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Let’s Have a Conversation About Diabetes

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Let’s Have a Conversation About Diabetes

Author: Mark Parkinson BSPharm:  President  AFC-CE

Credit Hours 2- Approximate time required: 120 min.

 

Educational Goal:

To answer question about diabetes.

Educational Objectives:

Answer the questions, what is diabetes and what causes it.

Give a description of Type I, Type II and Gestational Diabetes.

Provide a list of risk factors for developing diabetes.

List the sign to monitor for that indicates diabetes.

Explain what the consequences of uncontrolled diabetes.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

Mark Parkinson BsPharm

Let’s Have a Conversation About Diabetes

In 2015 the Center for Disease Control reported that over 30 million people in the U.S., or 9.4 percent of the population, had diabetes. They estimated that 12.2 percent of all adults over 18 years of age were affected by the disease and 7.2 million didn’t know they had it. They also observed that the prevalence of diabetes cases increases with age, reaching a high of 25.2 percent for those 65 years of age and older. There are many indications that the prevalence of diabetes is increasing. 

What does that mean for adult foster care? Up to one out every four of your current or future residents could have diabetes. Of those who do have the disease, one-quarter of them will not know they are afflicted. The implications are, caregivers need to understand the disease, recognize the symptoms, and know how to care for those with diabetes, even if no one is currently diagnosed. Let’s have a conversation about diabetes that I think will help you be prepared. You’ll ask the questions, and I will provide the answers. I will even discuss the background information so that you will understand my answers.

 

Image result for diabetes

What Is Diabetes, You Ask?

Answer: Diabetes mellitus is a collection of conditions that create too much glucose in the blood. Simply enough said but much more complex in its understanding. For those with the disease, something has gone wrong in how glucose is processed by the body.

Background: Let’s start with how glucose is normally processed.

Before we proceed with our discussion, we must clarify a point. There are two different diseases that have the word “diabetes” attached to them: diabetes mellitus and diabetes insipidus. Diabetes insipidus is a disorder that affects the way water flows through the body. It causes excessive urination and excessive thirst. Sometimes it’s nicknamed the bed-wetter disease. They have the same first name because both of their discoveries involved observing excessive urination and excess thirst. Diabetes insipidus is a rarer condition and is unrelated to blood glucose so we will not be covering it in this course.

Glucose

Glucose is a carbohydrate molecule known as a simple sugar. It is packed full of easily accessible energy. It is our preferred source of fuel. It is very important to every cell in our body, especially the brain. Our digestive system is set up to get it from the foods we eat. Our gut either absorbs it straight from the food we eat, breaks apart other more complex sugars like starches to get it, or coverts other molecules like proteins and fats into something similar to glucose.  

Having a constant fuel source is very important to our bodies. It is so important that our bodies convert excess glucose into fat and stores it away in our adipose tissues. When we can’t get enough glucose from our diet, we pull out our fat fuel stores and use them for energy. When even that is not enough fuel, our bodies break apart the proteins in our muscles and tissues and use them for energy. 

Glucose as a chemical is a highly reactive molecule. It can interact in many different ways with the various molecules in our cells.

Glucose is also hydrophilic, which means it is highly attracted to and mixes easily with water. Our body utilizes that property to move the glucose around the body in the water of our blood, lymph, and urine systems. Image result for diabetes

Insulin

When our cells need more fuel, they take in glucose via special molecular channels in the cell walls. These channels are usually closed to prevent leakage from the cell. It takes a special hormone called insulin to open them up. Insulin is also involved in storing away glucose as fat. The more insulin in the bloodstream, the more fat is stored away. Insulin is produced in the pancreas by specialized cells called beta cells.

That is the broad overview of how glucose metabolism normally functions. I left out a lot of details, but we have enough background to continue our talk.

 

I have heard there are different kinds of diabetes?

Answer: Yes, there are different types of diabetes mellitus (from now on I will just refer to them as diabetes). Their names have evolved over time as our understanding has grown.

Background: At first, doctors called everything with excessive urination and thirst diabetes. As we gained more knowledge, researchers realized that there were several different causes of those symptoms. Naturally, more descriptive names were added to help differentiate between the forms of the disease. In the past they have been referred to as juvenile and adult diabetes, early onset and late onset diabetes. Those names never quite described accurately enough what was going on. Currently the most common forms of the condition are simply referred to as Type I, Type II and Gestational diabetes. There are other forms of the disease, but they are rare, so we will not be covering them. Let’s talk further about the common varieties.

 

Type I

Related imageIn Type I Diabetes the body has lost the ability to make enough insulin to meet its needs. Without insulin, glucose can’t get into the cells. This triggers a series of metabolic events in the body. The cells send signals to the brain that they need more fuel. The brain automatically triggers an increase in appetite. The person eats more food, which results in more glucose in the bloodstream, but there’s no place for it to go. Normally excess glucose is stored away as fat, but insulin is also required in the fat storage system of our body so there is still no place for the glucose to go. Eventually the excess glucose spills out through the urine. Water follows the sugar out, so urination volume increases. Soon the body becomes dehydrated due to the increased urine volume. Soon the thirst drive increases to compensate for the loss of water. In the meantime, the cells still lack fuel so they can’t function well. The body starts to pump out its fats stores to try to make up the difference, but without insulin it’s to no avail. The body has run out of fuel, so its systems start to shut down.

Symptoms that caregivers should watch for in Type I diabetics are they always hungry, thirsty, and have to urinate a lot. They are weak and tired all the time and have a hard time thinking. Their fats stores get used up, which results in unexplained weight loss. The onset of this type of diabetes tends to happen very quickly.

 

What happened to the insulin?

Answer: The body accidently killed off the beta cells in the pancreas in an autoimmune response.

Background: Our immune system fights off invading microorganisms by having watchdogs, so to speak, patrolling the blood system. They’re called antibodies. When they detect a foreign material (scientifically called an antigen) they latch onto it. Then several things happen. Two important things in regard to Type I diabetes are: 1. The antibody connects to killer T cells and they destroy the antigen. 2. The T cells and the antibodies start to replicate and so are primed to kill off anything that looks like that original antigen. Unfortunately, there are antigens that are very similar to certain parts on the cell wall of Beta cells. In victims of Type I diabetes the immune system fights off the infection and goes after the beta cells too and wipes them out. Type I diabetes mostly affects children, but older adults can be affected too. Caregivers should watch for the signs of thirst, hunger, and fatigue in their residents who just got over a cold or flu.

 

Type II

Type II diabetes is a condition of insulin resistance. The pancreas’s beta cells are still there, but insulin is not having its full effect. Something is going wrong that is preventing the glucose from entering the cell as readily as it should. To compensate, the body starts to work harder in other areas. It keeps things going normally for a while, but it comes with extra costs. Eventually the costs become too high and the overworked systems start to fail. Gradually the classic diabetic symptoms start to appear. If steps aren’t taken to treat the disease, the symptoms get progressively worse.

 

What would it look like if one of my residents started to develop Type II Diabetes?

Response: At first, they would start having minor annoying symptoms that are easily ignored. But, you would start to notice that the problems are not going away by themselves. As the condition progresses, the annoyances would go from mild to moderate. The resident would start to complain more, and the symptoms would become more pronounced. Caregivers would start to see some of the following signs:

  • Increased appetite – The glucose-starved cells continue to send out “feed me” signals. The brain receives those signals and increases hunger.
  • Numbness and tingling – The extra “highly reactive” glucose attaches to nerve endings and disrupts their functions. Diabetics start to feel tingling or numbness in their fingers and toes.
  • Weakened immune response – Glucose can fasten itself to parts of the immune system and reduce its ability to fight off infections. Wounds, scrapes, and sores take forever to heal.
  • Blood circulation problems – Glucose can also attach to the walls of blood vessels, causing a host of other issues. At first it affects the smaller blood vessels and is seen as blood circulation problems (cold fingers and toes), and vision problems.
  • Unexplained weight gain – The beta cells are stimulated to pump out even more insulin to meet the extra need. The extra insulin stimulates more glucose to be stored away as fat. In type II diabetics this usually shows as unexplained weight gain, especially around the waist.
  • Increase in thirst – The body starts to lose too much water through urination. It will start to show as itchy, flaky skin; dry, cottony mouth; and of course, extra thirst.
  • Alertness and drive problems – Individual cells have problem functioning due to a lack of fuel. Collectively this shows as lack of drive and energy, mental fuzziness, and increased irritability.

 

I’ve heard of prediabetes, is that what we are talking about?

Answer: Yes, officially prediabetes means that the blood glucose is higher than normal but not enough to be diagnosed with diabetes. Unofficially some clinicians include the outward signs of Type II Diabetes, like being overweight. Practically speaking, all that prediabetes really means is something might be going wrong, so pay attention and help the resident start to live a healthier lifestyle.

 Image result for gestational diabetes

Gestational Diabetes

Gestational diabetes happens only in pregnancies and we have not nailed down exactly why yet. We do know that hormones produced by the placenta play a role. For some women, they seem to make it difficult to produce enough insulin. The extra weight and genetic makeup may also be a factor. Fortunately, the condition goes away after the pregnancy is done, but not for everyone. Those who do get gestational diabetes are now at greater risk for Type II diabetes. Like Type I diabetes, insulin shots may be needed right from the start to keep blood glucose down to healthy levels. Since pregnant residents in care homes are as rare as vegetarians at a hot-dog- eating contest, that is all we are going to talk about the subject.

 

What causes Type II diabetes?

Answer: We don’t know. Research has not figured out all the different causes yet.

Background: The insulin-glucose system is actually a very complex series of metabolic steps. Think of it as a long trail of dominos. If one domino falls, it triggers a chain reaction that eventually gets the glucose where it needs to be in the cell. Just like with a chain of dominos, if there is a problem anywhere in the series of actions, the final reaction does not take place and glucose can’t get into the cell. So far medical science has not been able to point at the one domino that’s the root of the problem. There even may be several factors involved.

Related image

Even though we have not figured out all the specifics yet, we do have a handle on the bigger picture. We can point to a list of characteristics that put people at greater risk for developing the disease. If caregivers knew which of their residents were at greater risk, they could start to monitor them more closely for the telltale signs.

 

What are the risk factors that I should be looking for?

Response: The risk of developing type 2 diabetes depends on a combination of factors. The more risk factors involved, the more closely you should monitor the resident. Here is what you should be looking for.

  • Genetics – It all depends on how you are built in the first place. The resident may have inherited a broken “domino,” or a weak one which will break if overworked. Caregivers need to get and pay attention to family histories containing cases of diabetes.
  • Race – This is inherited genetics again, but on a larger scale. African Americans, Mexican Americans, American Indians, Native Hawaiians, Pacific Islanders and Asian Americans are at higher risk. These groups may be at higher risk because of their genes and/or the lifestyles they are known to have. For example, this could include being overweight because of the kinds of foods their family traditionally eats.
  • Lifestyle – Eating a diet that results in being overweight or obese, coupled with inactivity, puts a lot of stress on the insulin glucose system and is unhealthy for the whole body.
  • Age – In general, the longer you use anything, the easier it is to break it. Those who are 45 years or older are at greater risk of developing symptoms.
  • Drugs – Sometimes medications can harm beta cells or put stress on the insulin-glucose pathways.

A list of drugs that may have the risk of diabetic side effects are:

  • Niacin, a type of vitamin B3
  • Certain types of diuretics, also called water pills
  • Anti-seizure drugs
  • Psychiatric drugs
  • Drugs to treat human immunodeficiency virus (HIV)
  • Pentamidine, a drug used to treat a type of pneumonia
  • Glucocorticoids – medicines used to treat inflammatory illnesses such as rheumatoid arthritis, asthma, lupus, and ulcerative colitis
  • Anti-rejection medicines – used to help stop the body from rejecting a transplanted organ
  • Health problems – Other health problems that affect the entire body or the pancreas can put stress on or break the insulin-glucose pathway.

List of health problems that are risk factors for diabetes:

  • Uncontrolled hypertension
  • HIV
  • Cystic fibrosis
  • Cushing’s syndrome
  • Acromegaly
  • Hyperthyroidism

 

Isn’t there some kind of outward sign that tells me that diabetes is starting to occur?

Answer: Type I diabetes occurs very fast. The classic diabetes signs of thirst, urination, hunger, fatigue, and mental confusion could happen in a matter of weeks, if not days. Type II diabetes happens so gradually, though, that it’s hard to recognize the classic signs. There are a couple of red flags you could watch for. One is having frequent urinary tract infections (UTI) and the other is called acanthosis nigricans.

Background – UTI

Normally the bacteria and fungi living in the urinary tract system are easily controlled by our body’s defenses. In diabetes, two things happen that throw off that balance. 1. The extra glucose in the urine becomes a food source for all the bacteria and fungi and they multiply at a greater rate. 2. The immune system has been compromised by the extra glucose hanging around. The result is that UTIs are more likely to happen. If your resident has more than three UTIs in a year, or has a kidney infection, it’s time to test for diabetes.

Image result for acanthosis nigricans

Background – acanthosis nigricans

Acanthosis nigricans is a skin condition that affects diabetic patients. It appears as dark, thick, and velvety skin around the neck or armpits. Look specifically at where the skin creases and folds. It kind of looks like dirt and sweat buildup, but it won’t wash off. 

I have an interesting personal story about acanthosis nigricans. Back when I was a pharmacy student, I was taught in-depth about diabetes. I was in class a long time memorizing and studying all the details. Somewhere in all those hours of study I started to notice the prediabetes signs and risk factors appearing in my wife. She had a sister with Type II diabetes, she kept getting yeast infections, and she was tired all the time, gaining weight and being miserable. I told her that she might have diabetes. You know what she said? “Are you sure?” Of course, I wasn’t sure, I was just a student. All those signs could be explained away by other conditions. Then I learned about acanthosis nigricans. I looked at her neck. Sure enough, a dark line had formed in the crease at the back of her neck. We had her blood glucose tested to confirm she had Type II diabetes. We had caught the condition early enough. To this day she has been able to avoid all the bad consequences of being a diabetic, and it’s all thanks to a student who was paying attention and a dirty-looking grey line at the back of her neck. I hope my story will be an inspiration to you to monitor your residents.

 

Wait a minute!

If no one is sure what causes diabetes, how can the doctor be sure my resident has diabetes?Image result for a1c test

Answer: There are definitive blood tests that the doctor can give the resident. They are Fasting Plasma Glucose Test (FPG), Random Plasma Glucose Test (RPG), and Glycated Hemoglobin Test (A1C).

Background: Glucose is highly regulated in our bodies. We are built to keep the concentration of blood glucose (blood sugar) at a certain level. Higher-than-normal concentrations just don’t happen normally. If the glucose concentration is higher as shown in these tests, the doctor knows for sure that something is wrong. 

Random Plasma Glucose Test: A blood sample is taken and placed in a blood glucose meter. If the reading is higher than 200 milligrams per deciliter (mg/dL) then diabetes is suspected. RPG is the least accurate of all the tests but easiest to administer. It’s usually used as a screener test.

Fasting Plasma Glucose Test: FPG is more accurate and involves not eating anything for eight hours. Then a blood sample is placed in the blood glucose meter. A reading of 100 to 125 mg/dL is considered prediabetes. If it's 126 mg/dL or higher on two separate tests, you have diabetes.

Glycated Hemoglobin Test: A1C is more accurate than RPG and does not involve fasting. If glucose hangs around too long it can become attached to a hemoglobin cell or it becomes “glycated.” Normally it doesn’t happen very often. An A1C test measures the concentration of the glycated hemoglobin in a blood sample. Any results 6.5 percent or higher on two separate tests indicates that the resident has diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes. Below 5.7 is considered normal.

There is another even more accurate test. It’s called an oral glucose tolerance test. After fasting you drink a glucose solution. Then, at certain times over the next two hours a blood sample is taken, and the glucose concentration is measured. It is usually reserved for tough cases because who wants to sit around for two hours and get poked all the time?

I had one of these tests in college. The professor wanted us to understand the concept. The syrup was labeled root beer flavored, but you almost couldn’t tell. It was the most potent sweetness I have ever experienced. It almost made me gag. Giving the blood samples wasn’t fun either. The professor made us poke ourselves. It turned out I didn’t have diabetes.

 

It seems to me that this is a lot of hassle. Why don’t I just let the doctor handle all this diabetes stuff?

Response: Yes, you could. Many fine caregivers have that same attitude. Here are a few things to consider, though. How often does a resident see the doctor? How long will that resident be in the same room as the doctor? Will that doctor be looking for diabetes symptoms? Doctors don’t normally screen for diabetes unless there are signs and symptoms. Will the resident tell the doctor about the small stuff that may be a sign of diabetes like, “I’m hungry and thirsty and need to pee a lot”? I think you are starting to see why there are so many undiagnosed diabetes patients. You certainly don’t have to be proactive about diabetes, but there may be consequences to that decision. I hate to think of what would have happened to my wife if I had not made those observations.

