Well: Study Questions Fat and Heart Disease Link

Many of us have long been told that saturated fat, the type found in meat, butter and cheese, causes heart disease. But a large and exhaustive new analysis by a team of international scientists found no evidence that eating saturated fat increased heart attacks and other cardiac events.

The new findings are part of a growing body of research that has challenged the accepted wisdom that saturated fat is inherently bad for you and will continue the debate about what foods are best to eat.

For decades, health officials have urged the public to avoid saturated fat as much as possible, saying it should be replaced with the unsaturated fats in foods like nuts, fish, seeds and vegetable oils.

But the new research, published on Monday in the journal Annals of Internal Medicine, did not find that people who ate higher levels of saturated fat had more heart disease than those who ate less. Nor did it find less disease in those eating higher amounts of unsaturated fat, including monounsaturated fat like olive oil or polyunsaturated fat like corn oil.

"My take on this would be that it's not saturated fat that we should worry about" in our diets, said Dr. Rajiv Chowdhury, the lead author of the new study and a cardiovascular epidemiologist in the department of public health and primary care at Cambridge University.

But Dr. Frank Hu, a professor of nutrition and epidemiology at the Harvard School of Public Health, said the findings should not be taken as "a green light" to eat more steak, butter and other foods rich in saturated fat. He said that looking at individual fats and other nutrient groups in isolation could be misleading, because when people cut down on fats they tend to eat more bread, cold cereal and other refined carbohydrates that can also be bad for cardiovascular health.

"The single macronutrient approach is outdated," said Dr. Hu, who was not involved in the study. "I think future dietary guidelines will put more and more emphasis on real food rather than giving an absolute upper limit or cutoff point for certain macronutrients."

He said people should try to eat foods that are typical of the Mediterranean diet, like nuts, fish, avocado, high-fiber grains and olive oil. A large clinical trial last year, which was not included in the current analysis, found that a Mediterranean diet with more nuts and extra virgin olive oil reduced heart attacks and strokes when compared with a lower fat diet with more starches.

Alice H. Lichtenstein, a nutritional biochemist at Tufts University, agreed that "it would be unfortunate if these results were interpreted to suggest that people can go back to eating butter and cheese with abandon," citing evidence that replacing saturated fat with foods that are high in polyunsaturated fats – instead of simply eating more carbohydrates – reduces cardiovascular risk.

Dr. Lichtenstein, who was not involved in the latest study, was the lead author of the American Heart Association's dietary guidelines, which recommend that people restrict saturated fat to as little as 5 percent of their daily calories, or roughly two tablespoons of butter or two ounces of Cheddar cheese for the typical person eating about 2,000 calories a day. The heart association states that restricting saturated fat and eating more unsaturated fat, beans and vegetables can protect against heart disease by lowering low-density lipoprotein or so-called bad cholesterol.

In the new research, Dr. Chowdhury and his colleagues sought to evaluate the best evidence to date, drawing on nearly 80 studies involving more than a half million people. They looked not only at what people reportedly ate, but at more objective measures such as the composition of fatty acids in their bloodstreams and in their fat tissue. The scientists also reviewed evidence from 27 randomized controlled trials – the gold standard in scientific research – that assessed whether taking polyunsaturated fat supplements like fish oil promoted heart health.

The researchers did find a link between trans fats, the now widely maligned partially hydrogenated oils that had long been added to processed foods, and heart disease. But they found no evidence of dangers from saturated fat, or benefits from other kinds of fats.

The primary reason saturated fat has historically had a bad reputation is that it increases low-density lipoprotein cholesterol, or LDL, the kind that raises the risk for heart attacks. But the relationship between saturated fat and LDL is complex, said Dr. Chowdhury. In addition to raising LDL cholesterol, saturated fat also increases high-density lipoprotein, or HDL, the so-called good cholesterol. And the LDL that it raises is a subtype of big, fluffy particles that are generally benign. Doctors refer to a preponderance of these particles as LDL pattern A.

The smallest and densest form of LDL is more dangerous. These particles are easily oxidized and are more likely to set off inflammation and contribute to the buildup of artery-narrowing plaque. An LDL profile that consists mostly of these particles, known as pattern B, usually coincides with high triglycerides and low levels of HDL, both risk factors for heart attacks and stroke.

The smaller, more artery-clogging particles are increased not by saturated fat, but by sugary foods and an excess of carbohydrates, Dr. Chowdhury said. "It's the high carbohydrate or sugary diet that should be the focus of dietary guidelines," he said. "If anything is driving your low-density lipoproteins in a more adverse way, it's carbohydrates."

While the new research showed no relationship overall between saturated or polyunsaturated fat intake and cardiac events, there are numerous unique fatty acids within these two groups, and there was some indication that they are not all equal.

When the researchers looked at fatty acids in the bloodstream, for example, they found that margaric acid, a saturated fat in milk and dairy products, was associated with lower cardiovascular risk. Two types of omega-3 fatty acids, the polyunsaturated fats found in fish, were also protective. But a number of the omega-6 polyunsaturated fatty acids, commonly found in vegetable oils and processed foods, may pose risks, the findings suggested.

