a personal and public safety issue if a person unknowingly leaves the bedroom under the influence of an agent such as Ambien.

Behavioral treatments Behavioral treatments for insomnia are clearly effective but may be quite timeconsuming. Also, experienced practitioners are not always available. Clinical psychologists who are experienced in treating insomnia Insomnia to page 16

2. Over-the-counter (OTC) medications 3. Prescription medications There is no evidence to suggest that “natural” remedies are particularly effective. Valerian root in particular has been shown to be ineffective. OTC medications are limited to diphenhydramine and doxylamine (ingredients in Tylenol PM and Advil PM). Although these drugs are widely used, there is very little scientific evidence that they actually improve the quality or quantity of sleep.

Prescription medications are limited to benzodiazepines (e.g., temazepam; brand name: Restoril), newer non-benzodiazepines (e.g., zolpidem; brand name: Ambien), and hypnotic, melatonin-like drugs (e.g., ramelteon; brand name: Rozerem). Both the benzodiazepines and nonbenzodiazepines are safe and effective when prescribed by physicians who are knowledgeable about both the limitations and the benefit/risk profile of these agents. Incidences of dependence, tolerance, or abuse are very low. Results for the melatonin-like medications have been disappointing.

Although antidepressant medications such as trazodone (brand name: Desyrel) and atypical, antipsychotic medications such as quetiapine (brand name: Seroquel) are frequently prescribed to treat insomnia, there is no evidence that these drugs are either effective or durable in treating insomnia, unless the patient has an insomniaassociated, major psychiatric disease.

There has been much media attention recently to incidents of complex behaviors—some with criminal, forensic implications—such as sleep walking, sleep eating, sleep driving, rage reactions, sleep sex, making telephone calls, or surfing the Internet while asleep after taking sleeping pills. Most of these behaviors have been associated with zolpidem. It remains unclear whether these behaviors can be attrib-

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15

5. Set an alarm to get up at the same time each morning.

Insomnia from page 15

may use a combination of techniques to help their patients, including: • Relaxation therapy—which uses techniques such as progressive relaxation, abdominal breathing, yoga, guided imagery, hypnosis, or biofeedback to help tense or anxious individuals prepare physiologically for sleep.

6. Do not nap during the day.

Go to bed only when sleepy.

• Sleep hygiene—which refers to the practice of avoiding waking behaviors that are likely to disrupt sleep. Sleep hygiene instructions may include keeping a regular wake/sleep schedule, avoiding naps, and avoiding caffeine after mid-afternoon. However, chronic insomnia rarely disappears entirely with these behavioral changes alone.

• Stimulus control—the underlying principle of which is to strengthen the relationship between the bed, bedroom cues, and sleep. Patients are requested to follow these steps: 1. Go to bed only when sleepy.

2. Use the bed only for sleep and sex.

3. If you are unable to sleep for 15 minutes, get out of bed and go to another room and do something relaxing. Do not do something that unconsciously rewards you for being awake in the middle of the night (e.g., taxes, housework, studying). Return to bed only when sleepy.

4. Repeat step 3 as often as necessary.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2011

• Sleep restriction—which leads to increased expression of sleep the next evening. For example, if a patient sleeps five hours each night, but is spending seven hours in bed, then restrict time in bed to five hours. The accumulating sleep deprivation will quickly lead to sleeping most of the five hours.

The length of time in bed can then be increased slowly, as long as the time spent asleep remains at 85 percent or more of total time in bed.

• Cognitive therapy—which may be appropriate for patients with chronic insomnia who have developed poor attitudes and beliefs about sleep, such as blaming all of their personal problems on their insomnia. The goal of this treatment is to change these beliefs into more positive and rational ones.

• Mindfulness-based stress reduction (MBSR)—a new behavioral treatment that appears promising and continues to receive significant attention at the University of Minnesota’s Center of Spirituality.

MBSR is a formal psychological and meditative approach to helping individuals manage and reframe the worrisome thoughts that interfere with sleep.

A combined approach to treatment Insomnia is a very common complaint. Although insomnia is a clinical diagnosis, formal sleep studies are rarely ordered unless there is reason to suspect a coexisting sleep disorder, such as obstructive sleep apnea (where one stops breathing consistently while asleep).

Furthermore, insomnia as a symptom would need to be evaluated first, because it could present as a coexisting feature of another medical condition. It is strongly suggested in these cases that the medical condition be treated optimally first before pursuing any sleep diagnostic studies. Following a thorough clinical evaluation, the underlying cause for primary insomnia can usually be identified and an effective treatment plan developed, often involving combined behavioral and medicinal approaches.

Michel A. Cramer Bornemann, MD, D-ABSM, FAASM, is a staff physician at the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center in Minneapolis. He is also lead investigator at Sleep Forensics Associates where he reviews criminal and civil cases involving sleep disorders.

Dr. Cramer Bornemann is also an assistant professor in the Department of Neurology and the Department of Medicine at the University of Minnesota Medical School in Minneapolis, and is a faculty instructor in the University of Minnesota’s Department of Biomedical Engineering.

FOR TYPE 2 DIABETES

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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

December Calendar 8

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Weathering Life’s Losses This adult grief group is for those who have experienced the death of a loved one.

Meetings are held every Thursday (call for holiday schedule). No registration required.

For more information, call 651-430-4586.

Thursday, Dec. 8, 6–7:15 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater Hope For Recovery Workshop Spend a Saturday learning about mental illnesses, treatments, coping strategies, the mental health system, and local resources.

Please bring your own lunch. Call NAMI Minnesota at 651-645-2948 to register for this free workshop, or for more information about additional workshops.

Saturday, Dec. 10, 9 a.m.–3 p.m., Regions Hospital, 640 Jackson St., Teeter Library, St. Paul Grandparenting: What Has Changed?

Discover the latest changes in infant care, methods of feeding as well as home, car, and toy safety. Aunts and uncles welcome, too! For questions, call 320-229-5139.

Monday, Dec. 12, 6:30–8:30 p.m., CentraCare Health Plaza, 1900 CentraCare Cir., Hughes Mathews Rm., St. Cloud Diabetes Education These meetings provide education and include time for questions for those with type 1 or type 2 diabetes. Free, but registration is required. Call Gene Anderson at 651-459-3143.