 

What are the consequences of uncontrolled diabetes?

Response: Uncontrolled Type I diabetes is deadly. If nothing is done, the patient will quickly end up in the hospital. Uncontrolled Type II diabetes is also very harmful. Eventually it will lead to multiple health problems, hospitalization, or death.

Background: Type I – When there is not enough insulin, cells starve. The brain is particularly sensitive to a drop in glucose. The brain will send signals to start breaking down our fat stores. When fat is broken down for fuel, a byproduct chemical called a ketone, which is acidic, is produced.  During Type I diabetes there is so much fat being broken down that it leads to a high concentration of ketones in the blood. This leads to Ketoacidosis. In ketoacidosis the blood has become too acidic, which can lead to a coma and death. Those who are beginning to experience ketoacidosis become confused, agitated, have a red face, breathe rapidly, and have a fruity breath.

 

If you see this in your residents, call 911.

 

 

Background: Type II – When there is too much glucose in the bloodstream for a long period of time, it starts to combine with tissues and causes harm in multiple ways. Diabetes Type II is also a condition of having too much lipids (fatty molecules in the bloodstream). It also adds to the patient’s long-term health problems.

The long-term consequences are:

  • Small blood vessels and capillaries. Glucose will stick to the walls of small blood vessels interfering in the proper function. Blood flow is affected, leading to circulation, eye, and kidney problems.
  • Major blood vessels. Eventually the larger blood vessels are also damaged by the glucose and lipids (fats). This leads to bladder problems, kidney failure, strokes, and heart attacks.
  • Nerve system. Long-term exposure to glucose can kill nerve cells, leading to numbness, tingling, and constant nerve pain. Injuries cannot be felt and are left untreated.
  • Immune system. Glucose can prevent parts of our immune system from working. Infections happen more often, and our body has a harder time removing damaged or malfunctioning cells. Infections occur but the diabetic can’t feel them. The infection grows to dangerous levels before they are treated. This leads to gangrene and amputations. Infections also lead to dental and gum disease. Malignant cells are not detected and destroyed by the immune system, leading to an increased chance for cancer developing.
  • Eventually the overworked beta cells wear out, resulting in a lower insulin production. Lower insulin levels hasten the occurrence of diabetes symptoms.

 

Conclusion

If you are having a hard time wrapping your brain around all of this diabetic stuff, picture in your mind’s eye a vision of what is commonly called a “brittle diabetic” case. They will be morbidly obese, sitting in a wheelchair due to a foot amputation, blind from eye disease, and constantly complaining of nerve pain and being cold from lack of circulation. They will never smile or interact with others because they have bad teeth, bad breath, and a smell of incontinency. Finally, they will die of a heart attack—but not before suffering from one or more strokes first. I know I have laid it on pretty thick trying to make my point. I hope you can see, though, that proactive diabetes monitoring and care is worth the effort.

 

As always Good Luck in your caregiving.

Mark Parkinson BS Pharm

 

References:

What is Diabetes? National Institute of Diabetes and Digestive and Kidney Diseases, NIH. 2018. https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes

National Diabetes Statistics Report, 2017. Centers for Disease Control and Prevention. 2017 https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Diabetes Mellitus. Wikipedia. https://en.wikipedia.org/wiki/Diabetes_mellitus

Diabetes insipidus. Mayoclinic.org. 2018 https://www.mayoclinic.org/diseases-conditions/diabetes-insipidus/symptoms-causes/syc-20351269

Age, Race, Gender & Family History. American Diabetes Association. 2017.           http://www.diabetes.org/are-you-at-risk/lower-your-risk/nonmodifiables.html#Race

Prediabetes. Mayoclinic.org 2018.  https://www.mayoclinic.org/diseases-conditions/prediabetes/symptoms-causes/syc-20355278

Gestational Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases, NIH. 2018.  https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational

Diabetes. Mayoclinic.org. 2018. https://www.mayoclinic.org/diseases-conditions/diabetes/diagnosis-treatment/drc-20371451

Carmella Wint and Marijane Leonard. What You Should Know About Diabetic Ketoacidosis. Healthline.com. Dec.4 2018. https://www.healthline.com/health/type-2-diabetes/ketoacidosis#causes

 

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Analyzing Alzheimer’s

Author: Mark Parkinson BSPharm:  President  AFC-CE

Credit Hours 2- Approximate time required: 120 min.

 

Educational Goal:

To educate Adult Foster Care providers about Alzheimer’s Disease.

Educational Objectives:

Report the prevalence of Alzheimer’s disease occurrences.

Explain the disease process and how it progresses.

Define neuroplasticity and cognitive reserve.

Explain different caregiver strategies.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

Image result for alzheimer's disease

Analyzing Alzheimer’s

Alzheimer’s disease is a term that looms large in our caregiving world. Its effects can be seen mainly in geriatrics, but mentally disabled homes and mental health homes may also be impacted. It has been estimated that before you die up to 50 percent of you who are reading this article will develop Alzheimer’s. The other half will be involved in caring for those who do have it. The prevalence of the disease in the general population will double every 20 years until 2040. In certain populations the prevalence is much higher. For example, those with Down syndrome, if they live long enough, may suffer with Alzheimer’s too. Why does Alzheimer’s disease happen? Why do residents act differently? Why do some get the disease while other don’t? Why does it happen later in life? It is my belief that if caregivers know the “whys,” they will be much better caregivers.

I feel obligated to tell you that Alzheimer’s disease is a very complex condition and we just haven’t figured out all the “whys” yet. I have researched the subject and condensed my findings into a form that I think you can digest. If what I write seems a bit off medically, remember this article is a compilation of ongoing research. Our understanding is going to change. Please look at the overall picture I’m trying to paint and use that knowledge to make your caregiving that much more powerful.

What we know so far….

Image result for national institute on aging logoAccording to the National Institute on Aging (NIA) of the National Institute of Health, “Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks.” In essence, brain function is altered because either the brain cells lose their connection to each other or the brain cells have died. It starts with a few cells here and there, and slowly progresses until the ability of the brain to function properly is ruined.

According to the NIA again, “In most people with Alzheimer’s, symptoms first appear in their mid-60s. Estimates vary, but experts suggest that more than 5.5 million Americans may have Alzheimer’s. Alzheimer's disease is currently ranked as the sixth leading cause of death in the United States, but recent estimates indicate that the disorder may rank third, just behind heart disease and cancer, as a cause of death for older people.”

 

What Causes Alzheimer’s?Image result for alzheimer's disease

 

Inside the Brain

Ultimately, Alzheimer’s disease is the result of the loss of brain tissue. To understand why this happens we must go over a little bit of the anatomy and physiology of the brain. The business of the brain happens between cells called neurons. Neurons have multiple branches extending out of them called dendrites. The dendrites stretch out to other neurons, coming very close but always leaving a tiny gap. The gap is called a synapse. When the brain functions, electrical signals flow down the dendrite branches to their end. When the electrical signal reaches the synapse, chemicals called neurotransmitters are released and they flow across the gap. The chemical molecules fit into special receptors on the receiving dendrite, which causes another electrical charge. That charge then flows down to the next neuron, and the signal is passed on.

After a certain point in our development the brain does not make any new neurons, but the brain tissue continues to expand. The individual neurons continue to grow, adding more and more dendrites with more and more synapses. As our brains learn to do things, new neural signaling pathways are built through the new dendrites and synapses. To help keep the neuron healthy the brain has two additional types of cells: astrocytes and microglia. They help clear away debris from between neurons and defend against bad things that could damage the cells of the brain. These cells are vital because once a neuron dies, it is gone forever.

Anything that interferes with the function of these cells would lead to signal transmission malfunction. Events like glucose metabolism problems (glucose is the preferred fuel of the brain), blood circulation issues (getting the fuel to the cells and clearing out waste), toxic chemicals (like alcohol, paint fumes, and lead), respiration difficulties, and age and health of the neuron can all have an effect on how many signals make it across the synapse.

Fortunately, we have billions of dendrites and trillions of synapses in our brain. If a dendrite fails, a synapse misfires, or even if an entire neuron dies, the brain can find an alternative path around the problem. It takes a lot of signal problems to cause functionality issues. Unfortunately, have enough of these malfunctions and the brain can’t find a detour path. That is when you start getting the outward signs that something is going wrong. 

The clinical indications of signal transmission failures are:

  • Memory loss
  • Declining muscle control
  • Confusion
  • Behavior changes
  • Paranoia
  • Disorganization
  • Agitation
  • Hallucinations
  • Acting out (lack of inhibitions)
  • Cognitive decline

 

Changes to the Brain in Alzheimer’s

In 1906 Dr. Alois Alzheimer, a German psychiatrist and neuropathologist, looked at the brain of an elderly female dementia patient who had died. Upon close examination he found many abnormal clumps and unusual tangles of tissue present. He started to see these same odd structures in other dementia patients. He published his research and his finding was used to identify similar dementia cases around the world. Today we identify the abnormal clumps as amyloid plaque and the unusual tangles as neurofibrillary or tau tangles. After over a hundred years of research there are still many unanswered questions, but we have made great strides in our understanding of the disease that Dr. Alzheimer first described.

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Amyloid Plaque

When an electronic nerve signal reaches a synapse, it is stimulated into releasing its neurotransmitter chemicals. One of those chemicals is a peptide molecule called a beta amyloid. Beta amyloids can hang around in the synapse and over time start to collect and stick together. The microglia cells, which have been described as the brain’s janitor, are supposed to clear out the beta amyloids from the synapse. If it fails in its job, the peptide molecules ball up together and form a clump so large that the synapse can no longer function. This takes a long time to happen. It is estimated that it takes about 10–15 years for plaque to build up big enough to cause problems on the microscopic level. If you’re 40 years old, you probably have some plaque hanging around as a normal part of growing older. It’s really no problem for the brain; it just sends the signal around the plaque.

In Alzheimer’s disease it is guessed (there is still some debate over the particulars) that when the amyloid plaque fills up a certain amount of the synapse, the microglia cells kick into overdrive and start releasing chemicals designed to clear out the plaque. Those chemicals work too well and clear out some of the synapse structure itself, causing permanent damage.

Tau Tangles and Inflammation

Somewhere during these intracellular events a transport protein called tau becomes super phosphorylated. Never mind the details—just know that when this happens, they become entwined and get tangled up. The tangle is toxic to the cell and can damage the neuron further. Eventually the microglial chemicals stimulate the astrocytes to get involved. They in turn try to contain the problem area through an inflammation reaction. If inflammation carries on too long, it also causes damage to cell structures. The culmination of all these harmful events overwhelms the repair mechanisms of the neuron. The dendrite shrinks, the synapse no longer functions and the neuron dies. When enough damage has occurred to the brain, the classic clinical dementia symptoms of Alzheimer’s start to appear.

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The Progression of Alzheimer’s Disease

No one knows yet why the Alzheimer’s disease process starts. For the vast majority it happens later in life and is categorized as late-onset Alzheimer’s. It is most likely the result of a combination of issues that cause plaque to form. Typically, the plaque starts to form while the patients are in their mid- to late forties. Clinical symptoms start to manifest themselves in the patient while they are in their sixties. For the unlucky few, it can happen much earlier in life and is categorized as early-onset AD. Early-onset AD probably occurs because of a genetic mutation. Usually Alzheimer’s-disease-caused brain damage starts in the hippocampus, the portion of the brain involved in memory formation. As the disease progresses, more and more areas of the brain are affected, and the brain loses significant mass.  

Not everyone who has amyloid plaque and tau tangles develop dementia symptoms. It could be argued that you really don’t have Alzheimer’s disease unless dementia starts to manifest itself. There are a number of factors that contribute to the development of dementia.

  • Genetics – There are several inheritable traits that can increase the chances of developing dementia symptoms, in particularImage result for alzheimer's disease the gene apolipoprotein E (APOE). A variant APOE ε4 is associated with early-onset Alzheimer’s. There is also evidence that points to spontaneous gene mutations that can lead to the disease.
  • Health – Conditions that put a strain on the neural system can speed up the development of mental problems. Obesity, cardiovascular disease, diabetes, alcoholism, and the like may lead to dementia.
  • Lifestyle – Poor nutrition, lack of physical and mental exercise, and little or no social interaction leads to a lack of dendrite and synapse development. This creates a low mental capacity reserve which is easy to overwhelm when plaque starts to form. (There’s less capacity to create detours around the problem.)

Stages

The symptoms of Alzheimer's disease gradually worsen over time, eventually ending in death. The rate at which the disease progresses varies between individuals. The average time a person lives after an Alzheimer’s diagnosis is four to eight years. My father, who was diagnosed with Alzheimer’s, lived another 20 years. Because the disease can last so long, they have broken up its progression into stages. 

Preclinical (no signs or symptoms) – The beginning changes to the brain start to occur on the microscopic level. Beta amyloid is starting to build up in the synapse.

Mild (early stage) – The patient can still function independently, but the outward signs are starting to appear. Memory loss, trouble finding the right word, misplacing objects, etc. Amyloid plaque has started to block messaging pathways. The hippocampus has started to lose function and short-term memory suffers.

Moderate (middle stage) – The requirement of extra caregiving becomes prominent in the life of the patient. Dendrites and synapses have been destroyed and the brain starts to lose significant mass.

Severe (late stage) – The patient loses the ability to respond to their environment, creating a need for a greater level of nursing care. The neurons themselves have died by this point.

Rarely do victims die from a lack of brain function. They usually die from some other cause. My father died from an MRSA infection and the lack of desire to live. At the time he was confined to a bed in a nursing home with little or no recognition of visitors.

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Questions Still Remain

We have learned a lot about Alzheimer’s, but several mysteries still remain.  There are multiple examples of patients not fitting the typical disease profile. For example, there are plenty of people with the APOE gene that do not develop the disease. Also, there are those who have amyloid plaque and tau tangles but can function independently up until their death due to other causes. It may be due to healthy lifestyle choices, greater brain system development, or some yet-to-be discovered trait.

Neuroplasticity and Cognitive Reserve

A leading predictor of patient functionality despite disease indicators is the concept of neuroplasticity and of cognitive reserve.

  • Neuroplasticity – “The brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.” Source medicinenet.com
  • Cognitive reserve – “The extent to which the brain can sustain damage, as from Alzheimer's disease, stroke, alcohol overuse and head injury, without affecting intellectual capacity.” Source https://medical-dictionary.thefreedictionary.com/cognitive+reserve

In my opinion, it comes down to the brain’s ability to reroute itself around the Alzheimer’s damage. It has been shown in studies that people with high literacy, educational levels, and social interactions tend to have a higher-than-average ability to avoid the functionality problems of the disease. 

 

Caring for Alzheimer’s Patients

There is no cure for Alzheimer’s disease, but there are medications and therapies that can help retain normal brain function longer. They are most effective if applied in the early stages of the disease. So where does that leave the residential caregiver in a care home? In my opinion, your good caregiving techniques can have the greatest impact on the development of the dementia symptoms of Alzheimer’s. Even if you are not taking care of a diagnosed Alzheimer’s patient, all your residents need careful monitoring for symptoms, serious mental stimulation, physical activity, a healthy diet, and proper medication management as part of your basic care. That includes developmentally disabled homes and mental health homes whose residents may be in greater danger of developing AD later in their life. 

In regard to Alzheimer’s, the underlying care concepts that need to be applied to all your residents are: 1. developing greater brain function capacity, 2. recognizing disease symptoms as soon as possible, and 3. once diagnosed, retaining functionality for as long as possible. I put up my mother’s caregiving efforts as proof of concept. She recognized the symptoms early, kept my father physically healthy and socially active, and managed his medications very well. 

 

Developing Greater Brain Capacity

I must admit, development of the brain is a challenging care concept in a care home. You’re not a school, and fortunately you don’t have to be. There are plenty of things you can do in a care home that stimulate the mind.  Here are a few ideas that you could easily use at any home. 

  • Reverse the sedentary tendencies of your residents. Schedule regular walks, trips, and activities. Encourage outings with family. Get exercise equipment for your home. Involve your residents in the chores of the house.
  • Provide mental stimulation. Watching TV is okay but there is so much more you can do. Get a playback device with headphones for the residents’ use. Today there are so many choices: smart phones, iPads, laptops, cassette recorders, and mp3 players. For those devices, get audio books, music collections, games, and other such programs. You don’t even have to buy them in some cases. Many residents have monthly allowances that just accumulate, and family members are just looking for things they could give their loved one as gifts.
  • Keep the residents from getting into a rut. Schedule a variety of activities and have a ready supply of options to choose from. Get a puzzle table, subscribe to magazines, establish a small library, supply hobby materials, provide letter-writing materials, get pets, make a garden, etc.…
  • Change up the environment to exercise the senses. Make a big deal of holidays with decorations. Plan special meal nights. Provide a variety of smells. Provide room plants and floral arrangements. Use and change up table centerpieces.