The researchers then looked at data from the randomized trials to see if taking supplements like fish oil produced any cardiovascular benefits. It did not.

But Dr. Chowdhury said there might be a good explanation for this discrepancy. The supplement trials mostly involved people who had pre-existing heart disease or were at high risk of developing it, while the other studies involved generally healthy populations.

So it is possible that the benefits of omega-3 fatty acids lie in preventing heart disease, rather than treating or reversing it. At least two large clinical trials designed to see if this is the case are currently underway.

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Well: A Surgical Procedure’s Risks, Unmentioned

Personal Health

Jane Brody on health and aging.

Many patients assume that, like prescription drugs, surgical procedures and instruments undergo extensive testing and must be government-approved. It's not necessarily so.

Developers, of course, do test new instruments, and practitioners often train with an expert before using them unsupervised to treat patients. And the Food and Drug Administration must confirm an instrument's safety and effectiveness before it can be marketed — but only if the device is deemed significantly different from others already approved.

Surgical techniques, however, are not subject to the stringent approval process that drugs go through. And as with drugs, problems with new procedures may not become apparent until after they have been used many hundreds or thousands of times.

Such is the case with a popular treatment for a very common medical problem: uterine fibroids. The technique, called electric or power morcellation, has widespread appeal for both surgeons and patients. It is used during laparoscopic or robotic-assisted operations that are fast and effective, require only a tiny incision or none at all, and involve less pain, a shorter hospital stay and a quicker recovery. In most cases, these operations are safer than traditional surgery.

As recent reports have shown, however, power morcellation can also cause serious and sometimes life-threatening complications. Experts say that prospective patients are often not told about these risks before consenting to the operation.

The technique involves insertion of a tiny instrument with a rapidly rotating blade, the morcellator, that breaks up the fibroid so that it can be sucked out through the small opening of a laparoscope. But problems can arise months or years later if pieces of tissue escape into the pelvic cavity and seed themselves on other organs.

This problem is all the more serious if the fibroid that was morcellated happens to have contained a hidden cancer. Although the overwhelming majority of fibroids are benign, there is no certain way to tell before their removal if they harbor a cancer, which happens in 1 in 400 to 1 in 1,000 cases.

One such case involves a 41-year-old Bostonian, Dr. Amy J. Reed, an anesthesiologist and a mother of six, who now has a Stage 4 leiomyosarcoma after undergoing uterine morcellation. It is a rare but particularly aggressive uterine cancer. Dr. Reed and her husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon, are waging a campaign through Change.org to halt use of the technique.

Despite several preoperative tests, neither Dr. Reed nor her surgeon suspected that cancer lurked within the fibroids that were removed. If she had had a traditional operation in which the fibroids were cut out or the entire uterus removed intact, it is highly unlikely that the cancer would have spread.

From 1983 through 2010, 13 unexpected uterine sarcomas were reported after uterine surgery on 5,666 patients. Among 1,192 women who underwent morcellation, two developed sarcoma that spread within the abdomen.

After reviewing the medical records of more than 1,000 women who received morcellation for fibroids, specialists at Brigham & Women's Hospital in Boston found a ninefold higher rate of unexpected sarcoma than is now quoted to patients considering the procedure.

"These data suggest uterine morcellation carries a risk of disseminating unexpected malignancy with apparent associated risk of mortality much higher than appreciated currently," the researchers wrote in the journal PLOS One in 2012.

Even benign uterine tissue, when it is spread to other parts of the abdomen during morcellation, can grow in places it doesn't belong and cause pain, infection or bowel obstruction.

There is a technique that could make morcellation safer: encasing the tissue to be removed in a bag before it is broken up. But thus far, the procedure is infrequently used, and few surgeons are skilled in the technique.

Other established ways to treat bothersome fibroids are free of this potential risk, though complications like wound infection are possible.

Fibroids are extremely common, affecting half or more women during their reproductive years, when hormones foster their growth. They develop from the smooth muscle tissue of the uterus, ranging in size from tiny to huge, and often shrink after pregnancy and menopause.

Most women with fibroids are unaware they have them, but others can experience symptoms like prolonged heavy periods, bleeding between periods, pelvic pressure, constipation, frequent urination, backaches and anemia. They can sometimes cause infertility or miscarriage.

Fibroids are typically detected through a pelvic exam, sonogram or M.R.I., sometimes with saline solution or a dye used to better define their size and location.

Nothing needs to be done about a fibroid that causes no distress. Large, bothersome fibroids can often be shrunk by several months of treatment with medications that block estrogen and progesterone, causing temporary menopause and its attendant symptoms.

The "morning after" pill, mifepristone (RU-486), also can shrink fibroids, and Evista may do likewise, but only in postmenopausal women. Sometimes a low-dose oral contraceptive is used to reduce bleeding caused by fibroids without shrinking their size.

Noninvasive ultrasound surgery under M.R.I. guidance can be used to heat and destroy a fibroid without damaging the uterus. A fibroid also can be destroyed by injecting small particles into uterine arteries to cut off its blood supply.