Wednesday, Dec. 14, 2–3:30 p.m., Arlington Hills United Methodist Church, 759 County Rd. B E, Maplewood Twin Cities Young Breast Cancer Survivors This group is for those ages 20 to 40 who have been diagnosed with breast cancer.

We offer support and education pertinent to the issues faced by younger individuals.

For more information, call Susan at 612-273-6434 or Ann at 612-273-2151.

Thursday, Dec. 15, 6:30–8 p.m., Hope Lodge, 2500 University Ave. S.E., Minneapolis

Holiday Health and Safety Tips Give the gift of health and safety to yourself and others by following these holiday tips from the Centers for Disease Control and Prevention (CDC):

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Women’s-Only Heart Health If you are a woman living with heart disease, you are invited to join other women to discuss your experiences, strategies for heart-healthy living, and solutions to the challenges you face. Each week, guest speakers and featured topics will help you learn about ways to improve your heart health. Call Susan White at 612-775-3074 to register in advance.

Monday, Dec. 19, 6–7:30 p.m., Minneapolis Heart Institute, 920 E. 28th St., Lower Level, Minneapolis

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Parkinson’s Support Group Are you looking to connect with others who are living with the challenges of Parkinson’s? Join us on the third Wednesday of each month. You will have opportunities both to give and receive support, take an active role in educating yourself, and learn about the tools to help you live to the fullest with Parkinson’s. Free. For more information, call 651-438-0750.

Wednesday, Dec. 21, 2–3 p.m., Hastings Senior Center, 213 Ramsey St., Hastings

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Lupus Education and Support Support groups have been shown to have positive effect on the wellness of lupus patients. Come and share your personal stories, learn about educational materials and resources, and socialize with others who understand the challenges of living with lupus. For more information, call the Lupus Foundation of Minnesota at 952-746-5151.

Wednesday, Dec. 28, 6–7:30 p.m., Anoka City Hall, 2015 First Ave. N., Committee Rm., Anoka

Wash your hands often. This is one of the most important steps you can take to avoid getting sick and spreading germs to others.

Wash your hands with soap and clean running water for at least 20 seconds.

Manage stress. Keep a check on overcommitment and overspending. Get support from family and friends. Keep a relaxed and positive outlook.

Travel safely. Don’t drink and drive, and don’t let someone else drink and drive.

Wear a seat belt every time you drive or ride in a motor vehicle. Always buckle your child in the car using a child safety seat, booster seat, or seat belt according to height, weight, and age.

Watch the kids. Keep potentially dangerous toys, food, drinks, household items, choking hazards (like coins and hard candy), and other objects out of kids’ reach. Learn how to provide early treatment for children who are choking.

Handle and prepare food safely. Avoid cross-contamination by keeping raw meat, poultry, seafood, and eggs (including their juices) away from ready-to-eat foods and eating surfaces. Cook foods to the proper temperature. Don’t leave perishable foods out for more than two hours.

Eat healthy, and be active. With balance and moderation, you can enjoy the holidays the healthy way. Choose fresh fruit as a festive and sweet substitute for candy. Find fun ways to stay active, such as dancing to your favorite holiday music.

For more information, visit www.cdc.gov/family/holiday/

20 Car Seat Safety Research shows 80 to 90 percent of car seats are used incorrectly. This class will demonstrate the proper use of car seats to protect children. No need to purchase a car seat before coming to class, but bring one if you have it. For more information, call 952-428-3104.

Tuesday, Dec. 20, 6–8 p.m., St. Francis Medical Center, 1455 St. Francis Ave. Conference Ctr., Shakopee

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 DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

19

AGING

The

“Dementia Dozen�

12 tips for caregivers of Alzheimer’s disease patients

By Marlene Graeve, RN, CHPN

The Alzheimer's Association reported in 2011 that 5.4 million American people have Alzheimer's disease, and that nearly 15 million Americans provide unpaid care.

Eighty percent of this care is provided in the home and is delivered by family caregivers. Caregivers report high levels of stress, which can negatively impact health and financial security. It is natural for family members to want to do the right thing, but it can take a toll on the entire family.

After three years of struggling on her own, my sister contacted me to confide that she was hesitant to continue caring for her mother-inlaw, Alice. A 30-minute visit seemed like hours and often involved arguments and difficult interactions.

Alice lived in an assisted-living community, and even though she had staff to help her, her family was very involved in her care. Memory loss, personality changes, resisting care, and repetitive questions were but a few of the Alzheimer’s symptoms she exhibited. Tearful, angry phone calls became commonplace. The family struggled with mom’s repeated question, “Why can’t I go home?�

Only after my sister asked for help did the lightbulb go on for me.

My family was struggling, as none of them had training in dementia caregiving. Here I was, a health care professional working with an Alzheimer's Association trainer and teaching my own staff about dementia care, yet I had not realized that my own family needed help.

That is how the “Dementia Dozen� evolved—from a letter I wrote to my sister that she then copied for other family members to read before they visited their mother and grandmother. These 12 suggestions can help you, too, feel better equipped as you care for a loved one with Alzheimer's or another form of dementia.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2011

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Twelve tips for caregivers

1 Don’t argue. Reprimanding is futile and only causes frustration.

Dementia care is about comfort, not cure.

2 Offer frequent snacks and fluids. Pacing is common for those with Alzheimer’s, so meals may have to be eaten on the fly. Offer meals or snacks at least every three to four hours to prevent dehydration and weight loss. Try favorite foods, or if all else fails, try foods that are sweet and soft, as those are generally accepted.

3 Communicate at eye level. You may have to kneel if your loved one is sitting in a wheelchair. Don’t just speak with the family and ignore the person with dementia; he or she will feel excluded and depersonalized.

4 Watch your “nonverbals”: eye expression, tone of voice, and body language. Show that you value them as a person. Being respectful takes extra time and patience, but it’s crucial.

5 Use the four S’s: speak slowly, simply, and smile. A smile can go a long way when words are not making sense. Use eye contact, and keep your sentences short and uncomplicated. You might say: “Brush your teeth now,” as you offer a toothbrush.

6 Use the four R’s: redirect, reapproach, reassure, and reminisce. Examples: “Let’s go for a walk first;” or “I will come back after I get you a glass of water;” or “Tell me about your garden.” Plan to be rebuffed and plan a strategy well ahead of time. Memorize the four R’s and practice using them daily so they become second nature.

cause; perhaps a nap is needed, or the television is too loud or has been on too long.

Caregiving can be tedious.

