Saturday, May 24, 2008

Zen and the Art of Coping With Alzheimer's

Zen and the Art of Coping With Alzheimer's

John Eckert holds hands with wife Dorothy, who has Alzheimer's disease, at their home in Norristown, Pa.

Matt Rourke/Associated Press

John Eckert holds hands with wife Dorothy, who has Alzheimer's disease, at their home in Norristown, Pa. The incidence of Alzheimer's will greatly increase in the coming years, experts say.

In Brief:

The number of Alzheimer's patients is expected to increase dramatically in coming years, straining the health care system.

Scientists have not discovered the cause nor devised effective treatments. Even diagnosis is difficult.

In the absence of therapies, attention has turned to teaching the skills necessary to cope with demented patients.

Increasingly caregivers are encouraged to validate the feelings and perceptions of the person with Alzheimer's.

During the YouTube forum with the Democratic presidential candidates in July, the first question about health care came from two middle-age brothers in Iowa, who faced the camera with their elderly mother. Not everybody with Alzheimer’s disease has two loving sons to take care of them, they said, adding that a boom in dementia is expected in the next few decades.

“What are you prepared to do to fight this disease now?” they asked.

The politicians mouthed generalities about health care, larded with poignant anecdotes. None of them answered the question about Alzheimer’s.

Science hasn’t done much better. There is no cure for Alzheimer’s and no way to prevent it. Scientists haven’t even stopped arguing about whether the gunk that builds up in the Alzheimer’s brain is a cause or an effect of the disease. Alzheimer’s is roaring down — a train wreck to come — on societies all over the world.

People in this country spend more than a $1 billion a year on prescription drugs marketed to treat it, but for most patients the pills have only marginal effects, if any, on symptoms and do nothing to stop the underlying disease process that eats away at the brain. Pressed for answers, most researchers say no breakthrough is around the corner, and it could easily be a decade or more before anything comes along that makes a real difference for patients.

Meanwhile, the numbers are staggering: 4.5 million people in the United States have Alzheimer’s, 1 in 10 over 65 and nearly half of those over 85. Taking care of them costs $100 billion a year, and the number of patients is expected to reach 11 million to 16 million by 2050. Experts say the disease will swamp the health system.

It’s already swamping millions of families, who suffer the anguish of seeing a loved one’s mind and personality disintegrate, and who struggle with caregiving and try to postpone the wrenching decision about whether they can keep the patient at home as helplessness increases, incontinence sets in and things are only going to get worse.

Drug companies are placing big bets on Alzheimer’s. Wyeth, for instance, has 23 separate projects aimed at developing new treatments. Hundreds of theories are under study at other companies large and small. Why not? People with Alzheimer’s and their families are so desperate that they will buy any drug that offers even a shred of hope, and many will keep using the drug even if the symptoms don’t get better, because they can easily be convinced that the patient would be even worse off without it.

It is telling, maybe a tacit admission of defeat, that a caregiving industry has sprung up around Alzheimer’s. Books, conferences and Web sites abound — how to deal with the anger, the wandering, the sleeping all day and staying up all night, the person who asks the same question 15 times in 15 minutes, wants to wear the same blouse every day and no longer recognizes her own children or knows what a toilet is for.

The advice is painfully and ironically reminiscent of the 1960s and ’70s, the literal and figurative high point for many of the people who are now coping with demented parents. The theme is, essentially, go with the flow. People with Alzheimer’s aren’t being stubborn or nasty on purpose; they can’t help it. Arguing and correcting will not only not help, but they will ratchet up the hostility level and make things worse. The person with dementia has been transported into a strange, confusing new world and the best other people can do is to try to imagine the view from there and get with the program.

If a patient asks for her mother, for instance, instead of pointing out that her mother has been dead for 40 years, it is better to say something like, “I wish your mother were here, too,” and then maybe redirect the conversation to something else, like what’s for lunch.

If Dad wants to polish off the duck sauce in a Chinese restaurant like it’s a bowl of soup, why not? If Grandma wants to help out by washing the dishes but makes a mess of it, leave her to it and just rewash them later when she’s not looking. Pull out old family pictures to give the patient something to talk about. Learn the art of fragmented, irrational conversation and follow the patient’s lead instead of trying to control the dialogue.

Basically, just tango on. And hope somebody will do the same for you when your time comes. Unless the big breakthrough happens first.

Thursday, May 22, 2008

The New Power Generation

The New Power Generation

Sure, shopping for electronics is no picnic. You drive to a store so large it's visible from space and wander the maze-like aisles until you find what you need. But at least there's a clerk or two there to help you—often poorly informed and commission-motivated, but it's help nonetheless.

Shop for batteries, though, and you're on your own. People usually buy batteries from grocery or drugstore racks. Asking a clerk which battery is best for your digital camera will probably earn you only a glazed look and a shrug.