If this sounds like a lot of work, it’s really just a matter of planning and using the resources at hand. Libraries, the Internet, and thrift stores can reduce the costs.

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Recognizing the Early Symptoms

There are plenty of lists out there that itemize all the early Alzheimer’s symptoms. Here is one from the Mayo Clinic:

  • Depression
  • Apathy
  • Social withdrawal
  • Mood swings
  • Distrust in others
  • Irritability and aggressiveness
  • Changes in sleeping habits
  • Wandering
  • Loss of inhibitions
  • Delusions, such as believing something has been stolen

The problem with these lists is that most of the items on them are also the normal signs of aging. How can you tell if it’s Alzheimer’s or not? My answer has always been, “When in doubt, send them out.” (To the doctor, that is.) But, I understand your reluctance to go through the effort. It can be upsetting to the resident and the family, not to mention annoying to the doctor. Here is where you can apply what you have learned in this lesson.

Alzheimer’s is a “diseased-caused” loss of brain function that results in abnormal brain function. It is a brain that is starting to have difficulty rerouting its signals around a damaged area. It’s not forgetting where the resident placed their dentures, it’s finding the dentures tucked in a sock drawer. It’s not having difficulty writing down an address, it’s looking at the pen and asking what it’s for. It’s not forgetting a name, it’s forgetting a person. Look for the un-usualness of the behavior and the inability to function appropriately. Make notes and put them into a file. Then send off the file to the doctor with a request for a diagnosis.

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Diagnosis

There is no one test that can definitively point to a diagnosis of AD. The doctor must look at all the signs and evaluate the whole person. As a professional caregiver it would be good for you to be prepared for what may come up at the doctor’s office. Being prepared will help you gain the cooperation of the resident during the exam.

 

The doctor’s evaluation may include:

  1. Medical history – The doctor will ask about family histories, other recent illnesses, medications, other signs or symptoms that may be occurring.
  2. Physical exam – The doctor may examine the patient and perform some tests. He will be trying to rule other causes of memory loss and dementia that might be causing the mental problems. The doctor will be looking for anemia, infection, diabetes, kidney disease, liver disease, certain vitamin deficiencies, thyroid abnormalities, and problems with the heart, blood vessels, and lungs. The doctor will be asking a lot of questions that the caregiver should be prepared to answer. If a family member is transporting the resident, then the doctor’s questions need to be anticipated and the answers need to be written down in the file that is sent with the resident.
  • What kind of symptoms have you noticed?
  • When did they begin?
  • How often do they happen?
  • Have they gotten worse?

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The Alzheimer’s Association has a great doctor visit checklist. I recommend you use it. Click on the link or copy and paste it in your Internet search field. 

https://www.alz.org/media/Documents/doctor-visit-checklist.pdf

  1. Neurological exam – The resident’s brain functionality with be evaluated. The doctor may look for signs of strokes, Parkinson's disease, tumors, or fluid accumulation on the brain. He or she will be looking at the resident’s reflexes, coordination, muscle tone and strength, eye movement, speech, and sensation patterns.

  The doctor may perform mental status tests (Mini-Mental State Exam (MMSE) and the Mini-Cog test). They are designed      to   test a range of everyday mental skills. The answers can be scored, which gives the doctor an objective evaluation of              mental   function. An MMSE score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than    12   indicates severe dementia. The doctor may use computer programs that perform the same function.

  1. Advanced testing – If required, the doctor may perform genetic testing that looks for things like the APOE gene. They may also perform brain structure examinations with an MRI, CT, or PET machine.

Medications

There are two considerations with regards to drugs and Alzheimer’s disease: quality of life and behavior control. If you can’t cure the disease or even slow it down, then it comes down to making the most of what remains for as long as possible.

 

  • Brain functionality – There are two types of medications: cholinesterase inhibitors (Aricept, Exelon, Razadyne) and memantine (Namenda). They help reduce cognitive symptoms (memory loss, confusion, and problems with thinking and reasoning) in the early stages of the disease. In short, they help the synapses pass on signals until they get too damaged to function. Caregivers should watch for nausea, appetite loss, bowel movement changes, and headaches. If there is a sudden increase of dizziness or confusion it might be the medication.
  • Sleep cycles – Getting the days and nights mixed up is a common feature of AD. In addition, many medications used for behavior control have daytime drowsiness effects, which adds to the problem. The caregiver will have to realize that sleeping aids will not solve the problem, just help manage the situation. Watch for grogginess that leads to agitation and falls that in turn lead to broken bones.
  • Behavior control – Here again, caregivers must understand that there are no drug solutions to dementia behavior problems, just tools to help manage them. The brain matter is gone and no amount of drugs will bring it back. These drugs need to be used with skill and close monitoring of side effects. Most have the potential of causing worse problems than the ones they are intended to help with, including death. Don’t be surprised to find a doctor reluctant to prescribe them. Many of the following drugs will be familiar to you so don’t fall into the trap of trying to find a cure for the problem because they worked well in other cases.

 

Behavioral Medications:

Antidepressants-

for low mood and irritability

 

citalopram (Celexa)

fluoxetine (Prozac)

paroxetine (Paxil)

sertraline (Zoloft)

trazodone (Desyrel)

Anxiolytics-

for anxiety, and restlessness

lorazepam (Ativan)

oxazepam (Serax)

Antipsychotics-

for hallucinations, delusions, aggression, agitation, hostility, and uncooperativeness

 

aripiprazole (Abilify)

clozapine (Clozaril)

haloperidol (Haldol)*

olanzapine (Zyprexa)

quetiapine (Seroquel)

risperidone (Risperdal)

ziprasidone (Geodon)

 

*special note on Haldol – haloperidol takes up to four hours to see its full effect. Be careful with PRN re-dosing to avoid overmedicating the resident.

 

Caregiving Techniques

The resources for Alzheimer’s caregivers have greatly improved over the last 20 years. When I was running my adult foster care homes the only resource we had was to send them to a nursing home. We could also put a bell on the front door, so you could catch them before they wandered off.  Now you’re positively flooded with courses, advice, ideas, and regulations. To help you utilize all this good input I recommend establishing a caregiver tool box. Think of all the good advice as tools of the trade. Write them down in a notepad, just a short description that helps remind you of the main principles. You could also collect the entire article and file it in a file drawer. As with any set of tools, one must maintain them and refresh your memory on how to use them from time to time.  Here is my contribution to your tool box.

 

Caregiver Mindset

A lot of caregiving in adult foster care homes is based on the active cooperation of the resident. If the resident becomes uncooperative, you try to gain their cooperation through reasoning and techniques that rely on the resident’s comprehension of the situation.  I like to call it “motherly bossing.”

Motherly bossing only works so far in Alzheimer’s disease. Why? Because the disease process is preventing the thought signals from getting to where they are supposed to go. The Alzheimer’s resident mentally can’t cooperate like your other residents because they physically have lost the ability to do so. Caregivers will have to develop a new mindset: “Effect behavioral changes by controlling the environment more than controlling the patient.”  The more advanced the disease process, the more you’ll have to rely on “manipulating” the resident to behave appropriately. In a nutshell: Do not confront; divert instead.

What does that mindset of caregiving look like? Here are few examples:

  • If the resident says, “The sky is red,” you say, “What a lovely shade you have discovered. Let’s celebrate your discovery. Let’s go get a cookie.” The resident then concentrates on getting to satisfy their appetite, not getting stressed out because of the hallucination.
  • If the resident tries to wander off, divert their attention by saying, “It’s much too cold to go out without a sweater. Go find a sweater to put on.” Of course, before you give that assignment, you place all the sweaters where only you can find them. When they give up searching for the sweater, pull one out and take a walk with them.
  • Decorate with relaxing perpetual motion items like a fish tank. The resident then can watch the fish instead of causing trouble.
  • Avoid stress through relaxing music and aromas.
  • Get the resident something to take apart. Something to occupy their mind and time with.
  • Have patience and let the disruptive behavior run its course. If it’s safe to do so, let them act a little off-kilter. I know it’s annoying, but you will be less stressed if you stop trying to make the resident do what they mentally can’t do.
  • Keep track of events that triggers disruptive behaviors and purposely control them. For example, provide a place where visiting children can play away from the Alzheimer’s patient.

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Conclusion

The prevalence of Alzheimer’s disease in the population, coupled with the disruptive nature of dementia and memory problems, makes this a major issue in care homes. Care providers will find themselves better able to cope with the demands of care that will be asked of them if they understand the disease and the limitations it causes the resident. Every resident in a care home will find benefit in serious mental stimulation to build mental reserves. Medications can help retain mental functionality in the early stages of the disease. In the later stages of the disease controlling the environment will be more useful in caregiving than controlling the resident.

 

As always Good Luck in Your Caregiving Efforts.

Mark Parkinson  BSPharm

 

References:

Caregiving for Person with Alzheimer's Disease or a related Dementia. Centers for Disease Control and Prevention. https://www.cdc.gov/aging/caregiving/alzheimer.htm

Alzheimer’s and Dementia Facts and Figures. Alzheimer’s Association. 2018.  https://www.alz.org/alzheimers-dementia/facts-figures

Alzheimer’s Disease Fact Sheet. NIH Publication No. 16-AG-6423.  https://order.nia.nih.gov/sites/default/files/2018-09/alzheimers-disease-fact-sheet.pdf

Alzheimer’s Disease and Related Dementias. National Institute on Aging, NIH. https://www.nia.nih.gov/health/alzheimers

Lisa Genova. What you can do to prevent Alzheimer's.  Ted Talk Vancouver BC.  April 2017.  https://www.youtube.com/watch?v=twG4mr6Jov0

Richard Mayeux and Yaakov Stern.  Epidemiology of Alzheimer Disease. Cold Spring Harb Perspect Med. 2012 Aug; 2(8): a006239. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405821/

Alzheimer’s and Dementia. Alzheimer’s Association. 2018.  https://www.alz.org/alzheimer_s_dementia

Cognitive Reserve. https://medical-dictionary.thefreedictionary.com/cognitive+reserve

 

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Principles of Side Effect Management

Author: Mark Parkinson BSPharm:  President  AFC-CE

Credit Hours 2- Approximate time required: 120 min.

 

Educational Goal:

To explain the principles of side effect management.

Educational Objectives:

Define what a side effect is and list what causes them.

List possible action the doctor may take to manage the side effect.

Provide caregiver side effect management strategies.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

                                Principles of Side Effect Management

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Adult Foster Care providers are in an unusually ambiguous area of the care giving spectrum. On the one hand they are viewed as the very bottom of the professional spectrum, being less than CNAs. They have absolutely no medical decision-making power and must defer almost everything to someone else. On the other hand, they are almost as powerful as the resident’s family members in getting things done. I have seen adult foster care providers say something to effect of “I will do anything you tell me to do but I demand that you do this or that and do it now.” And the amazing thing is the doctor listens and obeys.

Why is that? You are the primary caregiver, 24 hours a day, 7 days a week. You are in the best position to see and react to the needs of the patient. Any doctor worth his salary knows this and respects it. You are also the patient’s representative or advocate. It’s part of your job to look out for the interests of the patient. Being both on the medical care team and yet having the responsibility to get the medical team moving creates some challenges for the in-home care giver.

No other aspect of medical care illustrates this unusual caregiving position than that of managing the side effects of drugs and other therapies. You are in the position to see side effects occur before anyone else. You are also the one who is responsible for activating the health care team to take care of the problem. To help make you more skillful in this area I present to you the following lesson.

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What is a side effect?

A side effect is any reaction or effect that the drug or therapy was not originally approved for. Approved for is a key phrase we’ll cover later. All drugs can have multiple responses in the body. This happens due to several factors.

Some of the mains ones are:

 

 

  1. The chemical (drug) stimulates reactions all over the body. It is very hard to guide a drug to a specific part of the body. Once in the blood stream it goes everywhere. If you wanted the drug to control swelling in the legs, it’s also going to affect the glands that control water flow into the eyes. Thus, a potential effect of water pills is vision problems.
  2. The body over reacts or under reacts to the drug. If you take a diabetes drug to get rid of extra blood glucose and the body over reacts and takes out too much blood glucose, then the body doesn’t have enough fuel to keep going. The side effect then would be being tired and mental confusion.
  3. The body breaks down the drug poorly. Iron containing drugs are hard to digest. It flows through the digestive tract never making into the blood stream. This can cause an upset stomach and constipation.
  4. The body can break the drug down in unusual ways (metabolization). It can cut the drug at point b instead of point a. Thus, the body has created a new drug that flows through the body causing different actions. Some blood pressure meds can cause a dry cough that won’t go away because of a certain metabolite.
  5. The body can overreact to the drug as a harmful substance and our body’s defenses kicks in. Nausea and Vomiting is the stomach stomach’s way of getting rid of troublesome substances fast. Diarrhea is the same effect.
  6. The immune system can be hypersensitive to a substance causing an allergic response. The body throws up defensive walls of inflammatory responses that results in swelling, redness and itching.
  7. Everyone body is built differently. Those variations can cause drugs to act differently in different people. As a pharmacist I have seen drugs that are supposed to make you drowsy make some people hyper active.
  8. Interactions between other medications or food being taken. Drinking coffee or other caffeinated drinks make theophylline produce side effects more often. Taking Ibuprofen and Warfarin makes it easier to bruise the patient.

Not all side effects happen with the same severity. The reaction could be mild to very severe, temporary verses constant. They also can change over time. The reaction could range from fading until it disappears by itself to increased intensity until it becomes life threatening or causes permanent damage. Some are even helpful and therapeutic. Regardless of the side effects presentation medical professional must react to them.

 

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The Doctors Reaction

With all these possible reactions, you can see why every drug has the potential of having effects in the body that are different than the one the government has approved the drug for. If side effects do occur the doctor has four choices.

 

 

  1. Take advantage of the side effect. A side effect is not necessarily a bad thing. A doctor has the right to make his own choices how to use a drug despite what the government thinks. If the doctor sees a benefit, why not take advantage of it. The drug trazadone (Deseryl) is used just as often as a sleeping aid as for an antiseizure pill even though it has never been approved as a therapy for insomnia. When a doctor uses a drug for a use other than the government approved one it’s called an “off label” use.
  2. Wait and see. Often side effects are only temporary reactions and go away by themselves. The body either compensates for the reaction or just gets used the effect. This fading of side effect usually happens by 2-3 weeks. Often you will see a doctor only react to a report of a problem on the 3rd or 4th week of therapy.
  3. Do nothing. If a side effect occurs, it becomes a balancing act between benefit and side effect. This is seen a lot in short term therapies like antibiotics or PRN meds. Killing off the infection is much more important than being tired from the drug. Adult Foster Care providers sometimes has to fight with the doctor over this one. What the doctor sees as not a problem can be a big issue for the care provider. It is okay to be aggressive with the doctor as long as you’re professional about it and communicate clearly.
  4. Change the drug regime. If a side effect becomes troublesome a change can come into two forms. 1. Change the drug to an alternative therapy or change the dose, and 2. Add a drug to manage the side effect. I’ve seen care providers and patient’s do this a lot. They see a reaction and ask for a pill to take care of it. The “a pill for every ill” mentality. Soon there are a lot of drugs being taken. In my opinion it would be wise to ask, is that pill really all that necessary? Why not just change the med that’s causing the problem in the first place and get rid of all the extra baggage.

Allergic reactions

An allergy is a reaction to any substance (antigen) that triggers the production of antibodies called Immunoglobulin E (IgE). These antibodies travel to immune cells that produce chemicals that cause the allergic response in the body. First time exposure to an antigen may not produce an allergic response, but the body has become sensitized to it. More exposure to the antigen can create a greater sensitivity. The greater sensitivity the greater the allergic response. The allergic response may become so intense that lungs swell, breathing becomes difficult and possibly death may occur. Such a deadly response is called anaphylaxis. That is why allergic response side effects should be taken very seriously. Even the mild allergic responses may be a precursor to something more serious later on.

Obviously not all side effects are allergic responses though the patient may call it that. I have heard it over and over again. Side effects like an upset stomach was called an allergy. The main difference is that true allergic responses involve antibodies and may turn deadly. True allergy symptoms are:

Image result for side effects'* hives (itchy red spots on the skin)

* itching

* nasal congestion (known as rhinitis)

* rash

* scratchy throat

* watery or itchy eyes

* swelling

* wheezing

* flushing of the face

* difficulty swallowing

Do not hesitate to call the doctor if these symptoms occur. Record these reactions in the patients file. I recommend recording the specific reaction that occurred. Example, allergic response to Vicodin, hives and itching occurred. If the last four on the above list happens it might be wise to skip the doctor and call 911. It all depends on the severity of the reaction. When in doubt call it out.