Fibroids can be removed laparoscopically or robotically without damaging the uterus. If the fibroid is contained within the uterus, it can often be removed with surgical instruments inserted through the vagina and cervix. Some fibroids may be destroyed by applying heat or electric current to the uterine lining.

Very large, multiple or deep fibroids may require more traditional surgery, called an abdominal myomectomy, that spares the uterus, or with a hysterectomy, a more serious operation involving removal of the entire uterus, ending a woman's menstrual periods and ability to bear children.

If you are contemplating treatment for symptomatic fibroids, your doctor should answer several important questions before you choose a method:

What is the nature of the problem, and how necessary is it to treat it?

What procedures are known to be effective, and what are the risks and benefits of each?

What is the approach you recommend, and how much experience do you have with it?

What are its possible complications, and how often do they occur?

Without a clear understanding of treatment options, their potential hazards as well as their effectiveness, it is not possible to for you to give informed consent.

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The New Old Age Blog: Mammography’s Limits, Seldom Understood

A sad fact: None of the eight major clinical trials looking at whether regular mammograms reduce a woman's risk of dying from breast cancer has included women over age 75.

Older adults are frequently excluded from trials, a problem for those trying to treat them based on information, not hunches. This helps explain why the United States Preventive Services Task Force says the current evidence is "insufficient" to assess mammography's value for those over age 75, and why the American Geriatrics Society cautions against it for women with limited life expectancies.

Not only may mammograms not help, like any medical procedure, they may also harm. Mammograms can result in false positives that require additional tests, including biopsies, and bring anxiety. The scans may identify small tumors that wouldn't have caused problems for years — or at all, since older women are far more likely to die from other causes.

Yet once a mammogram detects even a non-invasive cancer, "it's very hard to decide not to be treated," said Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. Since most women over age 75 still get mammograms, thousands of them undergo unnecessary surgery, radiation and medication every year.

What women need, she and several colleagues agreed, is a "decision aid," a tool that clarifies a medical procedure and its likely results. Once they understand the pros and cons of mammograms, "women can make better decisions based on realistic information about their risks," she said. Dr. Schonberg, who has investigated breast cancer screening among older women for years, noted that women don't hear much about the cons.

She and her colleagues decided to put together an 11-page pamphlet, written clearly at a sixth-grade reading level. It points out that doctors don't know whether mammograms lower mortality in this age group. (Indeed, there is wide disagreement over whether regular mammograms lower mortality in any age group.) The guide estimates that out of 1,000 women over 75, three of those who get mammograms will die of breast cancer and so will four of those who don't, a tiny difference.

Its charts show that heart disease, other cancers, stroke and dementia are far greater threats to elderly women. It even helps women calculate their life expectancy, to see whether a mammogram is likely to extend their lives.

Then the researchers tried a small pilot study, asking 45 women aged 75 to 89 who'd had a mammogram within two years to use the pamphlet.

Did it help? Maybe. Sort of.

Yes, the information did significantly improve their knowledge, results published in the journal JAMA Internal Medicine show. The women scored higher on a true-false test about the benefits and risks of breast cancer screening after they read the pamphlet than they had beforehand.

Yes, it did lead to more conversations about the decision with primary care doctors: In the five years before this experiment, patient medical records showed, only 11 percent had had such discussions. In the six months after reading the guide, 53 percent did.

And yes, the proportion of this small group who intended to continue screening dropped substantially, especially among those with a calculated life expectancy of nine years or less. In that group, 85 percent had earlier said they intended to get another mammogram; after the guide, 50 percent did. The guide didn't make a significant difference in the group with a longer life expectancy.

Women said they liked the pamphlet and found it useful. Their doctors said so, too.

And yet 60 percent of these older women went ahead and got another mammogram within 15 months, including more than half of those with a lower life expectancy.

It was tough to persuade women to start getting regular mammograms back in the 1970s, when the American Cancer Society and the former first lady Betty Ford began campaigning for annual screening. Decades later, it's tough to get older women to stop. Ditto for other cancer screenings — Pap tests, prostate tests, colonoscopies —among both older men and women.

These decisions involve more than a risk/reward calculation, clearly. When it comes to mammograms, "women go for reassurance, for affirmation of their health," Dr. Schonberg said. Her own studies show that "they felt this was the responsible thing to do," what Dr. Alexia Torke, associate director of the Indiana University Center for Aging Research, has termed "a moral obligation."

Some women don't recognize that there's a decision to be made at all. "Radiologists send you an annual reminder card," Dr. Schonberg said. "You're just told, 'go.'" (The Preventive Services Task Force recommendation is every two years, not annually, up to age 74.)

Still, this remains an individual decision. Women who see the whole picture and decide to continue with mammograms — Medicare pays for one each year — at least have reached an informed decision.

So I hope Dr. Schonberg's pamphlet gets widely circulated. She's about to test it with a much larger sample of about 500 women in Massachusetts and North Carolina, then report her findings.

And then we'll publish a link to the guide here, for anyone to use.