Know your limits and take care of yourself. It is wise to ask for help when you need it. The first symptom of caregiver burnout is often feeling overly tired or depressed. Only you can take care of you. As Sarah Ban Breathnach says in her book “Simple Abundance,” “Don’t wait until you are charred to recognize burnout.”

11

Visit the Alzheimer’s Association website www.alz.org or call their 24/7 Helpline at 800-272-3900.

12 Familiarize yourself with resources (see below). Ask for brochures, referrals, or to speak with someone in your geographic area. There may be caregiver support groups in a nearby community center. The National Family Caregiver Association (www.nfcacares .org) is another wonderful organization. Myriad tips are available, and you will soon realize that you are not alone.

There is power in knowledge and in collaboration with others. A long-term illness like Alzheimer’s disease needs all the help, compassion, and knowledge we as a community can provide. With the right tools, smiles can replace exasperation.

Marlene Graeve, RN, CHPN, is a registered nurse and certified hospice and palliative nurse at Sholom Roitenberg Assisted Living in St. Louis Park and at Superior Home Health Care in Lakeville.

7 Become aware of unexpressed pain and be proactive. Pain can be at the root of agitation, anxiety, and depression. It may be expressed as restlessness, sighing, hand-wringing, stiffness, insomnia, or unusual breathing. Something as simple as Tylenol given routinely can make a difference, but don’t administer it on your own without asking the doctor first.

8 Music enjoyment is universal, and the ability to enjoy music is seldom lost. Music can often be as effective as pharmaceuticals, and there are no side effects. Use music to energize in the morning and to calm at night, or just to reminisce. Rediscover favorite tunes (“You Are My Sunshine” or “Take Me Out to the Ballgame,” for example), or discover music that you both enjoy. Make it fun by clapping along with the music, tapping your toe, or dancing. You can use music to signal a routine such as naptime. Establishing healthy habits can eliminate anxiety or unacceptable behavior. Music should be easily accessible— put a CD player in the bedroom, bathroom, and/or kitchen.

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9 Relearn the person. What's important to him or her? Ask about jobs, hobbies, families, friends, and spirituality—but then truly listen.

If it comforts someone to read a prayer book, hold a rosary, listen to gospel music, or visit with the rabbi, for example, find a way to make it happen.

10 Dementia care is an art form; no rule works all the time.

Each person is unique. Keeping a bedside journal is one way to share information with family, friends, and staff on what works. Record things that trigger difficult behavior; record successes as well. Pay attention to the clock: mid- to late afternoon is when most outbursts occur and anxiety expressed. Fatigue or overstimulation may be the DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

21

TA K E C A R E

Nasal congestion A common cold, hay fever, allergies, sinusitis, deviated septum, overuse of some medications, nasal polyps, and even pregnancy can all result in nasal congestion. The symptoms are similar, but the diagnosis and treatment may be vastly different. Some symptoms improve on their own in a few days and others require over-the-counter treatments, prescription medication, or even surgery. There are many options to treat the symptoms as well as the underlying reason for the congestion.

Over-the-counter treatments Over-the-counter (OTC) treatment of nasal congestion falls into four main categories: nasal irrigation, decongestants, antihistamines, and mucolytics. Let’s look at each one more closely so you know what to choose the next time you or your family is suffering from nasal congestion.

Nasal irrigation

By Eric Becken, MD

Saline nasal irrigation is the first line of treatment for most causes of nasal congestion. It decreases inflammation, helps to clear mucus, and clears allergens and other irritants. The salt solution used for irrigation can be homemade, premixed, or mixed with commercially available salt packets. It is administered in many ways and is appropriate for all ages. Concurrent use of decongestants with saline irrigations is often helpful.

In infants and toddlers, nasal saline is best delivered with the child lying on its back. Place two to three drops in each nostril and wait for 30 seconds. Then sit the child up or lay on the stomach to clear the mucus. Avoid vigorous use of a nasal suction bulb, which can irritate the lining tissue. In elementary school-age children, nasal saline spray mist can be used as often as tolerated. The child should gently blow its nose before use.

Teenagers and adults have many more options for nasal irrigation. Spray mist irrigation, squeeze bottle irrigation, and a Neti pot are all reasonable choices. Spray mist is a low-volume, low-pressure irrigation that is simple to use. Squeeze-bottle irrigation (e.g., NeilMed Sinus Rinse) provides a high-volume rinse with mild pressure. Neti pots, commonly made of metal, plastic, or ceramic, rely on gravity and head positioning to deliver the saline and clean the nasal cavity and sinuses. The technique is difficult to master, however, and may be messy. All three options are beneficial and personal choice often dictates which is used.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2011

The two options for decongestants are topical sprays and oral medications. The most common topical sprays are oxymetazoline and phenylephrine, commonly sold as Afrin and NeoSynephrine, respectively. Both work very quickly by constricting the blood vessels within the nasal lining. They are safe for children as young as 4 years of age (contact your physician for use in younger children) and do not contribute to hypertension in adult patients. They should not be used for more than five days, however, due to a rebound effect that can cause significant nasal congestion that is difficult to treat. The most common oral decongestant is pseudoephedrine, which is available independently and in many combination medications. It works by constricting blood vessels throughout the body, including the nasal lining. It should not be given to children under 4 years of age or

to adults with high blood pressure or heart disease. Topical decongestants are often preferable due to fewer side effects and rapid onset of action. They are best used at the onset of congestion and may prevent a common cold from becoming a more significant infection that might require antibiotics.

Antihistamines Over-the-counter antihistamines are available in sedating and nonsedating varieties. Some are paired with pseudoephedrine. They effectively combat congestion due to allergies but will not offer any benefit for congestion from other causes.

Mucolytics These medications are designed to break down mucus to facilitate clearance from the nose and lower airways. The most common mucolytic is guaifenesin. This is available in many forms individually, and in combination with other medications under the brand names Mucinex and Robitussin. Guaifenesin is appropriate for adults and children older than 2 years of age. Patients with a history of kidney stones should consult their physician before using it, however, and all patients should drink plenty of water when using this medication. Nasal saline is another safe and effective mechanical mucolytic agent.

When to call the doctor

Congestion lasting longer than seven days should prompt an evaluation by your physician.

Most episodes of acute nasal congestion do not require a visit to a physician. These illnesses are often due to a viral infection (the common cold) and will improve without treatment.