 

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The Caregivers Reaction

Managing side effects is part of a caregiver’s job. It’s not “if” side effects will occur, it’s “when” the side effects happen. The caregiver must be prepared to react appropriately. Being prepared to act involves; 1. Knowing what to look for, 2. Monitoring for effect, 3. Knowing when and how to report, 4. Therapeutically managing the side effect.

 

 

Knowing what to look for

 

The most common occurrences make it on the list given to the patient. Less common but significantly important occurrences are also added, usually with a disclaimer that they do not occur as often. All the noted side effects including the less common ones are noted on the drug information sheet given out with each stock bottle of the drug. Drug information sheets are intended for medical professionals and include much more details. It takes some practice to be able to understand them but usually if asked for the pharmacist will give you one and answer any questions you have. I recommend that every caregiver take a look at a drug information page and compare it to the patient information page a couple of times. I think you’ll gain some important insights on how to spot side effects.

Non-drug therapies also can have unintended side effects but there is rarely and conveniently patient information sheet listing them. If there is patient information provided scan it for what to monitor for. If no information is provided I recommend getting in the habit of calling the therapist and asking about what to monitor for, including side effects.

Monitoring for Effect

Monitoring for effect may seem to be a straight forward proposition but it’s not. It’s more complicated than it appears. Doing it well is what separates the good homes from the mediocre ones. Side effects usually don’t pop up with a sign saying, “look at me, I’m a side effect”. They can occur gradually, are hidden or mimicking something else. It takes a practice eye and a concerted effort to catch side effects as they start to occur. I recommend the following caregiver techniques.

* Establish a base line or determine what is normal. It is a common medical practice to take measurements of patient’s vital signs. Care homes could also do a simpler version of vital signs. When a person moves in, consult with the doctor to determine what needs to be monitored then take measurements periodically. Without such directions from the doctor I recommend you consider the following easy to measure items, Weight, Ankle circumference, Blood pressure and temperature.

* To determine what’s normal on items harder to measure, establish a routine of daily living and take note of when it becomes harder to maintain that routine. For example, to notice side effects like dizziness pay attention how long it takes you to get a resident dressed in the morning. If it takes longer than normal, then investigate why. Variations from normal routines can give you a wealth of information.

* PRN logs can also tell you when things have changed. Pay attention to the frequency of the entries.

* Always look deeper into annoying circumstances. Events that stand out. When they occur ask yourself first, “is this a side effect talking”.

* When a resident complains include in your thought process, is this a side effect starting to manifest itself.

* Be vigilant for at least three weeks after a med change. Read the patient information page to know what to watch for.

Know When and How to Report

There are two purposes to report a side effect to the doctor. First being to inform the doctor. The more information he has the better therapy he can administer. Second is to start the needed medical intervention. If you don’t

report, the doctor thinks that everything is fine, the resident suffers, and your job gets harder.

If you are new to the profession of caregiving I suggest that you report every suspected side effect to the doctor. Pay attention to what kind of reaction the doctor has. After a while you’ll start to get a feel for what is important and what is not. Of course, what is important to a doctor and what is important to you are two different things. It’s okay to push a doctor if things are not going well for the resident or your home.

Those with more experience will know to have patience before reporting a side effect. Unless it is a significant reaction or instructed otherwise it is wise to see if the side effect goes away be itself. Two or three weeks should be a sufficient time to wait. If it goes beyond that, note the length of time the side effect has manifested itself and if it is getting stronger as time passes.

When reporting a side effect, you could report it to a home health nurse or to the doctor’s office themselves. I always found it easier to get a hold of the doctor’s nurse. Give sufficient details in your report. Include measurable facts. Always report in such a way that you get a response. Here are a few examples:

* Jane Smith has requested prn constipation relief pills daily for the past 3 weeks. It started shortly after the recent medication “name of drug”. The complaint has continued despite the prn laxative and an increase of fluid intake. Do you wish for me to continue the extra constipation pills?

* Robert Jones has developed a dry cough that has increased in frequency since taking the new blood pressure medication. Could this be the side effect listed on the patient information list that came with the new med?

 

Image result for managing side effectsManaging the Side Effect

Managing side effects entails reducing or eliminating the unwanted effect the medication or therapy has produced. This get a bit tricky for a caregiver who has no authority to make any therapeutic decisions. Yes, reporting the side effect and pushing the doctor to respond is in effect managing the side effect. But; what can you do if you’re waiting to see if the side effect goes away by itself? What if the side effect reaction is not very significant, just annoying? What if the doctor decides to do nothing? What do you do if the resident wants to refuse taking the medication because of the side effect? There has to be other things you can do beside wait for the doctor to respond. Here are some things that you can do as an adult foster care provider.

Refusing to take meds

A patient has the right to refuse any therapy for any reason. It’s part of their resident’s right. But they’re not free to avoid the consequences of that decision. The most poignant example I can think of is cancer therapy. Chemotherapy can be very rough on the patient. It’s easy to understand why a patient would want to refuse therapy if their hair is failing out and they’re throwing up several times a day. But if the residents refuse therapy they will suffer horribly and die from the cancer. When a resident wants to refuse a medication, the caregiver can do several things.

* Let the resident know that you are taking their complaint seriously. Often the refusal is just an awkward plea for respect and help. Tell them you have contacted the doctor and you’re doing something to help while we wait. Show the resident that you are writing down and recording their complaint.

* Educate the resident on the consequences of refusing. Do it in such a way that it appears to be a wise decision to take the therapy despite the side effects. Everyone likes to think they are smart.

* Educate the resident on why they are taking the medication. A rational person will sacrifice comfort if the reason is good enough.

* Distract the resident’s attention away from the side effect. If you dwell on a side effect of course you’ll feel it more.

* Use the habit of routine to reinforce the taking of meds. Use phrases like, “But, this is always what you have done, you sure you want to change?”

* If the resident is mentally impaired then discuss the issue with those with authority to act for the resident, like a son who has medical power of attorney.

* Defer to authority’s wisdom. Say things like, “The doctor thinks it’s wise for you to take this medication”. “Your family expects you to cooperate with therapy.”

* Take a temporary drug holiday. Refusal does not automatically mean not taking the drug from then on. Record in your MARS the refusal, then continue on as normal. If this occurs a lot notify the doctor with the details

Image result for medical records

Standing Orders and PRN medications

For those symptoms caused by the most common side effects, you could get standing orders and prn meds. You may never use them but being prepared just in case goes along way. Consider asking the doctor the following on all your residents. Medications or instructions for pain, fever, constipation, diarrhea, allergic reactions, dry mouth, dry eyes, and insomnia. Getting Standing Orders has to be weighed against having a lot of rarely used extra prescription bottles cluttering the medicine cabinet and their cost.

You could make it a form that all the doctor has to do is check a box and sign his name. You could use this form or make you own. Put the form in your computer so that you could customize it for each resident. Add or subtract from it as circumstances demand.

For example- (You have my permission to copy it for your own use)

 


 

Dear Doctor, your patient has moved into a licensed care home. We need your permission to administer PRN medications that might be needed. Please review the following list and check the box if you agree or write down your own standing orders. Then sign it at the bottom to validate the standing orders. Please send a copy to the pharmacy for fulfillment.

Thank You

Pain, Fever, Inflammation

Acetaminophen 325 mg: 1-2 pills PO every 4-6 hours PRN for pain or fever. QTY ____

Ibuprofen 200 mg: PO 1-2 pills PO every 6-8 hours PRN for pain fever or inflammation. Qty _____

Other ____________________________________________

Constipation

Milk of Magnesium: 30-60 mL/day PO at bedtime PRN constipation. QTY 1 bottle

Senokot: 1 to 2 tablets PO up to twice daily PRN constipation. QTY ____

Other ______________________________________________

Diarrhea

Loperamide 2mg: 1-2 pills PO daily PRN Diarrhea Qty _____

Other ______________________________________________

Nausea

Tums Regular strength: 2-4 tabs PO prn, Max: 15 tabs/24h Qty _____

Other ______________________________________________

Doctors Signature:

___________________________________________________


 

Home Remedies

Using home remedies to reduce the impact of side effects are a danger zone for adult foster care providers. Care providers are guaranteed to get in trouble if they make medical decisions or decide therapy. Home remedies may also mask how serious the side effects are becoming. In addition, some remedies are a complete waste of time with little more than old wife’s tales to back them up. Having said all that there are certain techniques that can be very useful in reducing the impact on the quality of life of your resident.

 

My list of home remedies for drug side effects

Here are some home remedies that I don’t think would land you in hot water.

Insomnia

The body wants to sleep but if the medication is causing issues then you can help by

* Keeping the bedroom quiet, cool and comfortable during sleep.

* Offer distracting activities that reduce anxiety and tension like gentle backrubs or foot massages near bedtime.

* Offer a light bedtime snack.

* Dim the lights before bedtime sending signals to the brain that it’s bedtime.

* Block out noises with soothing background sounds like a fan or white-noise machine.

* Lavender scents promote sleep

Nausea

Nausea is one of those side effects that usually goes away as the body gets use to a drug. Some things that can help reduce upset stomachs are; Give the medicine with bland foods like dry crackers, toast, or milk. Serve smaller, light meals, then augment with snacks. Avoid foods that are spicy or hard to digest. Watered down apple juice or warm sweetened watered-down milk can also help calm upset stomachs or try ginger ale or ginger tea. Drink clear liquids cold and sip slowly. Try Popsicles or gelatin. You can also try mental diversions, deep slow breathing, relation techniques and positive imagery.

Fatigue, Mental Confusion

Scheduled light activities like a walk wakes a person up. Engaging in conversations also helps fight mental fuzziness. Hold activities that require participation, like a card game, letter writing, puzzles, snacks etc…

Dry mouth

Often meds turn off saliva glands. The remedy is to stimulate them to function again. Try things that you have suck on like tart hard tack candy. Swabbing the mouth with glycerin and lemon juice also works. I also find that unsweetened carbonated drinks cut through a dry mouth very well. Ice chips work well too.

Constipation

You can fight constipation with an increase in fluids, adding more fiber to the diet and or serving prune juice or lots of fruit. Adding more physical activities gets gravity and muscle movement to help keep bowels moving.

Metallic Taste

If a metallic taste is making it hard to have an appetite, give strong tasting snacks like lemon drops or mints before eating a meal. Use plastic utensils to eat. Rinse your mouth with a salt and baking soda solution before meals. Try a solution of ½ teaspoon of salt and ½ teaspoon of baking soda in 1 cup of warm water. It may help neutralize bad tastes in the mouth. Prepare foods with a variety of colors and textures.

Fluid Retention, Edema

Promote physical activities like walking. Lotion the skin or massage the edema area often. Keep the feet elevated.

Diarrhea

Short term diarrhea is a part of life. It’s the body’s way of getting rid of things it doesn’t like. If diarrhea continues past four or five days, it may be the medications. At this point you have to determine the impact on the quality of life of you resident and compensate. You could try one or more of the following; Utilize the BRAT diet, (Bananas, Rice, Applesauce, and Toast). It will provide the resident with more soluble fiber. Increase fluid intake to avoid dehydration. Serve constipating treats like bananas or cheese. Active cultured yogurt is a good remedy for antibiotic cause diarrhea. Pickled foods also contain natural probiotics that might help.

Image result for Conclusion

Conclusion

Side effects from medications and therapies are a reality of modern medicine. Managing them is part of the caregiver’s job. Not all side effects are the same. They can vary in severity, duration, helpfulness and harm. Managing them becomes a balancing act between, benefit of the medication or therapy and harm to the body and impact on the quality of life. For adult foster care providers managing the side effect it is a matter of detecting them, monitoring to see if they go away by themselves, help reduce their effect on the quality of life of the resident and reporting all information to the doctor. In addition, the caregiver must play the role of patient advocate to motivate the care team when a push is needed. Being prepared to handle all the above will turn a mediocre caregiver into great caregiver. I hope this lesson has helped.

 

As Always, good luck in your caregiving.

Mark Parkinson BSPharm

 

References:

Cancer Symptoms: Tips to Help You Feel Better. WebMD.com 2017. https://www.webmd.com/cancer/dx-next-steps-16/ease-cancer-side-effects?page=2

Managing Cancer Side Effects at Home WebMD.com. 2017. https://www.webmd.com/cancer/dx-next-steps-16/managing-cancer-side-effects

Managing Cancer-related Side Effects. American Cancer Society. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects.html

Side Effects. Cancer.net, American Society of Clinical Oncology. 2018. https://www.cancer.net/navigating-cancer-care/side-effects

What to expect when a person with cancer is nearing death. American Cancer Society. 2018. https://www.cancer.org/treatment/end-of-life-care/nearing-the-end-of-life/death.html

Side Effects of Cancer Treatment. National Cancer Institute, NIH.August 9, 2018 . https://www.cancer.gov/about-cancer/treatment/side-effects.

Managing Common Side Effects. RxOutreach. http://rxoutreach.org/education-managing-common-side-effects/

David E.Kemp. Managing the side effects associated with commonly used treatments for bipolar depression.  Journal of Affective Disorder. Volume 169, Supplement 1, December 2014, Pages S34-S44. https://www.jad-journal.com/article/S0165-0327(14)70007-2/pdf

  1. Fookes, BPharm. Managing Common Drug Side Effects. Drug.com. Nov. 16,2018. https://www.drugs.com/article/drug-side-effects.html

Terry Matlen. The 5 Most Common Med Side Effects-and Their Fixes. Attitude, Inside the ADHD mind. https://www.additudemag.com/adhd-medication-side-effects/

Anthony Frew. General principles of investigating and managing drug allergy. Br J Clin Pharmacol. 2011 May; 71(5): 642–646.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093070/

What Is an Allergic Reaction? Healthline.com. https://www.healthline.com/health/allergies/allergic-reaction#symptoms

Trisha Torrey. Do Patients Have the Right to Refuse Medical Treatment? Verywell Health.com April 08, 18. https://www.verywellhealth.com/do-patients-have-the-right-to-refuse-treatment-2614982

 

Exam Portal

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Concerned About Cancer?

Author: Mark Parkinson BSPharm:  President  AFC-CE

Credit Hours 4- Approximate time required: 240 min.

 

Educational Goal:

To educate Adult Foster Care providers about cancer.

Educational Objectives:

Define the word cancer.

Describe how cancer is named, typed, graded, staged and classified.

List the known contributors to the development of cancer

Teach about the role of the caregiver in cancer

Define prognosis and survivorship in regard to cancer

Tell about the Grief and Coping Process

Define common cancer terms

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

 

 

 

 

Concerned About Cancer?

 

There are very few words that evoke more fear than the word Cancer.  According to the National Cancer Institute, “Cancer is among the leading causes of death worldwide. In 2012, there were 14.1 million new cases and 8.2 million cancer-related deaths worldwide.  In 2018, an estimated 1,735,350 new cases of cancer will be diagnosed in the United States and 609,640 people will die from the disease. The number of new cases of cancer (cancer incidence) is 439.2 per 100,000 men and women per year. Approximately 38.4% of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2011–2015 cases). It is estimated that the national expenditures for cancer care in the United States in 2017 was $147.3 billion dollars.” Source https://www.cancer.gov/about-cancer/understanding/statistics

Cancer in the mainstream media is always portrayed as a tragedy.  Invariably the story that is told is that those with cancer will be victims. They will have a long, slow, painful struggle with the disease, followed eventually by death. The stories about cancer treatments are also full of suffering, where even the caregiver experiences bitter emotions. It is no wonder that we avoid even the thought of the word cancer. How much of that story is true and how much are just fiction? What is cancer? Is it one disease or a collection of diseases? Do you catch it or are you born with it? What are the signs and symptoms? How is it diagnosed? How is it treated?  What is actually involved in taking care of those with cancer? 

Definition

The National Cancer Institute at the National Institutes of Health defines cancer as:

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems.”

Basically, cancer is a disease of abnormal cell growth and it can happen to any cell in the body. The transformation of a normal cell into a cancer cell is called carcinogenesis.

It all happens in the genes of the cell’s DNA. Genes are small subsections of the DNA. They are responsible for the different functioning of the cell. As the genes go about their business, errors can occur. Those errors are called mutations. The mutations can be caused by external events like toxic chemicals (we call them carcinogens), radiation, or naturally-occurring random events. Some forms of genes are more susceptible to changes than others. Those who inherit these forms of genes are predisposed to developing cancer. 

As gene errors accumulate in the DNA, the cell starts to function abnormally. Ordinarily the body can sense and control the abnormalities by killing the cell or programming the cell to die on its own. Sometimes that doesn’t happen and the abnormal cell starts to grow and divide, forming a mass of irregular cells called a tumor. If the tumor stays together in a mass, we call it a benign tumor. If the tumor grows out of control and pieces of the tumor break off, travel to other sites, and start to grow, we call it a malignant tumor. The process of spreading through the body is called metastasis. When malignancies occur, we call that cancer, though not all cancer forms tumors. 