---

Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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Doctor and Patient: Emergency Rooms Are No Place for the Elderly

Doctor and Patient

Dr. Pauline Chen on medical care.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who'd watched him hobble down the building's stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

"Of course, if things get worse before the week's up," I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, "come back here right away."

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man's face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. "Just admit him," she whispered. "It'll cost more, but it's the only way you'll be sure he's getting the right care."

I remembered the nurse's advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.

The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.

But given longstanding trends in American medicine, it's hard to imagine a health care setting more ill suited for the elderly than today's emergency rooms.

Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment's notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.

More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.

But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.

For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.

To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must "geriatricize" their emergency departments.

And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.

Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.

"Older adults aren't the kind of patients people gravitate toward," said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. "There's a reason you don't see the frail, cognitively and functionally impaired older patient on television medical shows."

Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual's experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.

"We can really become partners in improving care, instead of just putting a Band-Aid on the problem," Dr. Hwang said. "We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them."

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Well: To Keep Teenagers Alert, Schools Let Them Sleep In

COLUMBIA, Mo. – Jilly Dos Santos really did try to get to school on time. She set three successive alarms on her phone. Skipped breakfast. Hastily applied makeup while her fuming father drove. But last year she rarely made it into the frantic scrum at the doors of Rock Bridge High School here by the first bell, at 7:50 a.m.

Then she heard that the school board was about to make the day start even earlier, at 7:20 a.m.

"I thought, if that happens, I will die," recalled Jilly, 17. "I will drop out of school!"

That was when the sleep-deprived teenager turned into a sleep activist. She was determined to convince the board of a truth she knew in the core of her tired, lanky body: Teenagers are developmentally driven to be late to bed, late to rise. Could the board realign the first bell with that biological reality?

The sputtering, nearly 20-year movement to start high schools later has recently gained momentum in communities like this one, as hundreds of schools in dozens of districts across the country have bowed to the accumulating research on the adolescent body clock.

In just the last two years, high schools in Long Beach, Calif.; Stillwater, Okla.; Decatur, Ga.;, and Glens Falls, N.Y., have pushed back their first bells, joining early adopters in Connecticut, North Carolina, Kentucky and Minnesota. The Seattle school board will vote this month on whether to pursue the issue. The superintendent of Montgomery County, Md., supports the shift, and the school board for Fairfax County, Va., is working with consultants to develop options for starts after 8 a.m.

New evidence suggests that later high school starts have widespread benefits. Researchers at the University of Minnesota, funded by the Centers for Disease Control and Prevention, studied eight high schools in three states before and after they moved to later start times in recent years. In results released Wednesday they found that the later a school's start time, the better off the students were on many measures, including mental health, car crash rates, attendance and, in some schools, grades and standardized test scores.

Dr. Elizabeth Miller, chief of adolescent medicine at Children's Hospital of Pittsburgh, who was not involved in the research, noted that the study was not a randomized controlled trial, which would have compared schools that had changed times with similar schools that had not. But she said its methods were pragmatic and its findings promising.

"Even schools with limited resources can make this one policy change with what appears to be benefits for their students," Dr. Miller said.

Researchers have found that during adolescence, as hormones surge and the brain develops, teenagers who regularly sleep eight to nine hours a night learn better and are less likely to be tardy, get in fights or sustain athletic injuries. Sleeping well can also help moderate their tendency toward impulsive or risky decision-making.

During puberty, teenagers have a later release of the "sleep" hormone melatonin, which means they tend not to feel drowsy until around 11 p.m. That inclination can be further delayed by the stimulating blue light from electronic devices, which tricks the brain into sensing wakeful daylight, slowing the release of melatonin and the onset of sleep. The Minnesota study noted that 88 percent of the students kept a cellphone in their bedroom.

But many parents, and some students, object to shifting the start of the day later. They say doing so makes sports practices end late, jeopardizes student jobs, bites into time for homework and extracurricular activities, and upsets the morning routine for working parents and younger children.

At heart, though, experts say, the resistance is driven by skepticism about the primacy of sleep.

"It's still a badge of honor to get five hours of sleep," said Dr. Judith Owens, a sleep expert at the Children's National Medical Center in Washington. "It supposedly means you're working harder, and that's a good thing. So there has to be a cultural shift around sleep."

Last January, Jilly decided she would try to make that change happen in the Columbia school district, which sprawls across 300 square miles of flatland, with 18,000 students and 458 bus routes. But before she could make the case for a later bell, she had to show why an earlier one just would not do.

She got the idea in her team-taught Advanced Placement world history class, which explores the role of leadership. Students were urged to find a contemporary topic that ignited their passion. One morning, the teachers mentioned that a school board committee had recommended an earlier start time to solve logistical problems in scheduling bus routes. The issue would be discussed at a school board hearing in five days. If you do not like it, the teachers said, do something.

Jilly did the ugly math: A first bell at 7:20 a.m. meant she would have to wake up at 6 a.m.

She had found her passion.

She seemed an unlikely choice to halt what was almost a done deal. She was just a sophomore, and did not particularly relish conflict. But Jilly, the youngest of seven children, had learned to be independent early on: Her mother died when she was 9.