This lack of information is really too bad, because given the way battery lines have been expanding in recent months consumers could use some direction. Suddenly, each of the big three battery makers—Duracell, Energizer, and Panasonic—is touting long-life batteries tailor-made for electronics.

Do they really perform better? Do they deliver enough extra juice to justify their higher price tags? And are they easy to find at the corner drugstore? With cash in hand, I set out to survey several ­local stores and scoop up their best batteries, then put them to the test during days of sightseeing and shooting on a conveniently timed trip to San Francisco. Once back home, I put them through further paces with an additional high-drain device (a battery-sucking portable television) and a low-drain test using a cheap flashlight.

Bucks for Batteries

First things first: If I was going to test the crème de la crème of long-life batteries, I needed to know what average batteries could do. I picked up some basic Duracell and Energizer alkalines, as well as RadioShack and IKEA store brands.

I bought four-packs of Duracell CopperTops and Energizer Maxes for $3.99 apiece, and I paid $8.99 for a 12-pack of RadioShack's Enercell store-brand double-As. The cheery yellow IKEA batteries seemed an even bigger bargain at $2.99 for a 10-pack (and I've seen them on sale for $2), but I suspected that they wouldn't stand a chance against the forefront of battery technology.

Today's phalanx of new batteries is actually a broad array of new and old tech. One of the three superbatteries I looked at, the Energizer e2 Lithium, has been around since the 1990s but found a real purpose only with today's digital devices. The Duracell PowerPix and Panasonic Oxyride are more recent releases designed to meet the needs of high-drain devices.

Buying the high-performance batteries proved more of a challenge than expected. The first drugstore I tried, a Walgreens, offered a large rack of mostly Duracells that included some of the company's Ultra line but none of its PowerPix batteries. There were no Energizer e2 Lithium or Panasonic Oxyride batteries to be found. Only as I was checking out did I notice the rack of high-performance batteries behind the counter.

That proved the rule in nearly every store. Common alkaline and store-brand batteries were easy to find, but the high-performance batteries were hidden away. In one Rite Aid, alkalines were located in a large, easy-to-spot aisle rack, p­­hoto batteries and a few long-life batteries sat on a countertop display, and the other long-life batteries were hanging on a wall behind the photo counter. That's the first place you'd look, right?

Theft deterrence is likely the reason for the separate racks. PowerPixes cost about $7, and e2 Lithiums are quite pricey—almost $10. Although theft is no doubt a problem, separate racks create another issue: Before deciding which batteries are best for their cameras and remote-control Lamborghinis, customers need to be able to find all the choices. I have a feeling many people buy lower-performing alkalines simply because they can grab them easily on their way to the checkout counter.

Shooting Spree

To put these batteries through their paces in some realistic conditions, I picked up a Kodak Easy-Share C360 and first tested the control batteries around New York City. Having strong batteries is important, I discovered, since they not only determine how many pictures you can take, but they also affect the camera's refresh rate. Nobody wants to lose out on a great shot because the digital camera is still processing the last image. I took most shots without a flash, and because I was shooting rapidly, my numbers are quite a bit higher than the battery companies' claims.

The IKEA batteries fared the worst, with only 209 shots; the Energizer Maxes got 309, Duracell CopperTops 327, and RadioShack Enercells a big 374. Taking that many photos on a pair of double-As might sound like a lot, but it's chump change compared with the powerhouses to come.

Next up were the long-life batteries, which I used while shooting like a crazed tourist on my trip to San Francisco.

First up was the Duracell Ultra, which is simply an alkaline battery created with an improved manufacturing process. Duracell also makes a line called PowerPix, which is recommended for heavy shooters, but I stuck with the Ultra line, which was easier to find, to see what a high-performance alkaline battery could do. The Ultras lasted for 522 pictures (about half a cent per shot), giving me more than enough power to shoot every monument, museum, and arresting view in the downtown area.

My next contestant was the Panasonic Oxyride. The Oxyride is similar to a standard alkaline, but it uses an oxy-nickel hydroxide chemical process to generate more power, and it's made with a vacuum process that also enables more power. It produces a 1.7-volt discharge, rather than the 1.5-volt discharge of typical double-As, and this yielded noticeably shorter camera refresh times. Oxyrides typically cost more than alkaline batteries, but they live up to Panasonic's performance claims. I squeezed 989 shots out of a pair of double-As (that's one-fourth of a cent per shot), which capably carried me through Chinatown and Fisherman's Wharf.

Last up was the heavy hitter, the Energizer e2 Lithium. The e2 is made differently from traditional batteries (see the sidebar) and costs more, so I was curious to see if it would deliver.