However, congestion lasting longer than seven days should prompt an evaluation by your physician because it could be a sign that antibiotics or other treatments are necessary. There are a few warning signs that may accompany nasal congestion that should not be ignored and require more urgent medical attention:

vides your physician with an enhanced view into your entire nasal cavity.

Additional testing may be required to determine the exact cause of your nasal congestion. Some common tests are CT scans, allergy testing, and nasal cultures. CT scans give a detailed look into the sinuses and nasal cavity and are useful in establishing a diagnosis, evaluating the success and failure of prior treatment, and in surgical planning. Allergy testing is done to both confirm the cause of nasal congestion and to identify specific allergens. The two options for testing are the traditional skin scratch test and the RAST blood test.

Both give similar results and you should consult your physician to determine which test is appropriate for you. Nasal cultures are done to determine if an antibiotic is needed and should identify which one will be most effective. Your physician will determine which combination of testing is suitable for your specific case.

Many causes of nasal congestion are self-limited, but some will require treatment from a physician. This often includes oral antibiotics, nasal steroid sprays, oral steroids, nasal antihistamine sprays, oral antihistamines (pills), and possibly surgery. There is no one treatment that is best for all, and each patient should work closely with his or her physician to determine the optimal method for relieving nasal congestion.

Eric Becken, MD, joined Midwest Ear, Nose, and Throat Specialists in 2005 and is certified by the American Board of Otolaryngology. He is an active member of the American Academy of Otolaryngology-Head and Neck Surgery and the Minnesota Medical Association. Dr. Becken's practice includes the medical and surgical management of pediatric and adult ear, nose, and throat disorders, with a special interest in ear disease and hearing loss.

• Swelling around the eyes, cheeks, or forehead • Blurry vision • Heavy bleeding from the nose • A severe sore throat with redness of the tonsils or other areas of the throat

Living with gout?

Keep enjoying life’s simple pleasures.

What to expect at your doctor visit Your physician will take a thorough history, asking when your congestion occurs, how long it lasts, what the inciting factors are (dust, mold, seasonal changes, diet, etc.), what treatments you have tried before, and what their effects were. Your examination will consist of a detailed look in your nose and throat, and may include nasal endoscopy, which is performed in the office using topical anesthesia and a rigid or flexible fiber-optic endoscope. This procedure pro-

Gout is the most common form of inflammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another.

Learn more about managing this chronic illness at www.goutliving.org

DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

23

PRIMARY CARE

W

inter in Minnesota can be a magical time of sparkly snow and blue skies, but it can also be a time of icy sidewalks, shoveling snow, and seasonal illness like the flu.

Following are some tips on how to prevent and treat the flu as well as the common cold.

What is the flu?

Technically, the flu is a viral infection, usually a strain of the influenza A or B virus, and is a respiratory illness. Many people call gastroenteritis the flu, which can be confusing. Gastroenteritis is actually an inflammation of the stomach and/or intestines that causes diarrhea, vomiting, and cramping. Someone with respiratory flu usually has a sudden onset of fever, severe headache, muscle and joint aches, cough, and extreme exhaustion. Usually people do not have nasal symptoms or a sore throat.

Treating the flu The primary treatment for the flu is time. There are prescription medicines, but you need to start using them within 24 to 48 hours of becoming ill, and they usually only shorten the course of the flu by about 24 hours. The best thing you can do is rest, drink plenty of fluids, and avoid contact with other people— which means don’t go to work or school.

Painkillers

high fever (over 102 degrees), you should see your doctor, because infants can become dehydrated quickly. Watch for signs of dehydration: dark urine or not wetting diapers, dry lips, crying without tears, or no drooling. Make an appointment to see a doctor if your infant appears dehydrated.

It is very important for children and adults to stay well hydrated. Take small amounts of clear liquids frequently, because drinking a large glass of fluid all at once might cause vomiting.

Things like popsicles, jello, broth, and ginger ale are good ways to increase fluid intake. Products such as GatorAid or Pedialyte (for kids or adults) are good, too. But avoid liquids containing caffeine, as they can exacerbate dehydration.

What is a cold?

What is known as the common cold is usually caused by a virus, so antibiotics won’t help. Colds often have a slow onset, with symptoms worsening and changing over time. Common symptoms are stuffy or runny nose, cough, and sometimes fever or chills. Most of the time you just need to let your body heal itself, but your HCP can prescribe medicines to help stop coughing and wheezing or to clear a stuffy nose. You can also use nonprescription treatments such as acetaminophen or ibuprofen to help with aches or pseudoephedrine to help with stuffiness. If you cannot breathe through your nose, oxymetazoline nasal spray (brand names: Afrin and Allerest) will bring instant relief, but do not use for more than four days. The best time to use it is before going to bed so that you can breathe well (and then, hopefully, sleep well) during the night.

Cold flu

&

Analgesics such as acetaminophen (brand name: Tylenol) and ibuprofen (brand names: Advil and Motrin) can help with fever and body aches.

Alternating the two every four to five hours can be helpful, but ask your health care provider (HCP) first. The maximum amount of acetaminophen in 24 hours for a healthy adult is 4000 mg (1000 mg

By Jane Kilian, MD four times), but limit use if you drink more than two alcoholic drinks (including beer) per day, or if you have liver disease.

The dosage for ibuprofen is 800 mg three times in 24 hours (2400 mg total). Taking ibuprofen with food or milk decreases the chance of stomach upset. You should not take ibuprofen if you are pregnant, have kidney failure, are on a blood thinner such as warfarin (brand names: Coumadin and Jantoven), or are taking another nonsteroidal anti-inflammatory drug (NSAID) such as naproxen (brand name: Aleve).

Dosage for children is based on their weight. Read package inserts carefully before administering any medication. When in doubt, ask your HCP. Do not take any of these medicines, at these doses, for more than 10 days without talking with your HCP. If you are that sick, you need to be seen by a clinician.

season

Drink plenty of fluids Dehydration is a risk with fever and diarrhea. If you are caring for an infant with a

24

MINNESOTA HEALTH CARE NEWS DECEMBER 2011

What about strep throat?

With “strep throat” (named after the streptococcus bacteria), you have an extremely sore throat, fever, and sometimes headache and/or nausea. Children especially seem to have stomach aches with strep infections. Usually those with strep throat don’t have a cough, nasal symptoms, or body aches. Most clinics can do a quick test for strep. If you have strep, you need antibiotics and cannot work or go to school until you have been taking medicine for at least 24 hours.