And she is energetic and forthright. That year, she had interned on a voter turnout drive for Missouri Democrats, volunteered in a French-immersion prekindergarten class, written for the student newspaper, worked at a fast-food pizza restaurant and maintained an A average in French, Spanish and Latin.

"It's about time management," she explained one recent afternoon, curled up in an armchair at home.

That Wednesday, she pulled an all-nighter. She created a Facebook page and set up a Twitter account, alerting hundreds of students about the school board meeting: "Be there to have a say in your school district's decisions on school start times!"

She then got in touch with Start School Later, a nonprofit group that provided her with scientific ammunition. She recruited friends and divided up sleep-research topics. With a blast of emails, she tried to enlist the help of every high school teacher in the district. She started an online petition.

The students she organized made hundreds of posters and fliers, and posted advice on Twitter: "If you are going to be attending the board meeting tomorrow we recommend that you dress up!"

The testy school board meeting that Monday was packed. Jilly, wearing a demure, ruffled white blouse and skirt, addressed the board, blinking owl-like. The dignitaries' faces were a blur to her because while nervously rubbing her eyes, she had removed her contact lenses. But she spoke coolly about the adolescent sleep cycle: "You know, kids don't want to get up," she said. "I know I don't. Biologically, we've looked into that."

The board heatedly debated the issue and decided against the earlier start time.

The next day Jilly turned to campaigning for a later start time, joining a movement that has been gaining support. A 2011 report by the Brookings Institution recommended later start times for high schools, and last summer Arne Duncan, the secretary of education, posted his endorsement of the idea on Twitter.

The University of Minnesota study tracked 9,000 high school students in five districts in Colorado, Wyoming and Minnesota before and after schools shifted start times. In those that originally started at 7:30 a.m., only a third of students said they were able to get eight or more hours of sleep. Students who got less than that reported significantly more symptoms of depression, and greater use of caffeine, alcohol and illegal drugs than better-rested peers.

"It's biological — the mental health outcomes were identical from inner-city kids and affluent kids," said Kyla Wahlstrom, a professor of educational research at the University of Minnesota and the lead author of the study.

In schools that now start at 8:35 a.m., nearly 60 percent of students reported getting eight hours of sleep nightly.

In 2012, the high school in Jackson, Wyo., moved the first bell to 8:55 a.m. from 7:35 a.m. During that academic year, car crashes by drivers 16 to 18 years old dropped to seven from 23 the year before. Academic results improved, though not across the board.

After high schools in the South Washington County district, outside Minneapolis, switched to an 8:35 a.m. start, grades in some first- and third-period classes rose between half a point and a full grade point. And the study found that composite scores on national tests such as the ACT rose significantly in two of the five districts.

Many researchers say that quality sleep directly affects learning because people store new facts during deep-sleep cycles. During the rapid-eye-movement phases, the brain is wildly active, sorting and categorizing the day's data. The more sleep a teenager gets, the better the information is absorbed.

"Without enough sleep," said Jessica Payne, a sleep researcher and assistant professor of psychology at the University of Notre Dame, "teenagers are losing the ability not only to solidify information but to transform and restructure it, extracting inferences and insights into problems."

Last February, the school board in Columbia met to consider later start times. "It is really reassuring to know that students can have a say in the matter," Jilly told them. "So thank you, guys, for that."

The moment of decision arrived at the board's next meeting in March. Jilly sat in the front row, posting on Twitter, and addressed the board one last time. "I know it's not the most conventional thing and it's going to get some pushback," she said, referring to the later time. "But it is the right decision."

The board voted, 6 to 1, to push back the high school start time to 9 a.m. "Jilly kicked it over the edge for us," said Chris Belcher, the superintendent.

It is now seven months into the new normal. At Rock Bridge High School, the later end to the day, at 4:05 p.m., is problematic for some, including athletes who often miss the last period to make their away games.

"After doing homework, it gets to be 11:30 p.m. pretty quickly," said Brayden Parker, a senior varsity football player. "I would prefer to get home by dark and have more time to chill out."

The high schools in the district have tried to adjust, for example by adding Wi-Fi access to buses so athletes can do homework on the road. Some classes meet only one or two days a week, and are supplemented with online instruction. More sports practices and clubs convene before school.

Some parents and first-period teachers are seeing a payoff in students who are more rested and alert.

At 7:45 a.m. on a recent school day, Rock Bridge High, a long, one-story building with skylights and wide hallways, was sun-drenched and almost silent.

Then, like an orchestra tuning up, students gradually started arriving, some for debate club and choir, others to meet in the cafeteria for breakfast and gossip. Laughter crackled across the lobby, as buses dropped off more students, and others drifted in from the parking lots. The growing crowds could almost be described as civilized.

At 8:53 a.m., Jilly burst through the north entrance door, long hair uncombed and flyaway, wearing no makeup, lugging her backpack.

"Even when I am late to school now," she said, dashing down a corridor to make that 8:55 bell, "it's only by three or four minutes."