 

Name, Type, Grade and Stage

Any cell of our body has the potential to become malignant. This leads to a confusing amount of diseases we could call cancer. According to the National Cancer Institute at the National Institutes of Health there are over 100 types of cancer. The Cancer Research Institute states that there are over 200 varieties. To help make sense of the mind-boggling number of variables in the disease, modern medicine classifies and categorizes each occurrence. 

 

Name

Commonly the cancer is named from where the cancer first originated. For example: breast cancer, skin cancer, etc.  We still call it breast cancer even if it spreads to the bones or other places in the body. That leads to a lot of confusion, so modern medicine classifies and categories cancer disease names more definitively. 

Medical terminology builds up cancer names using different aspects of what they are trying to name, thus describing the condition as well as giving it a name. In cancer names the beginning of the word references where the disease originated. The ending of the term refers to the classification or type of cancer cell that has occurred.

 

Prefix examples: 

Organ or tissue of origin

 

hepatocarcinoma (liver)

lipocarcinoma (fat) 

Size and shape of the cells

 

giant cell carcinoma

spindle cell carcinoma

small-cell carcinoma

Type of cell in an organ

 

ductal carcinoma of the breast

Merkel cell carcinoma

 

Suffix example:

Carcinoma

Cancers derived from epithelial cells. This group includes many of the most common cancers and includes nearly all those in the breast, prostate, lung, pancreas, and colon. 

Sarcoma

Cancers arising from connective tissue (e.g. bone, cartilage, fat, nerve), each of which develops from cells originating in mesenchymal cells outside the bone marrow.

Lymphoma Leukemia

These two classes arise from hematopoietic (blood-forming) cells that leave the marrow and tend to mature in the lymph nodes and blood, respectively.

Germ cell tumor

Cancers derived from pluripotent cells, most often presenting in the testicle or the ovary (seminoma and dysgerminoma, respectively).

Blastoma

Cancers derived from immature "precursor" cells or embryonic tissue.  

Source https://en.wikipedia.org/wiki/Cancer

 

I have always appreciated the way medical terminology puts so much information into a single term. It may lead to great big complicated words, but if you look up the various parts of the word you can tell what is going on just by the name.

Let’s break apart a scary, big cancer name.

Neuroblastoma: neuro – nerves,  blastoma – cancer of precursor cells

Or a type of cancer that forms in immature nerve tissue.

A cautionary word about tumor names

The suffix -oma means tumor, but not all tumors are cancerous; some are benign.  If you see -oma ending a word, do your research before jumping to any conclusions. The suffix -noma does mean cancer.

 

Type Classification

Cancers are broadly grouped as solid (tumor mass) or liquid (blood cell cancers. They are further classified by where the cancer started.

Cancer Classifications:

1. Carcinomas are cancers that occur in epithelial (surface) tissues in the body.

2. Sarcomas occur in connective tissue. For example: bone, cartilage, fat, blood vessels, and muscles.

3. Myelomas are cancers that occur in plasma cells in the bone marrow.

4. Leukemias are a group of different blood cancers of the bone marrow.

5. Lymphomas are cancers of the immune system cells.

6. Mixed cancers arise from more than one type of tissue.

Source https://www.medicinenet.com/cancer_101_pictures_slideshow/article.htm

 

Grade

Tumor grade is the description of a tumor based on how abnormal the tumor cells and the tumor tissue look under a microscope. It gives important clues on the potential of a tumor to grow or turn cancerous and spread. It ranges from almost-normal-looking cells (well differentiated) to abnormal cells that lack normal cell structures (poorly differentiated or undifferentiated). There are several different grading systems. It all depends on the type of cancer being described. In general, it is a simple number.

Cancer Grades:

GX

Grade cannot be assessed (undetermined grade)

G1

Well differentiated (low grade)

G2

Moderately differentiated (intermediate grade)

G3

Poorly differentiated (high grade)

G4

Undifferentiated (high grade)

Source https://www.cancer.gov/about-cancer/diagnosis-staging/prognosis/tumor-grade-fact-sheet

Breast cancer and prostate cancer have a grading system that is a bit more complicated, but the general rule of thumb is the higher the grade, the greater potential for bad news.

 

Stage

The stage of a cancer is determined generally by how far the cancer has spread. The stage is often used by doctors in their diagnosis of the disease. 

Cancer Stages:

Stage O

This stage describes cancer in situ, which means “in place.” Stage 0 cancers are still located in the place they started and have not spread to nearby tissues. This stage of cancer is often highly curable, usually by removing the entire tumor with surgery.

Stage I

This stage is usually a small cancer or tumor that has not grown deeply into nearby tissues. It also has not spread to the lymph nodes or other parts of the body. It is often called early-stage cancer.

Stage II  Stage III

In general, these two stages indicate larger cancers or tumors that have grown more deeply into nearby tissue. They may have also spread to lymph nodes but not to other parts of the body.

Stage IV

This stage means that the cancer has spread to other organs or parts of the body. It may also be called advanced or metastatic cancer.

Source; https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/stages-cancer

 

 

Causes of Cancer

                                                                      Because of people’s strong reaction towards cancer, any story about it is big news. News outlets know that the word “cancer” sells. In my opinion, the consequence of this sensational news coverage is that it seems like just about everything causes cancer. Of course, that is not true. A lot of things have to line up in order to make it past the body’s cancer defenses. In fact, it’s pretty hard to point to any one thing and say, “That is the thing that caused your cancer.” It would be more accurate to say that thing or those things contributed to the development of your cancer. Generally speaking, 90–95 percent of cancer cases are most likely caused by outside factors. That leaves the remaining 5–10                                                                               percent as being due to inherited genetic weakness in the DNA or in the anti-cancer                                                                                   defenses.

 

Known Contributors to the Development of Cancer

As you recall from earlier in this article, cancer is a result of abnormal genes that cause the DNA to not function normally. Plus, the abnormal cell is not killed off by the defenses but instead grows out of control. I would also like to point out that you cannot “catch” cancer from someone who has it, except in the very rare cases of pregnancy or cancer-containing tissue donation and blood transfusion. Here is a general list of known contributors to the development of cancer.

  • Chemicals – Certain chemicals called carcinogens interfere with the molecular functioning of cells and their DNA. Tobacco smoke contains over 50 carcinogens and causes 90 percent of lung cancers. Other famous carcinogens are benzene and alcohol. Exposure to carcinogens does not guarantee a development of cancer, but greater exposure increases the chances significantly.
  • Diet, inactivity, obesity – Up to 35 percent of cancers have a dietary component. Eating large amounts of certain foods, lack of physical exercise, and especially obesity leads to a general decline of health and a weakening of our immune and endocrine (hormone) systems. The chemicals in the foods we eat may also be factors in cancer. For example, a high-salt diet has been linked to cancer.
  • Infection – Viruses, bacteria, and a few parasites interfere with a cell’s functioning, which may lead to cancer. Virus infections that lead to carcinomas are classified as oncoviruses.
  • Radiation – High-dose or long-exposure-time radiation disrupts the atoms in our cells. Disorder enough of the wrong atoms and you get cancer. Radiation sources include radioactive material, ultraviolet light from the sun, and possibly high-voltage power lines.
  • Cell-damaging agents – Physically damaging a cell over and over again can lead to errors in the repair process that can lead to cancer. Two examples of this are mesothelioma, caused by asbestos, and esophageal cancer, caused by stomach acid in the throat (GERD).
  • Autoimmune disease – Diseases like celiac disease, Crohn’s disease and ulcerative colitis also make a cell repair itself over and over again. The extra repair and the repeated inflammatory process increase the chance of malignancies.
  • Hormones – Hormones that play a role in cell proliferation do not cause cancer but can make it grow faster. Think of it like stepping on the gas of the cancer engine. Estrogen and breast cancer and testosterone and testicular cancer are two examples.
  • Defects – Congenital (inherited) defects in any of the cell repair genes or the anti-cancer cell mechanisms can predispose an individual to developing cancer. Those whose parents died of breast cancer are at greater risk themselves.

 

The Role of the Caregiver in Cancer

I know that some of you are thinking, “This is all very interesting, but what has it got to do with me? I’m no doctor. What has all this cancer stuff got to do with my job? I don’t have anything to do with cancer.” In-home caregivers have a greater role in cancer than what you might think. In my opinion Adult Foster Care providers have the most prominent role in preventing cancer, are in the best position for early detection of cancer, and they play a major role in patient compliance with treatment. In addition, they are probably the most influential on the day-to-day perceptions and attitudes of the patient. All of the above are key components in the detection and treatment of cancer. It is my hope that this article helps prepare you for your important roles in this disease. Let’s take a look at some of the tools at your disposal.

 

Perspectives and Cancer

Image result for cancer danger newsThe society that we live in has made cancer a very serious subject. The news we read and the stories we hear affects our perceptions and perspectives.  Negative doom-and-gloom perspectives increase the impact of the disease on both caregiver and patient. Gaining a proper perspective, one that is defined by knowledge and not by fear, increases the effectiveness of care and treatment and results in more positive outcomes.

The truth is, not all cancer cases involve long, drawn-out, difficult treatments and lead to death. The most common form of cancer, non-melanoma skin cancer, accounts for about one-third of cancer cases worldwide and rarely ends in death. There are many cancer cases treated by a simple surgery to remove the tumor. Even in cases that are more serious, advances in cancer care have greatly improved treatment results.  Regardless of the seriousness of the cancer it is important to remember: 1. positive perspectives increase positive outcomes, 2. the earlier a cancer is diagnosed and treated, the better, and 3. there is always something that can be done for cancer victims, even if it is just making them feel more comfortable.

 

Prevention and Cancer

Of course, the most effective treatment for cancer is preventing it from happening in the first place. Since 70–90 percent of cancers are caused by environmental factors, the lifestyle choices we make are the most important factors in preventing cancer. Adult Foster Care providers are in a position to help maintain healthy lifestyle choices more so than any other medical provider. In my opinion, that gives In Home caregivers the most prominent role in the prevention of cancer. Image result for cancer danger news

For the In-Home caregiver, it all comes down to managing the risk factors that lead to the potential of cancer. I am not recommending stressing about every little thing. With all the fake news and pseudo-science about cancer we are bombarded with every day, that would be an impossible effort. What is doable is concentrating on the major risk factors of tobacco, obesity, alcohol use, poor diet, ultraviolet radiation (sunshine), physical inactivity and pollutants. In general, what that means is establish good caregiver business practices. Run your home right and the cancer risks take care of themselves. Keeping your residents healthy is all that is required.

There are a couple of additional things that you could do to manage the risk of cancer. 

  1. For mental health homes, caregivers must understand the role of nicotine and alcohol use in therapy. Their residents use these cancer-causing agents as a self-treatment. By replacing them with more effective therapy you reduce the need, making it easier to control their use.
  2. There are vaccinations that can control the infections that can cause cancer. They are the human papillomavirus vaccine to prevent cervical cancer in females, and the hepatitis B vaccine to prevent liver cancer. Not everyone needs to be vaccinated, just those at risk. For hepatitis B that would be children and adolescents younger than 19 years of age and adults who are at risk for hepatitis B virus infection. For human papillomavirus vaccine it is recommended for girls aged 11 or 12 and boys before the age of 26. Human papillomavirus is spread by sexual contact. If there is no chance of that occurring, there may not be a need for vaccination. Consult with a physician on a case-by-case basis.
  3. You can check your home for radiation sources. It has been reported that approximately one out of every 15 houses in the U.S. may have elevated levels of radon, a naturally occurring radioactive gas.
  4. Check on family history of cancer. This will help identify hereditary risk factors. You would think that the primary care physician would cover this. But as you already know, not everyone fills out the doctor’s paperwork completely. Also, there are those who go doctor-hopping. The more switching of doctors, the more likely things will get missed. You have time to be thorough while doctors do not.
  5. Ultra-violet radiation is usually not a problem for care homes. Your problem is just the opposite; it’s hard to get them out into the sunshine. If you are concerned, using a simple sunscreen and wearing a hat are sufficient enough precautions.
  6. If you’re worried about carcinogenic chemicals in the foods you serve, the rule of thumb is to cook from scratch. Also, avoid barbequed and pickled foods and foods with high salt content. It may be an effort to cook from raw ingredients, but there are other benefits that make it worth your while. It’s easier on the budget, it usually tastes better, and it’s good for marketing. (Potential customers love hearing about home-cooked meals made from scratch.)

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Detecting Cancer

Detecting cancer when it starts is almost impossible. It starts too small, can happen anywhere in the body, and its signs and symptoms are non-existent. As it grows it is still very hard to spot because of all the variable ways the disease can present itself. Cancer has been called the great imitator because symptoms often look like another disease’s processes. Even doctors have a difficult time diagnosing cancer. They usually have to take a sample and send it off to a lab for verification. The process is called taking a biopsy. Detection usually is a matter of doctors recognizing the possibility of cancer by the patterns of abnormalities they see in the signs and symptoms. The sooner they recognize the possibility, the more promising the outcome. That is where the In-Home caregiver comes into play. 

The Adult Foster Care provider can be the eyes and ears of the doctor. If you’re observant you will see the changes and abnormalities before any other medical professional. This early detection is key to successfully treating cancer. The earlier, the better is the rule of thumb.

Before you get all excited, you’re not diagnosing the patient, you’re just looking for the possibility that something is wrong with your resident. If you become aware of certain symptoms occurring, you can bring them to the attention of the doctor and follow up by asking the right questions.

Image result for signs and symptoms

The general signs and symptoms of cancer include:

  • Unusual fatigue that is not helped by resting. Some blood changes like in leukemia or cancer-caused chronic bleeding can leave victims anemic and weak.
  • Weight loss without trying. Almost half the people with cancer lose weight. This is often the first recognizable sign that shows up.
  • Unexplained pain that is persistent and is hard to treat. That includes headaches that for lasts days.
  • Skin changes that include new moles, lumps, and thickening or unusual marks. Look for unusual color changes like yellowing of the skin and red patches. Also look for itchiness and unexpected hair growth.
  • Changes in bowel or bladder function, especially if there is bleeding involved. Blood in the stools makes them look tarry or like coffee grounds.
  • Voice changes or a cough that is severe or lasts more than three weeks. Here again, if blood comes up that’s an automatic trip to the doctor.
  • Fever is always a sign that the body is trying to fight something. If the fever doesn’t go away, then that’s a sign that the problem is not going away. Time to see the doctor.
  • Sores that don’t heal, including sores in the mouth. Even a minor sore that doesn’t heal should be looked at.
  • Continued indigestion, bloated feeling, or trouble swallowing.
  • In men: changes in the testicles or penis. That includes pain, a lump, redness, or a change in size or shape. Watch for complaints about painful peeing.
  • In women: breast changes. Look for lumps, sudden changes in size, discharge from the nipples, spots, or other changes in the skin around the nipples. Watch for bleeding between periods or bloating that isn’t linked to PMS.

If you take this list at face value you could think, “Most of those happen just about every week in my house. How will I ever be able to see cancer coming when those symptoms are so common?” It’s all about knowing your residents and seeing what’s not normal. You’re looking for the unexplained change from the regular routine. If you can say, “Well, that’s not right. I can’t figure out what’s causing that,” then you’d be justified in calling the doctor. Look for the unusual combination of symptoms or the problem that will not go away or is difficult to fix. When deciding if you should bring up the “Is it cancer?” question with the doctor, remember what cancer is, how it is formed, and what it might look like. If all the signs fit the cancer profile, then you would be justified. If you have a few misidentifications, it’s no big deal. Learn from each time so you can add it to your experience at knowing what is normal and not normal. It’s always better to be safe than sorry, just don’t overdo it and wreck your reputation.

Screening for Cancer

Unfortunately, cancer can occur without symptoms. There are medical tests that can detect cancers even if there are no signs at all, but they can be expensive and time-consuming. Using these tests to screen for cancer becomes a balancing act between expense and benefit. The more risk factors there are, the more justified the screening tests become. Consult with the resident’s doctor about which tests should be given and when. If there are concerns, I recommend that you put a note in the resident’s file as a reminder to get the patient screened at the appropriate times.

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In general, the United States Preventive Task Force (USPTF) and the Center for Disease Control recommends the following.