Treating coughs and congestion Coughs can respond well to drinking a warm liquid (tea or lemonade) with some honey. Consume plenty of fluids to stay well hydrated. Congestion can be eased with humidity: Sit in the bathroom with the door closed and a hot shower running, or put a pan of water on the stove, bring to a boil then turn it down to a simmer and breathe in the steam.

(Some menthol or eucalyptus in the pan will be soothing, but be careful not to burn yourself.)

Alternating hot and cold packs on the face can also help ease sinus congestion. Using a nasal saline spray or a Neti pot can help, too.

• Acetaminophen (brand name: Tylenol) 1000 mg four times in 24 hours. Limit use if you drink more than two alcoholic drinks (including beer) per day or if you have liver disease.

• Ibuprofen (brand names: Motrin, Advil) 800 mg three times in 24 hours. Take with food. Do not use if you are pregnant, have kidney failure, or are on blood thinners such as warfarin (brand names: Coumadin and Jantoven). Do not use with other NSAIDs such as naproxen (brand name: Aleve).

• Naproxen (brand name: Aleve) 500 mg twice in 24 hours. Do not use if you are pregnant, have kidney failure, or are on blood thinners such as warfarin (brand names: Coumadin and Jantoven). Do not use with other NSAIDs such as ibuprofen.

Dosage for children is based on their weight. Read the package insert for weight/ dosage instructions. When in doubt, talk with your health care provider. Do not take any of these medicines, at these doses, for more than 10 days without talking with your health care provider. If you are that sick, you need to be seen by a clinician.

Maximum doses of pain relievers for healthy adults:

For sick parents If you are sick, stay home. If you are tired, nap.

Don’t go to the office—your colleagues don’t want your germs. You will be back to full speed more quickly if you take time to recover fully.

If you are a sick parent at home, this is the time to call in favors from other parents. Ask them to watch your children so you can nap. It is difficult to rest while caring for small children. Forget about guilt; you can return the favor when they need help.

Get a flu shot It is not too late to get a flu shot. Also, keep the inside of your nose moist by using a nasal saline spray or small amount of Vaseline (not Vicks Vaporub) in your nose at night. If the lining of your nose gets dry and cracks, bacteria and viruses can enter.

When to visit the doctor

Whether you have a cold or the flu, make an appointment to see your HCP if you experience any of the following: • Dehydration and fever (dark urine, parched mouth) • Unable to keep even small amounts of fluid down • Chest pain • Wheezing or shortness of breath • Coughing until you vomit, or coughing so much you cannot sleep • Symptoms that last more than 10 days or worsen after a week

Preventive measures Eat a well balanced diet, get enough sleep, and get some exercise daily when not sick. Wash your hands often. Don’t share drinks or eating utensils with someone who might be sick. Clean all surfaces at home and at the office, including phones and computer keyboards, doorknobs, and handles. And try to create a culture in your workplace that encourages people to stay home if they are sick.

Your colleagues and their families will appreciate it!

Jane Kilian, MD, is a family practice physician who works in St. Paul at the Family Health Services Clinic on Larpenteur Avenue near Como Park.

• You start to feel better, then symptoms recur.

Independent Practitioners ... freer to give you: More Attention More Choices And be your best Advocate

Thank you for choosing independent medical care.

In the next issue..

• Meningitis • Orthodontic exams • Verifying prescriptions

www.midwestipa.org • 952-883-3133 DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

25

PA L L I AT I V E C A R E

Music therapy at end of life Bringing comfort to patients and families

By Katie Lindenfelser, MMus, MT-BC

I

’d like to sing about the angels that came last night to tell me I don’t have to go through this anymore,” said 8-year-old Maria, a leukemia patient in a children’s hospital. The song that Maria wrote brought comfort and understanding and helped inform her mother and hospital clinicians; her song was her way of saying she did not want any more treatments, and it helped her be an active participant in the decisions being made about her health care.

The role of music therapy in promoting healing in a variety of health care settings, including hospice, is growing. Though there are therapeutic benefits to playing music simply as entertainment, music therapy involves much more than that. It is an established health care profession that uses music to address specific physical, emotional, spiritual, cognitive, and social needs of individuals of all ages and with a variety of conditions or illnesses. The American Music Therapy Association (AMTA) reports that in 2009, nearly a million people in the United States received music therapy services in a variety of settings, including hospitals, hospices, other care facilities, and schools.

Music therapy in the hospice setting Most of my work as a music therapist has been with children and adults who are nearing the end of their lives, or actively dying. In Minnesota, nearly 30 boardcertified music therapists are working in end-of-life care, and music therapy has expanded into almost all hospice programs for children and adults in our state.

Whatever an individual’s or family’s cultural practices or religious beliefs, the many elements of music make it accessible and comforting to nearly everyone at all different times during their end-of-life journey.

Music therapists typically use live music to address the needs of each patient and family; the sidebar lists some of the instruments that music therapists often use in this setting.

There are known benefits for having a music therapist as a member of a multidisciplinary, end-of-life care team. Music therapy provides a holistic approach to addressing familiar end-of-life symptoms such as agitation, anxiety, pain, and distress. Because music bypasses the neural pathways that inform individuals of their pain, a music therapist can help ease a patient’s pain by redirecting the patient to focus on the music rather than the pain. Similarly, redirecting patients to listen or sing along to a favorite song often relieves their agitation and anxiety.

Sometimes the words of the song together with a soothing melody bring comfort and greater understanding of life’s journey.

26

MINNESOTA HEALTH CARE NEWS DECEMBER 2011

Music therapy in hospice

At other times, music selected by the patient and family The instruments and equipment that music therapists use in hospice and provides comforting familiarity and an opportunity to palliative care settings can include: reminisce. Even unfamiliar music, improvised on a • musical instruments that are portable and easy for non-musician patients piano, guitar, or harp, often brings a sense of peace and and families to use, e.g., the autoharp, Reverie harp, Q-chord, Native release.