A version of this article appears in print on 03/14/2014, on page A1 of the NewYork edition with the headline: To Keep Teenagers Alert, Schools Start to Let Them Sleep In.

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Well: Ask Well: Laser Treatments for Nail Fungus

Q

How effective are laser treatments for toe nail fungus?

Is there any medical evidence suggesting that laser treatments actually work for fungal infections in toenails?

A

Laser treatments for nail fungus have become fairly common since the procedure was approved by the Food and Drug Administration four years ago. Several kinds of laser therapies are now available, but there is limited evidence that the treatments work.

The appeal of lasers is that they selectively heat and destroy harmful fungi while sparing healthy surrounding tissue. And some small studies and lab tests suggest they can kill the fungi and cure the condition.

But in one of the best studies to date, published last year in The Journal of the American Academy of Dermatology, researchers at the University of Alabama at Birmingham found that laser treatments produced no improvements in patients with toenail fungus, even after five sessions.

The procedures are generally not covered by insurance, and a course of treatment typically involves multiple sessions, each costing hundreds of dollars, said Dr. Andrea Bershow, the director of the nail procedure clinic at the Minneapolis VA Health Care System.

"I think we want it to work, but the evidence just isn't quite there yet," said Dr. Bershow, who published a report last year that reviewed current research. "The studies that have shown efficacy have been small, they haven't been randomized controlled trials, and most of them have been funded by the actual laser companies themselves."

Dr. Bershow says she frequently treats patients with the oral drug Lamisil because it is cheap, it works and it is generally very safe. But many people are reluctant to take it because in very rare cases it may cause liver damage. When all else fails, some patients elect to have their toenail removed and the nail matrix medically destroyed to prevent the nail from growing back.

Dr. Bershow is frequently asked about laser treatments, but she never recommends them.

"The reason is that I don't know if it works, but it does cost a lot of money," she said. "I would hate to tell someone to go try something that insurance doesn't cover, that could cost them thousands of dollars, and that may or may not work."

Do you have a health question? Submit your question to Ask Well.

13.58 | 0 komentar | Read More

Doctor and Patient: Emergency Rooms Are No Place for the Elderly

Doctor and Patient

Dr. Pauline Chen on medical care.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who'd watched him hobble down the building's stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

"Of course, if things get worse before the week's up," I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, "come back here right away."

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man's face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. "Just admit him," she whispered. "It'll cost more, but it's the only way you'll be sure he's getting the right care."

I remembered the nurse's advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.

The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.

But given longstanding trends in American medicine, it's hard to imagine a health care setting more ill suited for the elderly than today's emergency rooms.

Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment's notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.

More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.

But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.

For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.

To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must "geriatricize" their emergency departments.

And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.

Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.

"Older adults aren't the kind of patients people gravitate toward," said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. "There's a reason you don't see the frail, cognitively and functionally impaired older patient on television medical shows."

Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual's experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.

"We can really become partners in improving care, instead of just putting a Band-Aid on the problem," Dr. Hwang said. "We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them."

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Well: To Keep Teenagers Alert, Schools Let Them Sleep In

COLUMBIA, Mo. – Jilly Dos Santos really did try to get to school on time. She set three successive alarms on her phone. Skipped breakfast. Hastily applied makeup while her fuming father drove. But last year she rarely made it into the frantic scrum at the doors of Rock Bridge High School here by the first bell, at 7:50 a.m.

Then she heard that the school board was about to make the day start even earlier, at 7:20 a.m.

"I thought, if that happens, I will die," recalled Jilly, 17. "I will drop out of school!"

That was when the sleep-deprived teenager turned into a sleep activist. She was determined to convince the board of a truth she knew in the core of her tired, lanky body: Teenagers are developmentally driven to be late to bed, late to rise. Could the board realign the first bell with that biological reality?

The sputtering, nearly 20-year movement to start high schools later has recently gained momentum in communities like this one, as hundreds of schools in dozens of districts across the country have bowed to the accumulating research on the adolescent body clock.

In just the last two years, high schools in Long Beach, Calif.; Stillwater, Okla.; Decatur, Ga.;, and Glens Falls, N.Y., have pushed back their first bells, joining early adopters in Connecticut, North Carolina, Kentucky and Minnesota. The Seattle school board will vote this month on whether to pursue the issue. The superintendent of Montgomery County, Md., supports the shift, and the school board for Fairfax County, Va., is working with consultants to develop options for starts after 8 a.m.

New evidence suggests that later high school starts have widespread benefits. Researchers at the University of Minnesota, funded by the Centers for Disease Control and Prevention, studied eight high schools in three states before and after they moved to later start times in recent years. In results released Wednesday they found that the later a school's start time, the better off the students were on many measures, including mental health, car crash rates, attendance and, in some schools, grades and standardized test scores.

Dr. Elizabeth Miller, chief of adolescent medicine at Children's Hospital of Pittsburgh, who was not involved in the research, noted that the study was not a randomized controlled trial, which would have compared schools that had changed times with similar schools that had not. But she said its methods were pragmatic and its findings promising.