  • Breast cancer: Women who are 50 to 74 years old and are at average risk for breast cancer get a mammogram every two years. A mammogram is an x-ray of the breast. A magnetic resonance image, (MRI) which uses radio waves and magnets, can also be used.
  • Cervical cancer: Women between the ages of 21 and 65 should get a Pap test. The Pap test takes tissue samples and look for cancer cells. At age 30 it is recommended to take an HPV test. The HPV test looks for the virus human papillomavirus that can cause cancer. If these tests come up negative, it may be several years before another test is needed.
  • Colorectal cancer: Everyone between the ages of 50–75 should get regular colorectal exams. Between the ages of 75–86 patients should consult with their doctor to see if there is a need for further exams. There are several tests that the doctor can perform, which include: stool tests every 1–3 years, flexible sigmoidoscopy every 5 or 10 years, colonoscopy every 10 years, and CT colonography (virtual colonoscopy) every 5 years.
  • Lung cancer – For heavy smokers or former heavy smokers who have quit in the last 15 years it is recommended that a yearly screening with a low-dose computed tomography (LDCT) be taken.
  • Screening for ovarian, pancreatic, prostate, testicular, and thyroid cancers has not been shown to reduce deaths from those cancers, so the USPTF recommends against screening tests. The American Cancer Society does state, “Starting at age 50, all men at average risk should talk with a healthcare provider about the uncertainties, risks, and potential benefits of testing so they can decide if they want to be tested.”

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Prognosis for Those with Cancer

For those diagnosed with cancer, a thousand questions arise. How long do I have to live? How much am I going to suffer? What treatments should I get? They turn to the doctor for answers and the doctor gives them a prognosis. But a prognosis is not what you think it is.

According to Taber’s Cyclopedic Medical Dictionary, 16th edition, a prognosis is defined as a “Prediction of course and end of disease, and the estimate of the chance of recovery.” In other words, it’s the doctor’s best guess on how the disease will progress. But all things considered, it’s a pretty good guess because it is based on a mountain of statistics.

 

How a Prognosis Is DeterminedImage result for prognosis

For years medical science has been collecting statistics on everything cancer-related including:

  • The type of cancer and where it has occurred in the body.
  • The stage of the cancer.
  • The cancer’s grade. Grading provides important clues about the likelihood of how the cancer grows and spreads.
  • Certain traits of the cancer cells.
  • What the age and health of the cancer victims are and how it affects the progression of the disease.
  • How patients respond to the various treatments.

The data has been sorted, labeled, categorized, and cataloged. Then, statisticians take over and try to boil all that data down to useable numbers. Doctors can use this information to make a pretty good prediction about how a particular type of cancer will progress. These predications can also help determine which treatment to choose. To help you get a better understanding of what a cancer prognosis is all about, let’s consider the following.

Estimating How Long a Cancer Victim Will Live. 

No one can tell how long a person who has cancer will live, but they can tell you the survival rate of others who have had that kind of cancer. It is usually expressed as a five-year survival rate. The five-year relative survival rate for women with cervical cancer is about 68 percent. This means that about 68 out of every 100 women with cervical cancer will be alive five years after diagnosis. Other examples are the five-year relative survival rate for early-stage cervical cancer, which is 92 percent. This means that 92 out of every 100 women with early-stage cervical cancer will be alive five years after diagnosis. For early-stage colorectal cancer, the five-year relative survival rate is 90 percent. For advanced-stage colorectal cancer that’s spread to distant parts of the body, the rate drops to about 13 percent. 

Points for Caregivers to Remember About Cancer Prognosis

  • A prognosis is a guess based on statistical averages of large groups of people. Individual reactions may vary from the norm.
  • Survival rates are based on known variables. If the variables change, the original prediction will be wrong.
  • A prognosis is actually very complex. If you or the resident is unsure what it means, ask the doctor for clarification.
  • Five-year rates, by definition, are five years out of date. New therapies are being developed all the time.

The Concepts of Survival, Cure and Remission

Survival is an all-encompassing term that includes those who are cured, those in remission, those who have relapsed and those still in active treatment. It would be unwise to relate the term “survival” with being cured. When it comes to cancer, nothing is that simple. In cancer, “cure” means that there are no traces of your cancer after treatment. Remission means that the signs and symptoms of cancer are reduced. Remission can be partial or complete. Complete means no signs of the cancer remain. Relapse means the symptoms have returned. 

With cancer there is always the chance that some cancerous cells are still there, undetected. There are also the underlying risk factors to consider. If nothing has changed, the chance for the cancer to return is still high. Even though the medical community considers many cancers “cured” if there are no symptoms after five years, it is still possible for the cancer to come back.  In cancer it should always be remembered that survival means alive, not disease-free.

Image result for bad medical newsThe Final Words on Prognosis

Not everyone can handle bad news. A prognosis can just be too intimidating, frightening or impersonal for some of your residents. If the patient doesn’t want to know the prognosis, you have to respect that. But, as the patient’s advocate and frontline caregiver, you should know as much as you can. If there is an issue with the resident not wanting to know the prognosis, I recommend getting a copy of the prognosis for your files. The information is just too important and its impact on your caregiving too great for you to not have it. Use the prognosis with skill and tact to ease the patient into what must be done in the future. 

 

Caregiving in Cancer

Cancer can happen anywhere in the body to any cell type. With that much variability, patient care in cancer becomes too broad a subject to cover in any one lesson in depth. There are, after all, entire books and college degrees dedicated to caring for cancer victims. If you are employed in a care home and have a resident with cancer, your caregiving duties will multiply in complexity and effort. In the beginning, almost nothing will change in your caregiving routine. But as the cancer progresses or the therapy gets more aggressive, no one caregiver can handle it all. You will become part of a team effort. The emphasis of your role will shift more towards being the patient’s advocate as well as the primary caregiver. Even with help, if the cancer progresses, there will be a point where cancer caregiving will be beyond what you can supply in an adult foster care home. So, my advice is, get a feel for the overall process, know where and how to get help, and know when to say, “That’s enough for me.”  The rest of this article will be written with that in mind. If you want more detailed training on cancer care specifics, then get the book or take the course. 

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Cancer Treatments

The ultimate goal of all cancer treatments is either killing off the cancerous cells or physically removing them from the body. There are several options open to the doctor, which include surgery, medical lasers, radiation, chemotherapy, immunotherapy and alternative therapy. Often the therapies chosen will change over the course of treatment and end up being a combination of several of the following options.

  • Surgery – Cutting out the cancer is the treatment of choice if the cancer is solid and isolated. In cancer’s early stages the doctor will try to remove the entire tumor during the diagnosis/biopsy procedure. If the cancer is too advanced or it’s impractical to remove it all, surgery still might be done to reduce the cancer’s mass, thus reducing the symptoms burden and increasing the comfort of the patient.
  • Medical lasers – High-intensity light devices known as lasers are used to shrink or destroy cancerous and precancerous tumors. They are most effective on surface cancers even if that surface is on an internal organ within the body. Lasers are more precise than surgery and have fewer side effects, but it takes special training and equipment. Of course, this makes laser therapy harder to find and more expensive.
  • Radiation – Ionizing radiation is used to reach into a cancer cell and disrupt the very atoms holding it together. If you disrupt enough of the atoms, especially its DNA, the cell will die. Unfortunately, what kills cancer cells will also harm healthy cells, including starting a secondary cancer. Radiation therapy must be very precise and specific.
  • Chemotherapy – Known as chemo for short, this is a collection of powerful chemicals that are used to make cells die. Traditionally this was a nonspecific therapy used to target cells that divide rapidly. It was hoped that it would kill all of the rapidly multiplying cancer cells before significantly harming the rest of the body. Recently there has been the development of more directed therapy that targets unique cancer-related functions. For example, chemicals that just block the estrogen receptors in breast cells.
  • Immunotherapy – The body has the ability to kill off cancer cells by itself. Immunotherapy is designed to support and enhance this ability. It is a relatively new science with new therapies in development, including stimulating the immune system and supplementing the immune system from outside sources.
  • Alternative therapy – There is more than one system of treating patients. Alternative therapy includes therapies traditionally not used in Western-style medicine. Since these therapies typically are not extensively studied, their use is dependent on the experience of the practitioner. Alternative therapy means therapies that are used instead of conventional methods and this route is quite controversial. What is gaining in popularity is the use of these therapies as add-on treatments. This has been referred to as complementary therapy.

 

Cancer Management

The underlying goal of cancer management is managing the patient, not the disease. It involves how the cancer reacts to the treatments and how the patient reacts to the treatments and the cancer. It’s a blend of medical treatment, symptom relief, side-effect management, emotional support, financial considerations, caregiving, and the choices the patient and their family have to make along the way. Cancer management is a team effort. As the primary caregiver and patient advocate, the process of cancer management is something the adult foster care provider should be deeply involved in. It’s going to take the caregiver being assertive enough to be included on the team.

 

Patient’s Reaction

It all starts with the patient’s reaction to the cancer diagnosis. There is going to be an emotional roller coaster as the patient tries to cope with the consequences of cancer. The resident and their family have much to contemplate and many decisions to make. There will be many questions. Help the resident find the answers. Be patient, positive, and professional. Help find the resources that they will need, including the will to keep going when times get tough. Speaking of getting tough, there might be times when therapy side effects are difficult to handle. Every caregiving fiber of your body will want to back off the therapy. You think you are being kind but in cancer you are literally killing them with your kindness. Stick to the therapies and help the resident to cope. 

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Grief and Coping

Grief will be a major component in their initial reaction. To help with the grief I suggest the work of David Kessler and Elisabeth -Ross and Grief.com. They describe the five stages of grieving. I quote Mr. Kessler’s website.

  1. DENIAL – Denial is the first of the five stages of grief. It helps us to survive the loss. In this stage, the world becomes meaningless and overwhelming. Life makes no sense. We are in a state of shock and denial. We go numb. We wonder how we can go on, if we can go on, why we should go on. We try to find a way to simply get through each day. Denial and shock help us to cope and make survival possible. Denial helps us to pace our feelings of grief. There is a grace in denial. It is nature’s way of letting in only as much as we can handle. As you accept the reality of the loss and start to ask yourself questions, you are unknowingly beginning the healing process. You are becoming stronger, and the denial is beginning to fade. But as you proceed, all the feelings you were denying begin to surface.
  2. ANGER – Anger is a necessary stage of the healing process. Be willing to feel your anger, even though it may seem endless. The more you truly feel it, the more it will begin to dissipate and the more you will heal. There are many other emotions under the anger and you will get to them in time, but anger is the emotion we are most used to managing. The truth is that anger has no limits. It can extend not only to your friends, the doctors, your family, yourself and your loved one who died, but also to God. You may ask, “Where is God in this? Underneath anger is pain, your pain. It is natural to feel deserted and abandoned, but we live in a society that fears anger. Anger is strength and it can be an anchor, giving temporary structure to the nothingness of loss. At first grief feels like being lost at sea: no connection to anything. Then you get angry at someone, maybe a person who didn’t attend the funeral, maybe a person who isn’t around, maybe a person who is different now that your loved one has died. Suddenly you have a structure—your anger toward them. The anger becomes a bridge over the open sea, a connection from you to them. It is something to hold onto; and a connection made from the strength of anger feels better than nothing. We usually know more about suppressing anger than feeling it. The anger is just another indication of the intensity of your love.
  3. BARGAINING – Before a loss, it seems like you will do anything if only your loved one would be spared. “Please God,” you bargain, “I will never be angry at my wife again if you’ll just let her live.” After a loss, bargaining may take the form of a temporary truce. “What if I devote the rest of my life to helping others. Then can I wake up and realize this has all been a bad dream?” We become lost in a maze of “If only…” or “What if…” statements. We want life returned to what is was; we want our loved one restored. We want to go back in time: find the tumor sooner, recognize the illness more quickly, stop the accident from happening…if only, if only, if only. Guilt is often bargaining’s companion. The “if onlys” cause us to find fault in ourselves and what we “think” we could have done differently. We may even bargain with the pain. We will do anything not to feel the pain of this loss. We remain in the past, trying to negotiate our way out of the hurt. People often think of the stages as lasting weeks or months. They forget that the stages are responses to feelings that can last for minutes or hours as we flip in and out of one and then another. We do not enter and leave each individual stage in a linear fashion. We may feel one, then another and back again to the first one.
  4. DEPRESSION – After bargaining, our attention moves squarely into the present. Empty feelings present themselves, and grief enters our lives on a deeper level, deeper than we ever imagined. This depressive stage feels as though it will last forever. It’s important to understand that this depression is not a sign of mental illness. It is the appropriate response to a great loss. We withdraw from life, left in a fog of intense sadness, wondering, perhaps, if there is any point in going on alone? Why go on at all? Depression after a loss is too often seen as unnatural: a state to be fixed, something to snap out of. The first question to ask yourself is whether or not the situation you’re in is actually depressing. The loss of a loved one is a very depressing situation, and depression is a normal and appropriate response. To not experience depression after a loved one dies would be unusual. When a loss fully settles in your soul, the realization that your loved one didn’t get better this time and is not coming back is understandably depressing. If grief is a process of healing, then depression is one of the many necessary steps along the way.
  5. ACCEPTANCE – Acceptance is often confused with the notion of being “all right” or “OK” with what has happened. This is not the case. Most people don’t ever feel OK or all right about the loss of a loved one. This stage is about accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality. We will never like this reality or make it OK, but eventually we accept it. We learn to live with it. It is the new norm with which we must learn to live. We must try to live now in a world where our loved one is missing. In resisting this new norm, at first many people want to maintain life as it was before a loved one died. In time, through bits and pieces of acceptance, however, we see that we cannot maintain the past intact. It has been forever changed and we must readjust. We must learn to reorganize roles, re-assign them to others or take them on ourselves. Finding acceptance may be just having more good days than bad ones. As we begin to live again and enjoy our life, we often feel that in doing so, we are betraying our loved one. We can never replace what has been lost, but we can make new connections, new meaningful relationships, new inter-dependencies. Instead of denying our feelings, we listen to our needs; we move, we change, we grow, we evolve. We may start to reach out to others and become involved in their lives. We invest in our friendships and in our relationship with ourselves. We begin to live again, but we cannot do so until we have given grief its time.

Source https://grief.com/the-five-stages-of-grief/

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Cancer Patient Care

Caring for the cancer patient consists of two general categories: Curing the cancer and supporting the patient. Curing the cancer could involve one or more of the previously discussed therapies. Caregivers should obtain a copy of the doctor’s care plan, or at least detailed instructions of what is expected of the caregiver. Be prepared to push for skilled nursing help to manage what will be required or a nurse to train and delegate tasks that must be done. It may seem overwhelming to the primary caregiver. Fortunately, you are not alone. There will be plenty of help from a whole team of medical professionals. I suggest keeping records of medical appointments, test results, medications and dosages, symptoms and side effects, and the names and telephone numbers for resources. Keep it in the resident’s file and show it to those who need to see the details. That includes the resident and their family, when appropriate.

Supporting the patient is called palliative care. It primarily involves monitoring the patient and managing their comfort levels. Basically, it’s all about maintaining normalcy or as close to normal as conditions permit. Fortunately for the resident with cancer it’s what adult foster care providers do best. We are specialists when it comes to maintaining a homelike environment for our residents. I am confident that your regular care routines will be adequate if you are prepared to handle the complications that may arise from both from the cancer and its therapy. A complete list of side effects and complications is impractical but here is a list of common ones:Image result for side effects

  • Fatigue
  • Anemia
  • Loss of appetite
  • Insomnia
  • Hair loss (mainly caused by treatments)
  • Nausea (which can be very severe)
  • Lymphedema
  • Pain
  • Immune system depression
  • Weight loss

 

The methods involved in providing supportive care will dependent on the resources and skilled help that is available to you. Remember the adult foster care standard of monitoring for unusual behaviors and complaints, then communicating them to the doctor, pharmacist, or home health nurse. Watch for changes in your PRN logs to help catch subtle changes over time. Here are a few other caregiver tools that might help:

  1. The American Cancer Society publishes some very comprehensive reports under the title “Track Your Side Effects During Cancer Treatment” at: https://www.cancer.org/treatment/treatments-and-side-effects/tools-to-monitor-treatment.html
  2. The American Cancer Society also publishes a Pain Diary, which could be very useful in pain management. It is found on the same page as above.
  3. I have a three-lesson course on pain management. I call it “Pain School.”
  4. There are advocacy groups for just about every type of cancer that there is. You can connect with them with a few easy Internet searches. Just type in the search field the name of the cancer and the term “support group” or “advocacy group.” For example, “bladder cancer support group.”
  5. Remember to utilize the support you get from the pharmacy. They are usually easier to get ahold of than the doctor. Some pharmacists specialize in cancer care.
  6. There are research groups that conduct clinical trials on new medications and therapies. Contact your doctor to get involved in one or conduct your own Internet search. Cancer.net has a list of them here: https://www.cancer.net/research-and-advocacy/clinical-trials/finding-clinical-trial

 

Long-Term Side Effects

If a case of cancer has been severe or the treatment particularly powerful, complications may arise months or even years after therapy has been discontinued. There is also the chance of secondary cancer developing. The caregiver should remain vigilant to unusual occurrences and report them to the doctor. After treatment ends you might ask the doctor if additional screening tests will be required. Those tests could include thyroid tests, lung functions tests, blood counts, electrocardiograms (EKGs), mammograms, x-rays and computed tomography (CT) scans.