American flute, and assorted percussion instruments like tambourine, Alfred, an elderly man living independently at his rain sticks, maracas, and ocean drums home, found that music reminded him of many of his • musical instruments that may be played for the patient by the music life experiences. The song “Home, Sweet Home,” for therapist and/or family members, e.g., piano, organ, guitar, flute, or harp example, validated the many years of comfort Alfred • large-print song sheets, hymnals, and music books including a varied repertoire had found in his small rural homestead following his years of wartime service. During our music therapy • personal CDs or iPods (including headphones) visits, he selected and sang songs from the World War I • laptop computers that contain an extensive library of music selections ranging in mood, style, and ethnicity era and the 1930s and 1940s. Hearing one song would remind Alfred of another. Even though his short-term memory was declining, he could recall specific details of memories from years ago. Listening to the music, Alfred’s Unique journeys, unique songs breathing relaxed, he smiled and laughed, his energy increased, and Watching the stress, anxiety, and pain melt from a patient’s face he had relief from his bone pain as his attention was redirected to a during a music therapy session at the end of life is an honor. Each different stimulus. song and instrument means something different to each hospice In another scenario providing music therapy, I used rhythm patient and family. Everyone has a unique story and journey—and and melody to match a dying woman’s breathing challenges by music provides a way to express that story and bring comfort on slowing the rhythm and softening to a lullabye or lament. “My that journey. anxiety is relieved and I can just be present to my mom’s journey ‘home,’” said her attentive daughter as she took in the sounds of the Katie Lindenfelser, MMus, MT-BC, is a music therapist, massage therapist, and reflexologist. She is founder and executive director of Children’s soft guitar and humming at her mother’s bedside.

Music therapy in pediatric hospice care For children, music is a part of learning and growing. When a child’s life is shortened due to illness, music can be essential to supporting the child and his or her family. Sometimes music offers the only opportunity children with life-limiting conditions have to make choices and to have some control over their environment, no matter their age or diagnosis. Children typically find joy in selecting their favorite instruments (often the drum or maracas) or in directing their sibling(s) to sing a particular song, as a means of expressing themselves and communicating with their sisters, brothers, and parents. Many families report that music therapy makes it possible to have fun and forget about the illness or anticipated death, just by being present in the moment and with the music. Parents are reminded that their child is still a child.

Just as young Maria wrote a song expressing her wishes and visions near the end of her life, siblings often write songs about what it’s like not to be able to play with their brother or sister, and to convey all that they wish for him or her. One mother said, “I am so happy they can sing about how they feel; I didn’t even know until hearing them sing about what this is like for them that they realize he will die.” Children and adults alike are often less self-conscious about using music rather than spoken words to express difficult feelings, especially when saying good-bye.

Lighthouse of Minnesota, a children’s respite and hospice home planned for the Twin Cities metro area.

Read us online wherever you are!

Music bypasses the neural pathways that signal pain and relieves agitation and anxiety.

www.mppub.com DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

27

PUBLIC HEALTH

W

inter is on its way: The leaves are changing color and the days are getting shorter. We Minnesotans love to talk about the weather, because it changes every time we look outside. In the northern Midwest, snow and ice are inevitable during winter months. Consequently, there is also a greater risk of injury due to slipping on the ice.

Falls: a leading cause of injuries According to the U.S. Centers for Disease Control and Prevention (CDC) website, falls are the leading cause of nonfatal injuries for ages 1 to 14 and 15 and older. Falls can cause moderate to severe injuries, including lacerations, fractures, or head trauma. In addition, the cost of resulting medical care is increasing: More than $20 billion is spent annually in the United States on fall-related care, and this is projected to climb to $54.9 billion by 2020.

As the temperature drops, hospital admissions increase exponentially. One study determined that the number of hospital admissions sometimes doubled after several days of snow and icy conditions, due to unsafe—i.e., not properly cleared— roads and sidewalks. Another study (by a physician in Wales)

Avoiding

the slippery slope

Preventing falls during winter

By Wendy Rader, PT, and Richelle Dack, DPT

Minnesota

Health Care Consumer November survey results...

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 November survey.

1. I am in favor of allowing individuals with terminal illness the option of choosing to end their lives through a painless and dignified medically managed process.

Percentage of total responses

50 40

28.3%

30 20

13.2% 9.4%

10

3.8%

35.8%

37.7%

20.8% 20 15 10 3.8%

5 0

28

Percentage of total responses

Percentage of total responses

25

Strongly agree

Agree

No opinion

Disagree

1.9% Strongly disagree

MINNESOTA HEALTH CARE NEWS DECEMBER 2011

Agree

No opinion

Disagree

4. I feel it is important for all immediate family members to be aware of the issues in an advance directive.

35 30

Strongly agree

Strongly disagree

35

70

30

60.4%

50 40 28.3%

30 20 10 0

5.7% Agree

No opinion

Disagree

35.8%

30 20 10

3.8%

5.7% 0.0%

Strongly agree

Agree

No opinion

Disagree

28.3%

30.2% 26.4%

25 20 15 9.4%

10

5.7% 5

5.7% 0.0%

Strongly agree

40

Strongly disagree

Strongly disagree

5. Matters of religious faith are very important to me in considering end-of-life planning.

80

60

54.7%

50

0

Percentage of total responses

40

60

45.3%

0

3. If given the choice, I would prefer to end my life in my home vs. in a medical facility.

2. I feel advance directives should be part of everyone’s medical record.

Percentage of total responses

Association

0

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

documented that the number of fractures tripled during days of ice and snow. Specific types of fractures, such as forearm and wrist, were even higher—16.5 times more common during icy and snowy conditions.

Here in the Upper Midwest the statistics are very similar. According to the Brain Injury Association of Minnesota, after a recent snow and ice storm, Hennepin County Medical Center documented a 20 percent increase in the number of emergency department visits due to falls.

During the winter months, falls are most common in those aged 25 to 59; during the rest of the year, falls are more common among the elderly.

Physiological and environmental causes Several factors can influence the likelihood of a fall; these can include both internal, physiological factors (such as dizziness, muscle weakness, medication interaction, or decreased vision) and external, environmental factors (such as clutter, unexpected change in walking surface, or ice and snowy conditions). With winter nearing, it is especially important to take extra precautions, as icy conditions can increase the risk of a fall.

Prepare before venturing outdoors At some point you will have to deal with the ice and snow. Determine if it is safe to venture out; be prepared to stay indoors if an errand or other type of outing is not essential. Install outdoor lighting with motion sensors to illuminate the areas outside your home.

Maintaining adequate visibility is an important and often overlooked factor in preventing falls. Repair or install handrails on all outdoor staircases as well, to provide additional support.