I didn't have to wonder for long. The e2 simply didn't stop, taking me through the Haight-Ashbury and every inch of Golden Gate Park, and even into a local dive for a little Sonoma white at the end of the day. In the end, I took 2,676 shots using two e2 batteries (one-fifth of a cent per shot), which makes them the best choice both for skinflints and for people who don't want to change batteries often. But they aren't without flaws. The e2s deliver only 1.3 volts, which causes noticeably slower refresh times. That's a nuisance when you're trying to shoot quickly.

See the digital camera test results.

TV, Timed

With better refresh rates and good value, the Panasonic Oxyride was my favorite for digital photography. I was surprised when it didn't do as well in a second test, powering the biggest battery vampire I could think of: an RCA portable television running off three double-A batteries. The IKEAs worked for 4 hours, the Dura­cell CopperTops for 4 hours 4 minutes, the Energizer Maxes for 4 hours 7 minutes, and the RadioShack Enercells for 4 hours 8 minutes. As for the high-performance batteries, the Duracell Ultras ran for 4 hours 45 minutes and the Energizer e2 batteries for 6 hours 15 minutes, but the Panasonic Oxyrides lasted only 3 hours 40 minutes. That's worse than any of the control batteries. What gives?

Then, just for kicks, I ran a battery test with a low-drain device, a flashlight, and the results were surprising. The low-end batteries all (except the slightly shorter-lasting IKEAs) powered the flashlight for more than 5 hours of constant use, while the high-performance batteries all burned out the flashlight's bulb long before they were drained. The Energizer e2s lasted an hour and a half, the Oxyrides 45 minutes, and the Duracell Ultras a scant 8 minutes. See the Cost Per Hour comparison.

The lesson is simple: Buy the right battery for the job. Long-life batteries deliver too much ­power for low-drain devices. Looks like there's some truth to the marketing hype after all.

Though the overall winner isn't clear-cut, it is clear that long-life batteries designed for digital gear offer good value and convenience—for digital cameras. They're more expensive, but they'll last forever—particularly the Energizer e2. Buying strictly based on cost? If you can find the IKEAs at $2 per 10-pack, don't hesitate to buy. When they're that inexpensive, the cost per shot matches that of the long-life Oxyride, and they outperformed everything else on our extreme TV run-down test, at just 19¢ for an hour of viewing. And one other thing I learned: If you're going to shoot thousands of photos while walking around all day, wear comfortable shoes.

Copyright (c) 2008Ziff Davis Media Inc. All Rights Reserved.

Cost per hour
RCA Portable TV
Batteries needed: 3 AA

Cost - Battery - Life span (hr:mm)
$.60 Panasonic Oxyride 3:40
.19 IKEA 4:00
.74 Duracell CopperTop 4:04
.73 Energizer Max 4:07
.54 RadioShack Enercell 4:08
.94 Duracell Ultra 4:45
2.03 Energizer e2 Lithium 6:15

Ultra Hardware Heavy-Duty Flashlight
Batteries Needed: 2 AA

$18.75 Duracell Ultra 0:08 (Blown blubs throw off price)
3.33 Panasonic Oxyride 0:45 (Blown blubs throw off price)
3.23 Energizer e2 Lithium 1:33 (Blown blubs throw off price)
.15 IKEA 4:04
.36 Energizer Max 5:31
.27 RadioShack Enercell 5:37
.36 Duracell CopperTop 5:45

Digital Camera Tests

Name - Cost per 2 batteries - Number of Shots - Pictures per penny
Duracell CopperTop $2.00 327 1.6
Duracell Ultra $2.50 522 2.0
Energizer e2 Lithium $5.00 2,676 5.4
Energizer Max $2.00 309 1.5
IKEA $0.60 209 3.5
Panasonic Oxyride $2.50 989 4.0
RadioShack Enercell $1.50 374 2.5

Why doctors give out antibiotics you don't need

medical examiner: Health and medicine explained.

The Pink-Bubble-Gum-Flavored Dilemma

Why doctors give out antibiotics you don't need.

An emergency room

While working a busy night shift in the ER recently, I evaluated a 13-month-old girl. On her chart, the triage nurse had written: "Infant with fever and runny nose. Mother here for antibiotics." The baby was fussy but probably more tired than uncomfortable. Between her squirms, she cooed and smiled at me. Her anxious and upset mother, however, was in far worse shape, repeatedly sticking a rubber bulb syringe up her infant's nostrils in a futile attempt to suck out an endless stream of snot. The mom was also really mad: She had been waiting for more than three hours for a doctor to see her daughter. Now she wanted antibiotics: specifically, a prescription for bubble-gum-flavored amoxicillin.