 

Survivorship
A patient who has had cancer is often called a cancer survivor. Those who go through this trial are changed by it. Emotions, relationships, perspectives, and attitudes can be altered. Some may even experience survival guilt. As the therapies are discontinued, the patient is faced with trying to get their life back to normal. Relief and/or anxiety may increase as attention from the care team is reduced. Cares, concerns, and fears may linger for years to come. The caregiver should be prepared to help the cancer survivor resident cope with the changes and emotions that cancer survivorship may produce.

Survival statistics:

The number of people who have had cancer has gone up greatly over the last 45 years in the United States. In 1971, there were 3 million people with cancer. Today there are more than 15.5 million.

  • About 67 percent of today’s cancer survivors were diagnosed five or more years ago.
  • About 17 percent of all cancer survivors were diagnosed 20 or more years ago.
  • Nearly half (47 percent) of survivors are age 70 or older.

Source: https://www.cancer.net/survivorship/what-survivorship

 

When Efforts Fail

Every patient has the right to choose not to be treated for cancer. It’s hard on the caregiver but the resident has the right to refuse treatment. In my opinion it’s okay for the caregiver to question that decision. Emotions and fears can run high and cloud the resident’s judgement. The caregiver can offer education to relieve fears and offer counsel to provide proper perspective. I think it’s okay to raise objections, just as long as the resident has the final say in the matter. Respecting the resident’s right to die is part of the job. There is also the case of treatment failure. The patient may want to live but the cancer may be beyond therapy. So, what do you do when lifesaving efforts fail? The answer is that treatments may fail, or patients may refuse them, but caregiving never stops. It just switches to different goals.

When death becomes inevitable, whether by choice or treatment failure, there will be added duties to perform. Caregiving may continue but provisions must be made for making the patient comfortable and saying their farewells. The Adult Foster Care provider is in a powerful position to provide meaningful support at this end-of-life time. Not only will you find yourself giving aid and comfort, but you will also be a friend, counselor, and facilitator to both resident and family. This time of greatest need can also be a time of your greatest fulfillment as a caregiver. This being said, it is also a time of decision for the adult foster care home. Should the resident stay or move on? There are perfectly good business decisions to move a heavy care resident out. Before that choice is made, you must know that there is plenty of help available to the caregiver.

Hospice

Hospice is a philosophy and type of care that no longer tries to cure but focuses on the comfort of the patient. In the United States, Medicare and other insurers pay for end-of-life care when there is a prognosis of less than six months to live. That time frame can be extended as long as the doctor can certify a terminal diagnosis. Hospice care comprises a team of specialists that includes a hospice doctor who leads the team, nurses, respite caregivers, pharmacist, counselors, therapists, and volunteers.  Usually the hospice team is employed by a hospice provider company. The patient has the right to change that company every review period.

The impact that hospice has on adult foster care is that there is always free help available 24 hours a day, seven days a week, but goals of therapy will be changed. Medical decisions will be made by the hospice doctor. He or she will concentrate on the patient’s comfort. There will no longer be any effort to cure the patient. Other therapies unrelated to the cancer may also be discontinued. The transition may be frustrating for the caregiver and challenging for the patient. No one likes change, especially the elderly and cognitively impaired. It will help to keep the channels of communication open.

When death is near, certain physiological changes will occur. Appetite and thirst will drastically reduce. Mucus may build up. Profound weakness may occur. Confusion may appear and the ability to mentally function may be reduced. Bodily functions may start to shut down. Keep calm and peaceful during this time. Move the resident’s position every few hours. Keep in mind the needs of the family during this time. It’s okay to rely heavily on the hospice care team.

 

Terminology

  • Oncology – study of tumors
  • Oncologist – cancer specialist
  • Malignant – a tumor that invades and spreads (metastasize)
  • Benign – tumors that don’t spread or cause harmful effects
  • Tumor – mass of cells that abnormally multiply
  • Carcinoma – the most common form of cancer
  • Sarcoma – a rare form of cancer in the supportive and connective tissue
  • Tumor biopsy – tumor tissue sample
  • Well differentiated – tumors that still look like the original source tissue. They generally have a good clinical outcome
  • Poorly differentiated – tumors that have a more primitive structure and may not resemble its original tissue. They generally have a poorer outcome
  • Tumor markers – substances produced by tumors or the body's response to the presence of a tumor
  • Prostate specific antigen (PSA) – tumor marker for prostate cancer
  • Ablate (ablation) – to remove or destroy the function of an organ or body tissue
  • Myelosuppression – side effect of chemo where rapidly dividing bone marrow cells is killed off
  • Remission – period of holding the cancer in check
  • Relapse – reoccurrence of cancer
  • Resect – to cut and remove a segment of an organ containing a tumor
  • Alopecia – hair loss
  • Apoptosis – programmed cell death
  • Debulk – surgically reducing the volume or amount of cancer
  • Mastectomy – surgery to remove all or part of the breast and sometimes other tissue
  • Refractory – no longer responsive to treatment

 

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Conclusion

Cancer will always be an emotionally charged, sensationally driven topic. Tragedy sells and there are few bigger attention-grabbers than cancer. Hopefully the basic info given in this course has enlightened you and cut through all that clutter. Yes, people die from cancer. It is equally true that more people are becoming cancer survivors. With ongoing research, informed caregivers, and educated patients, survivorship continues to grow year after year. Knowledge will always trump fear.

 

As always, good luck in your caregiving efforts

Mark Parkinson BSPharm

 

References:

What Is Cancer? National Cancer Institute. NIH   https://www.cancer.gov/about-ancer/understanding/what-is-cancer
Cancer. Wikipedia.  https://en.wikipedia.org/wiki/Cancer

Charles Patrick Davis, MD, PhD, Cancer. MedicineNet. WedMD. 8/9/2016.  https://www.medicinenet.com/cancer/article.htm#what_is_cancer

Cancer Basics, What Is Cancer? American Cancer Society. 2018. https://www.cancer.org/cancer/cancer-basics/what-is-cancer.html

Understanding Cancer: Metastasis, Stages of Cancer, and More. MedicineNet. WedMD. https://www.medicinenet.com/cancer_101_pictures_slideshow/article.htm

Carcinogenesis. Wikipedia. https://en.wikipedia.org/wiki/Carcinogenesis

Epigenetics. Wikipedia.  https://en.wikipedia.org/wiki/Epigenetics

One Cause to Cure. Cancer Research Institute. https://www.cancerresearch.org

Medical Terminology: Cancer. Quizlet.  https://quizlet.com/64594534/medical-terminology-cancer-flash-cards/

List of Cancer Types. Wikipedia. https://en.wikipedia.org/wiki/List_of_cancer_types

Stages of Cancer. Cancer.net. American Society of Clinical Oncology.         . https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/stages-cancer

Keith Mulvihill. 9 Surprising Sources of Radiation in Your Home. ThisOldHouse.com https://www.thisoldhouse.com/ideas/9-surprising-sources-radiation-your-home

What Is Breast Cancer Screening? Centers for Disease Control and Prevention. 2018. https://www.cdc.gov/cancer/breast/basic_info/screening.htm

What Should I Know About Screening? Centers for Disease Control and Prevention. 2018.  https://www.cdc.gov/cancer/cervical/basic_info/screening.htm

Understanding Cancer Prognosis. National Cancer Institute, NIH. 2018.  https://www.cancer.gov/about-cancer/diagnosis-staging/prognosis

Prognosis and Cancer Statistics: Questions and Answers. Everydayhealth.com. 2008. https://www.everydayhealth.com/cancer/understanding/prognosis-and-cancer-statistics.aspx

Understanding Statistics Used to Guide Prognosis and Evaluate Treatment. Cancer.net. American Society of Clinical Oncology.  https://www.cancer.net/navigating-cancer-care/cancer-basics/understanding-statistics-used-guide-prognosis-and-evaluate-treatment

Tumor Grade. National Cancer Institute, NIH. 2018 https://www.cancer.gov/about-cancer/diagnosis-staging/prognosis/tumor-grade-fact-sheet

 

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Antacids- Awareness and Appreciation

Author: Mark Parkinson BSPharm:  President  AFC-CE

Credit Hours 1- Approximate time required: 60 min.

 

Educational Goal:

Increase Adult Foster Care providers awareness of antacid drug class.

Educational Objectives:

Inform about the history of popular antacids.

Define the basic chemistry of gastric acid and pH.

Explain how antacids work.

List the side effect profile of antacids and what to monitor for.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

Antacids- Awareness and Appreciation

Antacid is one of those medicines that we all have seen on store shelves, on TV advertisements, and in our medicine cabinets all our lives. We see antacids so often we take for granted their use and understanding. Little do we appreciate the chemistry behind these wonderful remedies, and we are unaware of what they really do for us. So, let us now contemplate antacids.

Antacids are among the oldest known medical treatments in human history. There are records of antacids in ancient Sumerian texts written on clay tablets that date back 3500 years before Christ. They used a combination of milk, peppermint, and a material they found in plant ash. Today we call it sodium bicarbonate. Over the following centuries other materials were gradually added to the cures for upset stomachs. Their development was mainly a case of accidental discovery or trial and error. It was not until the development of the modern science of chemistry that we understood why these substances worked. After the basic principles were discovered, the full range of products we now call antacids were created.

 

The History of Milk of Magnesia.

In 1829 James Murray, an Irish doctor, used a magnesia solution to treat the stomach pain of a prominent local official. It worked so well that he was named resident physician of Anglesey and subsequently knighted for his work. After his death an English pharmacist, Charles Henry Phillips, created a set formula for the suspension of magnesia in 1873. He called it Phillips Milk of Magnesia.

 

The Basic Principles- Anatomy and Physiology

GI Tract

To understand the basic principles of antacids we must first consider how the gastrointestinal (GI) tract works. The GI tract is a system that takes in food, digests it by breaking it apart both physically and chemically, absorbs the nutrients, and expels what is left over as waste. It essentially is a tube that goes through the body which is closed off at various sections. In each section a different set of actions and reactions occur that processes the food we eat. For the purposes of this CE we will mainly concentrate on the acidity and alkalinity functions of the digestive systems.

Acid and Bases

An acid is any chemical that is capable of donating a hydrogen ion (proton or H+) in a chemical reaction. The higher the concentration of these hydrogen ions in a solution, the more acidic it is. Acidity is measured using the pH scale. The pH scale ranges from 0 to 14. The lower the number, the higher the acidity is, which is kind of counterintuitive. It’s a complex logarithm calculation math thing, so we won’t go into it. Hydrogen ions are very reactive with other substances. They can disrupt the chemical bonds that hold molecules together. This comes in very handy when we need to chemically break down the foods we eat.

A base (also known as an alkaline or caustic) is any chemical that is capable of donating a hydroxide ion (-OH). The higher the concentration of the hydroxide ion, the more caustic it is. On the pH scale acidic is 0–7 and alkaline is 7–14. The higher the pH, the more basic it is. It’s that logarithm math thing again. The hydroxide ion is about as reactive as an acid is, so our body also uses it to dissolve the food we eat.

You will notice that if you put an acid (H+) and a base (-OH) together you get HOH or H2O, water. Commonly we call the type of chemical reaction a neutralization (it’s that pesky but useful pH logarithm thing again). pH 7 is considered neutral. Neutralization is how the body controls the pH level of the food slurry solution as it passes through the gut.

 

The History of Pepto-Bismol

Bismuth salts have been used for medical purposes since the 1700s. In around 1900 a New York doctor started to sell a suspension of bismuth salts and called it Bismosal: Mixture Cholera Infantum. It was later renamed by the Norwich Eaton pharmaceutical company to Pepto-Bismol. In 1982 Norwich Eaton was bought by Proctor & Gamble.

 

pH and the GI Tract

It takes a lot of effort to break down the food we eat. We rely heavily on the acids and bases to do the job for us. The juices in our stomach are called stomach acid for a reason. Stomach acid measures on the pH scale at about 1–2 pH, the same as battery acid. As the food slurry passes into the intestine the body starts to neutralize it. The small intestine measures about pH4–5 and the large intestine ends with about pH7. A pH of 1–2 is very, very strong. It can dissolve just about everything we eat, kill most bacteria and other microscopic critters, and it can even eat through metal.

So why doesn’t the acid eat through our GI tract? The stomach has layer upon layer of protection. There are thick mucus layers; under that there is a layer loaded with more alkaline material ready to neutralize the acid, and stomach cells are among the fastest reproducers in our body. To top it off, each end of the stomach is closed off by strong sphincter muscles that keep the acid in the stomach. The intestine has similar defenses plus cells and organs that pump alkaline material in to neutralize the acid. The throat and esophagus have some protection too, but they rely mostly on the upper stomach sphincter for protection. Finally, the body controls the quantity of acidic material, keeping the volume low when there is no food to digest.

pH and the Symptoms We Feel

As just about everyone has experienced, sometimes our acid protection fails us. If the stomach acid leaks out through the upper sphincter we call that heartburn; if it occurs on a continual basis, we call that gastroesophageal disease (GERD). If the acid builds up in our stomach or small intestine and starts to cause problems, we call that a stomachache. If the acid makes it past the mucus layers and starts to eat a hole in our guts lining, we call

that an ulcer. Stomach acid may not be the only thing causing the symptoms, but it is certainly a major factor.

 

The History of Alka-Seltzer

Alka-Seltzer was produced by Miles Laboratories in 1931. It contains aspirin, sodium bicarbonate, and anhydrous citric acid. When added to water the bicarbonate and citric acid undergoes a chemical reaction with the water that creates the effervescent bubbles. Alka-Seltzer’s popularity is due in large part to its clever advertising and product effectiveness. Who can forget the slogan “pop pop fizz fizz, oh what a relief it is,” or “I can’t believe I ate the whole thing.”

 

The Basic Principle – The Chemistry of Relief

Medical research has discovered that many of the common symptoms that afflict patients are related to the simple acid-base chemical reaction. Several enterprising entrepreneurs thought that they could utilize the chemical mechanisms and created new products that could be used to relieve the acid-created problems. Even old tried-and-true stomach remedies were looked at with a greater understanding. The basic principle behind all of this medical activity was acid neutralization. Eventually all those products were combined under the drug category of antacids, or just antacids. Today there is a long list of approved antacid products. All of them utilize the same basic chemistry of relief.

 

Table: Basic Antacids

Antacid

Formula(1)

 

Neutralizing

Power

Unwanted Effects

Sodium Bicarbonate

NaHCO3

low

Fluid retention, Alkalosis

Magnesium Hydroxide

Mg(OH)2

high

Diarrhea, Magnesium toxicity

Aluminum Hydroxide

Al(OH)3

modest

Constipation, Drug or phosphate binding (inhibits absorption)

Calcium Carbonate

CaCO3

very high

Acid rebound

(1) Al= aluminum; Mg = magnesium; Ca = calcium; Na = sodium

Source https://www.iffgd.org/diet-treatments/antacids.html?showall=&start=0

 

Some Special Notes About Antacids -

  1. If sodium bicarbonate sounds familiar to you, it is. It’s part of every kitchen and many common food recipes. You probably know it as baking soda. Baking soda mixed in a drink has been a home remedy for decades. It is also an important ingredient in soda crackers, which explains why they are used so often to relieve an upset stomach.
  2. Antacids also inhibit the enzyme pepsin, which helps in the breakdown of proteins. Pepsin is also thought to contribute to indigestion problems.

 

The Pharmacology of Antacids

So far, we have discussed why antacids work. Now let’s get into some details on how they work. This section will be the most important to caregivers. They need to know what to expect from the antacids they dispense and what to watch out for. I am also going to pass on a few pharmacist tricks on how to make the medication more effective and easier to use.

Antacids vs. Time

The neutralizing effect of antacids works almost immediately when they come into contact with gastric acids. Unfortunately, since they don’t dissolve well in liquids, some of the chunks of the antacid never mix with the stomach acid. The longer it takes to dissolve completely, the longer it takes the antacid to work. In my experience products that are easier to swallow whole, like soft chews, gummy tablets, or some tablets, take longer to work.

Tablet vs. Suspension

Antacids work the best when they are ground up. The finer the grind, the greater the surface area that is available to interact with the gastric acid. That is why suspensions work faster and more potently than tablets. If tablets are used, make sure that they are chewed completely before swallowing. If needed, the caregiver could grind up and dissolve the tablet in a flavored drink before giving the antacid to the resident. If the flavor or texture bothers the resident, try hiding it in applesauce or chocolate pudding. The applesauce can hide the texture and the chocolate flavor usually can hide any other unappealing flavor.

Antacid vs. Food

Antacids are short-term measures; their effect is only temporary. Either all the antacid material is used up neutralizing the acid, or it passes through the stomach too quickly. One way for the caregiver to make antacids work for longer periods of time is to give it with food. Antacids given by themselves usually last about an hour. If you give them with food, movement through the stomach naturally slows down for digestion purposes. The antacid effect can be stretched out for up to three hours. Caregivers should know that the acids in highly acidic foods like orange juice and spicy foods will use up some of the neutralizing power of the antacid and waste some of its effect.