Plan ahead and purchase a few weeks’ worth of groceries (when weather permits), or ask family or friends to pick up something for you Or use a grocery delivery service; most grocery store chains offer local delivery service, but often ordering must be done via the store's Website.

The number of hospital admissions sometimes doubled after several days of snow and icy conditions, due to unsafe roads and sidewalks.

Clear a pathway

Falls on snow and ice are both predictable and preventable. There are steps you can take to reduce the risk of falling during the winter months. The first is to consider the environment: Snow is practically guaranteed in Minnesota. Snow and ice should be completely removed from walkways, steps, driveways, and sidewalks. If you have mobility or balance concerns, you may need help clearing your sidewalks.

Many schools, churches, and scout organizations will remove snow as a community service. You could also hire a snow removal service, though many will remove only snow accumulations greater than 4 inches. Keep a bag of snowmelt near your front and back doors, with a cup or scoop in each bag. Be diligent

Additional resources: Minnesota Falls Prevention Initiative 1-800-333-2433 or www.mnfallsprevention.org/ Fall Prevention Center of Excellence www.stopfalls.org Minnesota Brain Injury Association www.braininjurymn.org/aboutBrain/falls.php

about spreading it on walkways to prevent ice buildup. The best way to avoid a slip on the ice is to remove the ice first!

When out and about If you are out in the community and encounter a potentially unsafe area, stop to determine if you can cross safely. Be sure to check for black ice (ice that is invisible on roadways and sidewalks, especially at night). If you decide it is unsafe, turn around and find another route to your destination. If you must cross, carry a small bag of table salt, gravel, or cat litter to shake onto the surface for more traction. As you walk, bend your hips and knees slightly. Take smaller, slower steps, and place your feet flat on the ground as you cross, not heel-first. This lowers your center of gravity and reduces momentum, which increases stability. Be vigilant as you walk; look ahead as well as down.

Avoiding the slippery slope to page 33

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DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

29

L E G I S L AT I V E U P D AT E

Shutdowns, cuts, and stalemates: The story of health care in the 2011 legislative session

By Jesse Berg, JD, MPH

T

he biggest story from the 2011 Minnesota state legislative session was the hard-fought battle between Gov. Dayton and the Republicancontrolled House and Senate over taxes and spending, a struggle that ultimately resulted in the government shutting down for nearly three weeks. Emboldened as a result of Tea Party-backed electoral gains in 2010, Republicans began the session with near universal commitment against revenue increases and anything smacking of “Obama-care,” the derisive name affixed by party propagandists to the Patient Protection and Affordable Care Act of 2010 (ACA). The governor, meanwhile, won the election in 2010 on a platform that included tax increases on Minnesota’s highest

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earners and with a desire to implement the expansion of Medicaid eligibility made available as part of the ACA. Things were clearly headed for a collision, which is exactly what Minnesotans got.

The money has to come from somewhere Figuring out a way to bridge the $1.4 billion shortfall left at the end of the session was never going to be easy, especially considering that the legislature has been making significant cuts to health care programs and devising ways to raise revenue every year since 2002.

Unfor-tunately for providers, the 2011 session resulted in yet another round of reimbursement cuts. The total amount of cuts in the health and human services budget came to about $1.3 billion. Inpatient hospital services (10 percent); physician services (3 percent); outpatient hospital facility (5 percent); and physical-/occupational therapy, durable medical equipment (DME), lab, speech therapy, anesthesia, dental care, and a range of other services (3 percent) all were hit with reductions. State funding for medical education and research was cut by $25 million, a reduction of roughly 50 percent. The Prepaid Medical Assistance Program was also targeted, with cuts to plans ranging from 2 percent for elderly services to 10 percent for childless adults.

In another important cost-cutting measure, enrollees (adults without children) in MinnesotaCare with incomes of between 200 percent and 250 percent of the federal poverty level will be transitioned to the new Healthy Minnesota Contribution Program.

Individuals in this program will receive a defined amount of money based on their age to purchase their own health insurance in the private market. Coverage purchased under this program will have to cover mental health and chemical dependency, and comply with state law restrictions on abortion coverage.

Tackling fraud and abuse

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MINNESOTA HEALTH CARE NEWS DECEMBER 2011

A key component of the ACA is an enhanced focus on cracking down on perceived health care fraud and abuse through targeted funding and more rigorous oversight. The idea is that by rooting out fraud, governments can make public health care programs more cost-effective and sustainable over the long term.

The 2011 Minnesota legislature took a number of steps in this regard, including passing a law that requires the Commissioner of Human Services to unilaterally suspend payments to providers in the event a “credible allegation of fraud” is received. The definition of what exactly constitutes a credible allegation of fraud is ambiguous, and includes allegations (from any source) that have “indicia of reliability.” While the state is required to verify that this standard is met, it is not clear exactly what needs to happen for verification to occur. When a similar standard was adopted on the federal level under the Medicare program, many providers expressed concern

that the lack of clarity around the level of detail regulators would need could lead to unjustified payment suspensions and open-ended investigations. A similar concern would appear to be relevant under the new Minnesota law.

Time will tell whether those concerns will be validated.

Other fraud and abuse changes adopted during the 2011 session that have their basis in the ACA include the following:

The legislature has been making significant cuts to health care programs every year since 2002.

• The commissioner can withhold reimbursement to providers initially enrolling in state health care plans if their provider category has been deemed “high risk” under Medicare by The Centers for Medicare & Medicaid Services (CMS).

• The commissioner may require that providers enrolling in Medicaid have compliance plans containing certain core elements outlined by CMS. • Ability to revoke provider enrollment in Medicaid for up to one year if providers fail to maintain documentation relating to written orders for durable medical equipment and home health services.

• Unannounced site visits for providers designated “moderate” or “high” risk by CMS, along with criminal background checks and fingerprinting requirements for “high-risk” providers.

Along the same lines, a law passed in 2011 directs the commissioner to issue a request for proposals for a vendor to provide services on behalf of the state in detecting and preventing Medicaid fraud.

The commissioner is directed to have a contract in place with this vendor by Jan. 31, 2012.

Policy changes

Consumed as it was by brinksmanship over the shutdown, the 2011 session saw fewer developments in the health care policy arena than in other years. There were a few important laws that passed, however. For example, the state Electronic Health Records Technology Statute was amended to create a process under which financial incentives would be paid to qualifying providers for becoming “meaningful users” under CMS’ Electronic Health Records Incentive Program. The amended statute also establishes a process for auditing providers who receive electronic health record incentive payments to ensure that payments were appropriately made.