"Even schools with limited resources can make this one policy change with what appears to be benefits for their students," Dr. Miller said.

Researchers have found that during adolescence, as hormones surge and the brain develops, teenagers who regularly sleep eight to nine hours a night learn better and are less likely to be tardy, get in fights or sustain athletic injuries. Sleeping well can also help moderate their tendency toward impulsive or risky decision-making.

During puberty, teenagers have a later release of the "sleep" hormone melatonin, which means they tend not to feel drowsy until around 11 p.m. That inclination can be further delayed by the stimulating blue light from electronic devices, which tricks the brain into sensing wakeful daylight, slowing the release of melatonin and the onset of sleep. The Minnesota study noted that 88 percent of the students kept a cellphone in their bedroom.

But many parents, and some students, object to shifting the start of the day later. They say doing so makes sports practices end late, jeopardizes student jobs, bites into time for homework and extracurricular activities, and upsets the morning routine for working parents and younger children.

At heart, though, experts say, the resistance is driven by skepticism about the primacy of sleep.

"It's still a badge of honor to get five hours of sleep," said Dr. Judith Owens, a sleep expert at the Children's National Medical Center in Washington. "It supposedly means you're working harder, and that's a good thing. So there has to be a cultural shift around sleep."

Last January, Jilly decided she would try to make that change happen in the Columbia school district, which sprawls across 300 square miles of flatland, with 18,000 students and 458 bus routes. But before she could make the case for a later bell, she had to show why an earlier one just would not do.

She got the idea in her team-taught Advanced Placement world history class, which explores the role of leadership. Students were urged to find a contemporary topic that ignited their passion. One morning, the teachers mentioned that a school board committee had recommended an earlier start time to solve logistical problems in scheduling bus routes. The issue would be discussed at a school board hearing in five days. If you do not like it, the teachers said, do something.

Jilly did the ugly math: A first bell at 7:20 a.m. meant she would have to wake up at 6 a.m.

She had found her passion.

She seemed an unlikely choice to halt what was almost a done deal. She was just a sophomore, and did not particularly relish conflict. But Jilly, the youngest of seven children, had learned to be independent early on: Her mother died when she was 9.

And she is energetic and forthright. That year, she had interned on a voter turnout drive for Missouri Democrats, volunteered in a French-immersion prekindergarten class, written for the student newspaper, worked at a fast-food pizza restaurant and maintained an A average in French, Spanish and Latin.

"It's about time management," she explained one recent afternoon, curled up in an armchair at home.

That Wednesday, she pulled an all-nighter. She created a Facebook page and set up a Twitter account, alerting hundreds of students about the school board meeting: "Be there to have a say in your school district's decisions on school start times!"

She then got in touch with Start School Later, a nonprofit group that provided her with scientific ammunition. She recruited friends and divided up sleep-research topics. With a blast of emails, she tried to enlist the help of every high school teacher in the district. She started an online petition.

The students she organized made hundreds of posters and fliers, and posted advice on Twitter: "If you are going to be attending the board meeting tomorrow we recommend that you dress up!"

The testy school board meeting that Monday was packed. Jilly, wearing a demure, ruffled white blouse and skirt, addressed the board, blinking owl-like. The dignitaries' faces were a blur to her because while nervously rubbing her eyes, she had removed her contact lenses. But she spoke coolly about the adolescent sleep cycle: "You know, kids don't want to get up," she said. "I know I don't. Biologically, we've looked into that."

The board heatedly debated the issue and decided against the earlier start time.

The next day Jilly turned to campaigning for a later start time, joining a movement that has been gaining support. A 2011 report by the Brookings Institution recommended later start times for high schools, and last summer Arne Duncan, the secretary of education, posted his endorsement of the idea on Twitter.

The University of Minnesota study tracked 9,000 high school students in five districts in Colorado, Wyoming and Minnesota before and after schools shifted start times. In those that originally started at 7:30 a.m., only a third of students said they were able to get eight or more hours of sleep. Students who got less than that reported significantly more symptoms of depression, and greater use of caffeine, alcohol and illegal drugs than better-rested peers.

"It's biological — the mental health outcomes were identical from inner-city kids and affluent kids," said Kyla Wahlstrom, a professor of educational research at the University of Minnesota and the lead author of the study.

In schools that now start at 8:35 a.m., nearly 60 percent of students reported getting eight hours of sleep nightly.

In 2012, the high school in Jackson, Wyo., moved the first bell to 8:55 a.m. from 7:35 a.m. During that academic year, car crashes by drivers 16 to 18 years old dropped to seven from 23 the year before. Academic results improved, though not across the board.

After high schools in the South Washington County district, outside Minneapolis, switched to an 8:35 a.m. start, grades in some first- and third-period classes rose between half a point and a full grade point. And the study found that composite scores on national tests such as the ACT rose significantly in two of the five districts.

Many researchers say that quality sleep directly affects learning because people store new facts during deep-sleep cycles. During the rapid-eye-movement phases, the brain is wildly active, sorting and categorizing the day's data. The more sleep a teenager gets, the better the information is absorbed.