By my assessment, the child was not acutely ill: She'd had a low-grade fever for two days, her mother said, and a mild cough, but she had clear lungs and appeared well-hydrated. Her eardrum may have had some fluid behind it but wasn't red or bulging. Just as the baby was trying to put my stethoscope in her mouth, paramedics pushed through the ambulance doors with a patient who was having an acute stroke. I had to decide right then if I was going to give this mother the antibiotics she wanted, even though I thought her daughter probably didn't need them.

The profligate prescription of antibiotics—for children and adults with upper respiratory infections, sinus infections, and even middle-ear infections—is a problem because most of these illnesses are caused by viruses, not bacteria, which are what conventional antibiotics attack. Of more concern is the direct connection between antibiotic use and the emergence of drug-resistant "superbugs": As the medicine eliminates germs that are sensitive to it, drug-resistant mutant strains prosper. The result is a major public-health problem. Antibiotic-resistant infections such as methicillin-resistant Staphylococcus aureus may cause more deaths in the United States than AIDS does.

In the doctor's office or the ER, it's hard to tell the difference between bacterial and viral infections, and so doctors are tempted to prescribe antibiotics whenever they're unsure. That's especially true when doctors think that patients expect to take the medicine home, according to a recent study. Investigators interviewed patients with respiratory infections who went to the ER in 10 hospitals affiliated with medical schools, asking whether the patients expected to receive antibiotics and about whether they were satisfied with the care they received when they were discharged. The researchers also asked physicians why they prescribed antibiotics. The main conclusion was that doctors were significantly more likely to prescribe if they believed that patients expected them to—but did a lousy job predicting which patients those actually were. And the patients most satisfied with their care were the ones who left the ER with a better understanding of their condition, antibiotics or no antibiotics. The take-home message for doctors like me: Spend an extra five minutes talking to your patients about their medical problems, and you can send them away happy and without unnecessary medicine.

So once doctors absorb the result of this study and similar investigations, will they write fewer prescriptions? I bet not. To give out fewer antibiotics, the doctors will have to believe that their patients won't benefit from them. If you look closely at the ER study, 73 percent of the patients who received antibiotics for acute bronchitis had illnesses that were either deemed by their doctors to have likely been caused by a bacteria or to have origins that were in that gray toss-up area between a bacteria and a virus. If the doctors were right, and these were bacterial infections, they would, in fact, warrant antibiotics. Also, in many of these cases, the doctors gave other persuasive reasons for choosing antibiotics, including "ill appearance of the patient" and "concern about follow-up."

In my ER world, these factors, if intangible, are understood to be really important in helping us decide how to treat patients. The real dilemma of antibiotic prescriptions is that the most serious consequence for writing them unnecessarily is not a risk to the individual patient but the emergence of the superbugs that pose a risk to public health in general.

Nowhere is this tension between individual care and public health greater than in the ER. Office-based cultures for bacterial infections, which take days to turn around, are not feasible in what we call "the trenches." And because follow-up can never be assured, it's hard to follow recommendations such as those of the American Academy of Pediatrics, which advocates "watch and wait" for 48 to 72 hours for children with middle-ear infections rather than an immediate dose of antibiotics. If we overprescribe antibiotics in the ER, that's because in the trenches the care of one patient often trumps the care of the public. Maybe that's myopic, but there you have it. And it is why efforts to reduce antibiotic use by giving out more information about resistant infections or teaching doctors how to manage patient expectations may ultimately fall flat.

In the end, I did not prescribe antibiotics for the 13-month-old baby. Instead, I took the time to explain thoroughly why I didn't think she needed them (while my colleague took care of the stroke patient). But no matter what that study says, that mother left in a huff— highly dissatisfied, I can assure you. I'm not sure what I'll do the next time I see a similar case. Perhaps I will refuse to write the prescription again, notching another victory for public health. But, for all I know, something intangible will be different: Perhaps the kid just won't look right, or maybe the mother or father will seem too disorganized to be relied on to return if the kid worsens. And that may persuade me to send them home with a bottle of pink-bubble-gum-flavored amoxicillin. It's likely that the fussy kid and his parents won't sleep any better that night. But I will.

Zachary Meisel is an assistant professor of emergency medicine at the University of Pennsylvania. His research interests include injury prevention, patient safety, and prehospital care.

Sunday, May 18, 2008

What the heck is a Pinchot Plan?

NOTE: To avoid having to reply to everyone individually, I have created a FAQ regarding the Pinchot Plan.

I've been receiving various emails plugging a "retirement plan" called the Pinchot Plan. If you sign up you could collect thousands of dollars in checks every year, or so the article says. Sound intriguing? Read on.

Who is this mysterious Pinchot and what is this plan? Gifford Bryce Pinchot was born in 1865 and was the first chief of the United States Forest Service, as well as twice being Republican Governor of Pennsylvania.

Pinchot's fame comes from being one of the first people, if not the first, to come up with a method of commercial forestry management that was truly sustainable.