 

The History of Rolaids and Tums

Two popular antacid tablets whose active ingredient is calcium carbonate are Tums and Rolaids. Tums was invented in 1928 by the pharmacist James

Harvey in the basement of his St. Louis, MO, home. He originally made it to treat his wife’s indigestion. Rolaids was invented by American chemist Irvine W. Grote in the late 1920s in Chattanooga, TN. At first Rolaids had no flavoring, which made it very chalky-tasting. Later, a variety of flavors were added.

 

Antacid vs. Side Effect

Antacids are usually considered safe to use for the general public. As you already know from my other CE courses, there are always potential side effects to monitor for. Side effects from the occasional use of antacids usually go away by themselves. The more often they are used, the greater the chance of more serious effects occurring. Caregivers should be extra vigilant when new medications are started and when unusual occurrences crop up in long-term usage of antacids.

  • Magnesium-containing products cause diarrhea. Milk of Magnesia is usually given for this effect.
  • Aluminum-containing products cause constipation. Antacid manufacturers have added aluminum and magnesium together to offset each other’s effect.
  • Calcium also constipates. Caregivers should watch for this effect, especially if calcium supplements are also taken. You can manage this by drinking extra fluids.
  • Sodium bicarbonate creates CO2 gas bubbles when neutralizing acids. Though burping can give a satisfying feeling, bloating and gas pressure can be uncomfortable for some patients. The extra sodium might become a problem with low-sodium diets, weak kidneys, and uncontrolled high blood pressure.
  • Calcium carbonate and, to some extent, all other antacids can cause an acid rebound—an increase of acid production at a later time. It’s a matter of the antacid working too good. The homeostatic mechanisms of the body

will increase gastric acid production if its concentration falls too low. If this becomes a problem, caregivers can try lowering the antacid dose.

  • If large doses of antacids are used often, caregivers should monitor for milk alkali syndrome. Symptoms include headache, nausea, irritability, and weakness. Contact the doctor if this occurs.
  • High doses of aluminum can cause mental problems. It can also drop blood phosphate levels too low, causing muscle weakness, anorexia, and weakened bones. If the resident has osteoporosis or problems with anorexia, the caregiver should request another type of antacid.
  • Antacids should not be given to children under six years of age.
  • The extra minerals in antacids may contribute to certain types of kidney stones.
  • Antacids can interfere with some medications. Consult the drug information leaflets to see if it’s a problem. Here again the occasional antacid use is not a big issue. The more often they are used, the more monitoring is required by the caregiver.

 

Final Caregiver Notes

Antacids are symptom relievers only; they are not cures. If there is a serious underlying issue causing the acid symptoms, then taking an antacid is only hiding the problem. Caregivers should pay attention to the PRN log. If there is a sudden increase or prolonged use, the caregiver should start asking more questions—first to the patient, and then the doctor.

Peppermint naturally relaxes sphincter muscles. It can help move food through the stomach (hence after-dinner mints), which can help reduce stomach acid, but it can also exacerbate GERD problems. Use with skill and caution.

Remember, if foods like peppermint and soda crackers start to become therapy, contact the doctor first.

If the caregiver sees an unusual amount of mental confusion in their residents, check the PRN log for antacid use. If you see a correlation between the two, pass the observation on to the doctor and request blood tests to be done.

 

Conclusion

Antacid use for stomachaches and heartburn has been with us for centuries. When chemistry studies came along, we found out why these remedies worked. Antacids are generally considered safe and effective, but as with all therapies, they must be used with skill and monitoring. Side effects may occur, and more serious problems may be hidden with continued antacid use. Caregivers should always monitor for effect and pay attention to the PRN logs. The entries can give important clues that might be an indication of more serious issues that may be occurring.

 

As always Good Luck in your caregiving efforts.

Mark Parkinson BSPharm

 

References:

Heartburn Treatment. Cleveland Clinic. 08/15/2016.  https://my.clevelandclinic.org/health/treatments/9624-heartburn-treatment

Antacids. Healthline.com. 2018. https://www.healthline.com/health/antacids

  1. Fookes, BPharm. Antacids. Drugs.com. https://www.drugs.com/drug-class/antacids.html

Taking antacids. Medlineplus.com. NIH. https://medlineplus.gov/ency/patientinstructions/000198.htm

The History of Antacid. Kick Node. https://kicknode.com/the-history-of-antacid/

K.Thor Jensen. The Ancient History od Antacids. Geek.com. 7/5/2017.  https://www.geek.com/science/the-ancient-history-of-antacids-1705782/

Annette (Gbemudu) Ogbru, PharmD, MBA. Antacids. Rx List.com. https://www.rxlist.com/antacids/drugs-condition.htm

Antacids. Encyclopaedia Britannica.com. https://www.britannica.com/science/antacid

Antacids. International Foundation for Gastrointestinal Disorders. Sep.4.2015.   https://www.iffgd.org/diet-treatments/antacids.html?showall=&start=0

 

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Influencing Influenza

Author: Mark Parkinson RPh:  President  AFC-CE

Credit Hours 1- Approximate time required: 60 min.

Educational Goal:

Explain what the flu is and why it is important to get a flu vaccination.

Educational Objectives:

Define what influenza is.

Explain about the different types of the flu virus.

List the risk factors and complication of the flu.

Explain why it is important to get a yearly flu shot.

Tell how the flu is managed.

 

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

 

 

Influencing Influenza

 

I recently was driving around town and noticed all the signs plastered around pharmacies about getting a flu shot. It started to make me think. Who should get a flu shot? Why should you get a flu shot? Is the flu that big of deal to warrant a special trip out? I recalled memories from my pre-pharmacy days thinking that the flu was just a cold that just got more annoying? If I being a pharmacist had these thoughts I told myself that it was time to research and write a Continuing Education article on the flu. I intend to provide the answers to the caregivers who might be thinking the same kind of questions.

In quick summary- Yes, it’s worth paying attention to and No it’s just not a more annoying cold. Influenza, commonly shortened to just the “flu”, is a highly contagious illness that disproportionately affects children and the elderly. It can cause mild to severe cases including the deaths of tens of millions of people in the past. Without vaccination it continues to pose a significant health threat to the public in general and to the infirm and children specifically.

 

What is Influenza?

Influenza is a viral infection of the upper respiratory tract. In healthy adults the illness lasts between 1 to 2 weeks. Its initial symptoms appear like the common cold, mainly sneezing, coughing and a running nose. As the infection progresses, more advanced symptoms begin to appear. The advanced signs and symptoms of the flu are; fever over 100.4 F (38 C), aching muscles, chills and sweats, headache, a dry persistent cough, fatigue, weakness, and a sore throat. In those with compromised or under developed immune systems, influenza can lead to the death of the patient. Other infections have similar signs and symptoms. The common cold, pneumonia, bacterial infections and GI tract infection (stomach flu) have all been mistakenly called influenza.

Officially, influenza is only caused by the Orthomyxoviridae RNA virus, of which there are four types- A B C and D. Types A and B cause most of the seasonal epidemic outbreaks. Type C occurs occasionally, and Type D occurs mostly in animals. Type A generally produces the most virulent symptoms. Type B is milder and is seen a lot in in children.

Virus surfaces are covered with glycoproteins that interact with the body. Functionally we call them antigens. Each virus type has variations in these antigens that greatly affect how the virus infects its victims. The two most important ones are the hemagglutinin (H) and neuraminidase (N). The H type enables the virus to enter a cell and the N type promotes the virus spreading to other cells. These antigens stick out of the virus like pins in a pincushion. The body produces antibodies that recognize the antigens so that the immune system can find the virus and fight it off.

 

Unfortunately, the antigens are highly variable. So far, we have identified 18 (H) and 11 (N) types. You might recognize the name H1N1 virus that causes the swine flu. Each year the influenza virus mutates into a new variant and starts to spread. The body needs to produce a new set of antibodies to recognize the new variant before the immune system can be triggered. If the body cannot adapt quickly enough the infection starts to spread uncontrollably. The most dramatic example of this was the Spanish Flu at the end of WWI which caused more than 50 million deaths worldwide.

Because influenza has caused so much death and disease in the past, medical science and governments keeps a close watch on developing variations. They strive to develop vaccinations that stimulate the body to produce the necessary antibodies that recognizes the new mutation variant. When vaccinated patients come in contact with the new strain of the virus the body can recognize it and fight it off more quickly. This explains why it is wise to get a new flu shot each year.

 

Influenza is Highly Contagious

The influenza virus spreads through the community very quickly. It is possible to catch the flu and start spreading the virus to others even before you know you are sick. The virus travels through the air in vapor droplets produced when those who are infected cough or sneeze. New victims catch the disease when they inhale the virus or come in contact with the droplets on common surfaces like telephones, light switches, door knobs or even hands. Once the virus containing droplet is passed to the nose, eye or mouth of the next victim, the virus invades the surface and starts to multiply and spread. Those who start to show the signs of infection remain contagious 5 to 10 days after symptoms appear. Those with weakened immune systems like the elderly and children remain contagious slightly longer.

There are those who are more susceptible to catching the flu than others. You will notice that many risk factors on the following list are commonly found in adult foster care residents.

Risk factors for the flu-

  • Seasonal influenza tends to target young children and older adults.
  • Living or working conditions. People who live or work in facilities along with many other residents, such as nursing homes or military barracks, are more likely to develop influenza.
  • Weakened immune system. Cancer treatments, anti-rejection drugs, corticosteroids and HIV/AIDS can weaken your immune system. This can make it easier for you to catch influenza and may also increase your risk of developing complications.
  • Chronic illnesses. Chronic conditions, such as asthma, diabetes or heart problems, may increase your risk of influenza complications.
  • Pregnant women are more likely to develop influenza complications, particularly in the second and third trimesters. Women who are two weeks postpartum are also more likely to develop influenza-related complications.
  • People with a BMI of 40 or more have an increased risk of complications from the flu.

Source: https://www.mayoclinic.org/diseases-conditions/flu/symptoms-causes/syc-20351719

 

Complications

A healthy individual can fight off the flu infection in 1-2 weeks. For those who are vaccinated that time will be even less. Those who are not healthy or are under a lot of stress will feel the symptoms of the flu to a greater degree and may experience the following complications.

  • Pneumonia
  • Bronchitis
  • Asthma flare-ups
  • Heart problems
  • Ear infections
  • Stomach Problems and Diarrhea

 

Pneumonia is the most serious complication. In Pneumonia the lungs can become inflamed and possibly fill up with mucus, making it hard to breath. If conditions worsen, death can occur. Walking Pneumonia is also of concern. In walking pneumonia, the outward symptoms of the flu are felt less. The victim is unaware that their ability to breath is becoming compromised. In either case, caregivers should be very concerned if breathing starts to be impaired, even if the infection just appears to be a mild cold.

It is very rare for an adult to experience stomach problems or diarrhea with the flu, but it can occur in children. Those who claim to have a “stomach flu” are actually experiencing another kind of aliment. Ear aches are also uncommon in adults but may occur in children. Ear aches can be quite painful and stomach ailments can cause a lot of worry. Many concerned caregivers demand an antibiotic to “cure” the problem. Since most ear aches and “stomach flus” are caused by viruses the antibiotic will do nothing except cost money and created bacterial resistance. They’re are bacterial infections that can mimic the symptoms of the flu. It is very hard for caregivers to tell the difference between viral and bacterial caused infections. Fortunately, there are several tests the doctor can run that can diagnose between the two. I suggest that caregivers concentrate symptom relief and let the doctor worry about the cure.

 

Treating Influenza

The best treatment for the flu is to put effort into not catching it in the first place. Caregivers should practice “universal precautions”. It has been proven to halt the spread of disease. This is particularly important in the fall and winter months which is the height of cold and flu season. It is worth the effort because influenza free residents are easy to take care of residents.

If the flu does enter the home, try to stop its spread by isolating the infection as much as possible. The use of gloves and masks can help. Caregivers should pay attention to potential reservoirs of the virus like toothbrushes, razors, combs and denture cups. Take extra precautions in the cold and flu season. Monitor incoming friends and visitors for signs of infection. There are several cleaners that are labeled “sanitizers” that can kill the flu virus on infected surfaces including Pine Sol, Clorox and Lysol.

 

 

A mixture of 1/4 cup chlorine bleach to 1-gallon hot water will also disinfect. Caregiver could take advantage of the extra hot water of dishwashers and washing machines to clean infected items like dentures and toothbrushes.

 

For healthier adults, treating the flu mainly falls to symptoms relief and making the patient as comfortable as possible. There are several multi-symptom relieving “over the counter” medications that can work quite well. Though, dispensed with skill, single symptom relievers are generally more effective.

As a pharmacist I saw the general notion that if the patient felt better the OTC med “cured” the flu. As you already know that is not the case. This myth can be taken advantage of by caregivers to give comfort to a suffering resident. If the patient thinks they are getting a cure they may become more cooperative. The body will mostly cure itself in 1-2 weeks regardless of what the patient thinks. It really doesn’t matter either way as long as the caregiver is monitoring the resident for the signs of more serious complications that may occur.

For those who are unhealthy or stressed, which are the categories that most adult foster care residents fall under, a yearly flu vaccination is highly recommended. Even the most carefully administered home still exists in a flu ridden world. Caregivers can’t control all the ways that the influenza virus can enter their home. Flu shots are relatively pain free and easily obtained at a clinic, doctor’s office or pharmacy. It’s a good excuse for an outing away from the home for the entire house or individually with family members. Generally, flu shots are free through insurance or very inexpensive. Prescriptions are easily obtained. If family members take the resident to get a shot without a prescription be sure to notify the doctor’s office. I have even heard of instances of home health nurses or clinical pharmacists who review med lists providing vaccinations in your home. It never hurts to ask if such the service is available. If flu shots are impractical there is a more expensive version called Flumist which is inhaled. Flumist is not recommended for persons with egg allergies. As with all medical treatments there is a chance of unwanted sided effects occurring. Pain, itching or inflammation may occur at the injection site.

Allergic reactions are also possible, especially to those with egg allergies. If egg allergies are present, alternative vaccinations can be obtained. Tell those who are giving the shot in advance of the egg allergies or any other previous reactions to flu shots. As with all vaccinations you are trying to fool the immune system into fighting off a supposed infection. The vaccination may produce mild flulike symptoms that should go away by themselves. If they don’t or the symptoms get worse contact the doctor. There are rare reports of suicide ideation in teenagers who are clinically depressed after flu inoculations. Mental health homes should be alert to the possibility.

 

There are antiviral medications that can be used to shorten the course of the infection and decrease the severity of the illness. They are most effect within 48 hours after the start of symptoms, the sooner the better is the rule of thumb.

Over the Counter medications are;

  • Echinacea that can boost the immune system
  • Zinc lozenges like Cold Eeze prevent the viruses from multiplying
  • Homeopathic remedies have been reported to be effect in flu cases, like Oscillium and Zicam.

Prescription Antiviral medications are;

  • oseltamivir (Tamiflu) capsule or suspension. Monitor for unusual mental behaviors (self-injury and delirium)
  • zanamivir (Relenza) which is inhaled. Watch for milk allergies
  • peramivir (Rapivab) injection. Monitor for unusual mental behaviors

 

Other Important Notes

  • Prescription Antivirals are not approved for preventing (prophylaxis) viral outbreaks but they may be used in that roll if the risk for serious infection is high enough.
  • Despite internet claims there is no evidence that immunization causes autism in children.

 

Conclusion

Influenza is a highly contagious virus cause illness that happens to tens of millions of people each year. Normal it is a self-limiting illness that goes away in about a week. To those who are immunocompromised the flu can cause serious illness, other disease complications and even respiratory failure caused death. Caregivers should ensure those who are at risk get a yearly flu vaccine. They should also be particularly vigilant during flu season in universal precautions and sanitizing cleaning procedures. Care providers play a significant role in protecting their residents from the ravages of influenza.

 

As always Good luck in your caregiving efforts.      Mark Parkinson BSPharm

 

References:

Influenza (flu) Mayoclinic.org. 2018. https://www.mayoclinic.org/diseases-conditions/flu/symptoms-causes/syc-20351719

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season. Centers for Disease Control and Prevention. Recommendations and Reports / August 24, 2018 / 67(3);1–20

https://www.cdc.gov/mmwr/volumes/67/rr/rr6703a1.htm?s_cid=rr6703a1_w

Jeannette Wick, RPh, MBA, FASCP. Questions, Questions, Question: Influenza Takes the Nation by Storm. PowerPak.com. February 27, 2018. UAN: 0430-0000-18-012-H01-P

https://www.powerpak.com/course/preamble/116233

 

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