"Without enough sleep," said Jessica Payne, a sleep researcher and assistant professor of psychology at the University of Notre Dame, "teenagers are losing the ability not only to solidify information but to transform and restructure it, extracting inferences and insights into problems."

Last February, the school board in Columbia met to consider later start times. "It is really reassuring to know that students can have a say in the matter," Jilly told them. "So thank you, guys, for that."

The moment of decision arrived at the board's next meeting in March. Jilly sat in the front row, posting on Twitter, and addressed the board one last time. "I know it's not the most conventional thing and it's going to get some pushback," she said, referring to the later time. "But it is the right decision."

The board voted, 6 to 1, to push back the high school start time to 9 a.m. "Jilly kicked it over the edge for us," said Chris Belcher, the superintendent.

It is now seven months into the new normal. At Rock Bridge High School, the later end to the day, at 4:05 p.m., is problematic for some, including athletes who often miss the last period to make their away games.

"After doing homework, it gets to be 11:30 p.m. pretty quickly," said Brayden Parker, a senior varsity football player. "I would prefer to get home by dark and have more time to chill out."

The high schools in the district have tried to adjust, for example by adding Wi-Fi access to buses so athletes can do homework on the road. Some classes meet only one or two days a week, and are supplemented with online instruction. More sports practices and clubs convene before school.

Some parents and first-period teachers are seeing a payoff in students who are more rested and alert.

At 7:45 a.m. on a recent school day, Rock Bridge High, a long, one-story building with skylights and wide hallways, was sun-drenched and almost silent.

Then, like an orchestra tuning up, students gradually started arriving, some for debate club and choir, others to meet in the cafeteria for breakfast and gossip. Laughter crackled across the lobby, as buses dropped off more students, and others drifted in from the parking lots. The growing crowds could almost be described as civilized.

At 8:53 a.m., Jilly burst through the north entrance door, long hair uncombed and flyaway, wearing no makeup, lugging her backpack.

"Even when I am late to school now," she said, dashing down a corridor to make that 8:55 bell, "it's only by three or four minutes."

A version of this article appears in print on 03/14/2014, on page A1 of the NewYork edition with the headline: To Keep Teenagers Alert, Schools Start to Let Them Sleep In.

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Well: Ask Well: Laser Treatments for Nail Fungus

Q

How effective are laser treatments for toe nail fungus?

Is there any medical evidence suggesting that laser treatments actually work for fungal infections in toenails?

A

Laser treatments for nail fungus have become fairly common since the procedure was approved by the Food and Drug Administration four years ago. Several kinds of laser therapies are now available, but there is limited evidence that the treatments work.

The appeal of lasers is that they selectively heat and destroy harmful fungi while sparing healthy surrounding tissue. And some small studies and lab tests suggest they can kill the fungi and cure the condition.

But in one of the best studies to date, published last year in The Journal of the American Academy of Dermatology, researchers at the University of Alabama at Birmingham found that laser treatments produced no improvements in patients with toenail fungus, even after five sessions.

The procedures are generally not covered by insurance, and a course of treatment typically involves multiple sessions, each costing hundreds of dollars, said Dr. Andrea Bershow, the director of the nail procedure clinic at the Minneapolis VA Health Care System.

"I think we want it to work, but the evidence just isn't quite there yet," said Dr. Bershow, who published a report last year that reviewed current research. "The studies that have shown efficacy have been small, they haven't been randomized controlled trials, and most of them have been funded by the actual laser companies themselves."

Dr. Bershow says she frequently treats patients with the oral drug Lamisil because it is cheap, it works and it is generally very safe. But many people are reluctant to take it because in very rare cases it may cause liver damage. When all else fails, some patients elect to have their toenail removed and the nail matrix medically destroyed to prevent the nail from growing back.

Dr. Bershow is frequently asked about laser treatments, but she never recommends them.

"The reason is that I don't know if it works, but it does cost a lot of money," she said. "I would hate to tell someone to go try something that insurance doesn't cover, that could cost them thousands of dollars, and that may or may not work."

Do you have a health question? Submit your question to Ask Well.

13.58 | 0 komentar | Read More

Well: Emergency Rooms Are No Place for the Elderly

Doctor and Patient

Dr. Pauline Chen on medical care.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who'd watched him hobble down the building's stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

"Of course, if things get worse before the week's up," I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, "come back here right away."

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man's face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. "Just admit him," she whispered. "It'll cost more, but it's the only way you'll be sure he's getting the right care."

I remembered the nurse's advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.

The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.

But given longstanding trends in American medicine, it's hard to imagine a health care setting more ill suited for the elderly than today's emergency rooms.

Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment's notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.

More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.

But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.

For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.

To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must "geriatricize" their emergency departments.

And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.

Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.

"Older adults aren't the kind of patients people gravitate toward," said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. "There's a reason you don't see the frail, cognitively and functionally impaired older patient on television medical shows."

Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual's experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.

"We can really become partners in improving care, instead of just putting a Band-Aid on the problem," Dr. Hwang said. "We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them."

13.58 | 0 komentar | Read More