With the intent of addressing gaps in underserved communities, a new type of provider—the community paramedic—was authorized. Community paramedics will work under the direction of ambulance medical directors and in conjunction with patients’ Shutdowns to page 32

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.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

©2007 National Down Syndrome Congress

DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

31

Shutdowns from page 31

was similar to laws that passed in other states preventing physicians from discussing guns with their patients.

• Bills were introduced in both houses that would have repealed the right of minors to receive care for mental health, chemical dependency, and reproductive health without getting parental consent.

• H.F. 1334 would have expanded the scope of practice for chiropractors by allowing them to use all types of diagnostic imaging. This bill died in committee.

personal physicians to assist with care coordination. The law will It is clear that any allow paramedics to monitor and provide some treatment to patients progress in health care with chronic disease, and to perform in 2012 will start minor procedures intended to prevent emergency room services. The Department and stop with the of Human Services (DHS) will determine contentious and ongoing which procedures provided by these paramedics will be covered under state health debates over the care programs by Jan. 15, 2012.

Affordable Care Act. Modifications were also made in 2011 to the Vulnerable Adults Act. Laws passed What does the future hold? this year make it a crime for caregivers or With the first set of primaries for the comworkers in vulnerable adult facilities to engage in sexual conduct ing presidential election just over two months away, it is clear that with vulnerable adults in their care. In addition, the penalty was any progress in health care in 2012 will start and stop with the increased from a misdemeanor to a gross misdemeanor for those contentious and ongoing debates over the ACA. It will likely take a who have reason to know that their target is a vulnerable adult and decision by the U.S. Supreme Court on the constitutionality of the assault the person nonetheless. “individual mandate” included in the ACA to purchase health What failed to pass?

As in other years, a range of interesting and controversial bills were introduced, but they did not get very far in 2011. Highlights included: • S.F. 1476, which would have prohibited health care providers from asking patients about gun use or access to guns or ammunition. This bill was backed by the National Rifle Association and

insurance before Minnesota’s deeply divided legislators can move on to other issues.

Jesse A. Berg, JD, MPH, is a principal in the health law practice at Gray Plant Mooty in Minneapolis. He advises physicians, hospitals, and other providers on health care regulatory matters.

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Avoiding the slippery slope from page 29

Put your best foot forward Safe footwear is very important in the wintertime. According to the Tufts Medical Center Trauma Service in Boston, rubbersoled shoes are the best choice for slippery surfaces because they provide better traction. Or you can attach rubber overshoes or ice traction devices such as cleats to your shoes to improve stability. One such device is the Yaktrax Walker, mentioned on the CDC’s website. This and other ice traction devices are available at sporting goods and hardware stores, even at some medical supply stores. These stores also often carry special cane attachments with sharp tips to pierce the ice. With the flip of a lever, the device can retract the sharp end when indoors; no dismantling is involved.

Keep moving Another way to prevent falls in the winter—or at any other time of year—is to stay active. If you have ever had a fall or are concerned about your balance, consult with your primary physician to determine if there are any health issues that would preclude increased activity. Your physician can refer you to a physical therapist for evaluation (and treatment, if necessary). Community education programs and health clubs offer fitness classes that can help you stay active.

Be vigilant as you walk… Look ahead as well as down and check for black ice. … Bend your knees and hips; take smaller, slower steps; and place your feet flat on the ground, not heel-first, to lower your center of gravity.

Shopping malls often open early for walkers. Consult with your physician first, however, to determine if such activity is safe for you.

Winter is just around the corner It seems like only yesterday that we were enjoying Pronto Pups at the State Fair, but by the time you read this, winter will be here. In colder months, we need to consider how winter affects safety. Ice and snow can make walking outdoors dangerous for all ages, on paths, sidewalks, driveways, or other areas. There are ways to reduce your risk of falling. By taking preventive measures, your winter months can be enjoyable ones—as they should be in our beautiful state.

Wendy Rader, PT, and Richelle Dack, DPT, are physical therapists at the National Dizzy and Balance Center (NDBC) in Edina. Both specialize in balance, fall prevention, and vestibular rehabilitation.

DECEMBER 2011 MINNESOTA HEALTH CARE NEWS

33

Immunization from page 13

connection between vaccines and autism.

This small, fraudulent study did a tremendous disservice to children worldwide: Children in the U.K. died of measles because they were not vaccinated. Of the 23 measles cases in Minnesota in 2011, 14 children were hospitalized—11 of whom had not received the MMR vaccine. The average hospital stay for these children was five days, indicating that they were very sick.

Repeated studies have shown that there is no connection between vaccines and autism.

“What about problems that occur after a baby is vaccinated?”

During the first two years of a child’s life, lifelong health conditions start to emerge. Because a child is frequently vaccinated during these first two years, it is likely that the onset of the health condition will occur at the same time. One event has nothing to do with the other, but it’s often difficult to separate the two. So, because of timing, vaccination is often blamed for an emerging health condition. A wellknown doctor related that when he was preparing to give a 4-month-old baby his shots, the infant started to have a seizure. If that child—who was diagnosed later with a seizure disorder that requires ongoing medical attention—had been vaccinated first, the parents and others would likely have blamed the vaccine.

Do the responsible thing We live in a social world. Parents are always seeking ways to help our children interact with other children. So we need to work together to keep the community as healthy as possible. This means that each of us needs to do our part—i.e., vaccinate our children—to protect those who cannot be vaccinated for certain health conditions, or are too young to be vaccinated, or don’t respond to a vaccine. In 2008, there were five cases of Haemophilus influenzae type b (better known as Hib disease, which causes meningitis) in Minnesota, and one of the children died.

Three had not been vaccinated, including the child who died. One child was vaccinated but had immune system problems and needed to rely on community protection, but that did not happen.

If you are a new parent and are hesitant about your baby’s upcoming shots, or have delayed your child’s shots, get the facts—from reliable resources.

(See sidebar on p. 13.)

Don’t put your child at risk for a disease that can be prevented. Vaccinate!

Lynn Bahta, RN, is the Immunization Program Consultant for the Minnesota Department of Health.

Supporting Our Patients.

Supporting Our Partners.

SupportingYou. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life.

Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient.

To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

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