Saturday, January 8, 2011

What health care means to my wife - London Free Press

Only once have I seen my family doctor in a state of despair.

It happened a couple of months ago, when his normally cheerful demeanour gave way at the end of one of my wife's regularly scheduled medical appointments.

He shook his head, then conceded that there are times he feels like closing his practice or moving stateside. All the while, he tried hard not to display any disloyalty to his profession, his colleagues, his patients and the system that pays his wages.

He felt stymied.

A decade ago, Jacquelyn was active and mobile, despite a gymnastic injury to one knee that later required surgery. It slowed her a bit, but not much. She has always been adventurous: travelling to England for the chance to play her harp in Canterbury's cathedral, floating above the city in a hot-air balloon, riding a horse at a nearby stable.

Then a lower-back injury and a deteriorating knee began to take their toll. The first required many months of bed rest; the second got a referral from our family doc to an orthopedic specialist. After many weeks of waiting to see him, the diagnosis was swift and abrupt: Go home. The condition of the knee wasn't bad enough, compared to his other cases, to warrant any attention.

Fast-forward to now: It may have been the knee, the theory goes, that caused premature wear and tear in the opposite hip, which now requires replacement and which likely threw the ignition switch on a case of fibromyalgia.

In any event, Jacquelyn has seen her mobility decline drastically. At first, she resisted use of handicapped parking spaces, arguing that there were plenty of others worse off than she, but as dependence on her cane grew, she relented.

Last fall, about the same time that X-rays confirmed severe degradation of her hip joint, she went from one cane to two. The family doctor made a referral to another orthopedic surgeon. Time frame for that consultation: unknown. Time frame for surgery: even more unknown.

Her mobility dramatically decreased. On many days Jacquelyn doesn't venture downstairs. Extreme hip pain sometimes keeps her from sleeping for days.

We are at the halfway point of this column, so I'll stop now with medical details. My point is not to write so much about Jacquelyn as to take issue with the state of a health-care system that knowingly and consciously permits patients to go from active living to the point where they become imprisoned in their homes because the system can't adequately cope.

This is not a pity plea. If that's your reading of it, stop now and move along; there is plenty of other material on these pages.

Both Jacquelyn and I are aware of the need to live with life's circumstances and the genetic cards we're dealt. We're in our 50s and we're aging. We're fortunate to have a family doctor in the first place. In many respects, we are more fortunate than many other Canadians.

Neither she nor I believe that, in Ontario's health-care system, there should be any special treatment or queue jumping (though we know it happens). And that's precisely the point. What Jacquelyn has experienced is what we've all come to accept as commonplace in health care in this province.

We all know patients who have similar experiences. On her occasional ventures outside the house, she's heard from random individuals (mobility challenges appear to spark a lot of informal conversations) and medical professionals about waits that last years.

She's heard about lost decades and missed life opportunities. She's heard warnings and stories of grief and miserable surgical failures - but also of life-changing, restorative successes.

No reasonable person expects our overburdened health-care system to snap to the immediate, individualized attention for every would-be patient. But for those caught in indeterminate waits for procedures that could radically alter their quality of life, a line gets crossed when overwhelming pressure on the system becomes deception.

When websites provide wait times for medical procedures that are easily gerrymandered (they measure, after all, only the distance between consultation and surgery). When TV commercials cheerfully tout the many health-care options available to Ontarians. When the local LHIN, the health minister or her minions tweet about their remarkable successes in improving health care.

Or when a family doctor, in a moment of weakness at the end of his day, whispers heartfelt despair about that fact that a patient, despite what is medically possible, can't access timely treatment. And that to indicate anything else would be a bald-faced lie.

Thursday, January 6, 2011

Taking Pulse and Blood Pressure With an iPhone -

The smartphone is already the Swiss Army knife of the digital age, replacing the need for alarm clocks, GPS units and even digital cameras with the flick of a finger.
Can it do the same for home medical devices?
At the Consumer Electronics Show in Las Vegas, iHealth Labs, a start-up in Mountain View, Calif., has unveiled the iHealth Blood Pressure Dock, an attachment for iOS devices that can measure and record heart rate and blood pressure.
The kit, which costs $100, comes with a blood pressure cuff and a battery-powered dock that doubles as a charging station for the iPhone, iPod Touch and iPad. For now, the hardware is available for sale on the company's Web site. Eventually, it will also be sold in Apple retail stores and through The kit also requires a mobile application to log the results, which is available for free through iTunes.
Dr. Andrew Brandeis, a practicing doctor in San Francisco and a medical consultant and spokesman for iHealth, said that although the device is primarily aimed at people with hypertension or other chronic health conditions, it can also be helpful for anyone trying to live a healthier life.
"I can give someone a pill for their blood pressure, but what I really want to do is educate them about their habits that cause high blood pressure," he said. "If you can see your blood pressure is going up, you can try to get an idea about what you're doing that is affecting it. You start to see correlations between your blood pressure and your life."
The biggest advantage to those who buy iHealth's blood pressure system instead of a stand-alone machine, which is much cheaper to purchase, is that it will be incorporated into a patient's daily routine of waking up and checking their cellphone, the company says.
"You charge your device at night and when you wake up, the blood pressure cuff is sitting right there next to it," he said.
Taking daily readings at home may also offer more accurate and consistent results than those taken at a doctor's office, he said.
"White coat syndrome is a term used for what happens when patients come in to see the doctor," he said. "They are stressed out because they hate going to the doctor and their blood pressure is higher. But if you take it at home, before your coffee and e-mail, you get a much more accurate reading."
Patients can also share their results with a physician, either via e-mail or by showing them the phone or iPad with the data on it during their next doctor visit.
The application can also push readings to Twitter and Facebook as a way to generate positive reinforcement about good readings among a user's social network, Dr. Brandeis said.
Eventually, the company hopes to also release other home health kits, including a blood glucose monitor and a connected scale.
"This is a doorway to an entire new ecosystem of self-monitoring and gleaning health information about yourself," said Dr. Brandeis.

Wednesday, January 5, 2011

Overcrowded ER may have played role in death - Montreal Gazette

When Mieczyslaw Figiel died last February in the corridor of Maisonneuve-Rosemont Hospital's emergency room, right next to the triage nursing station where an ambulance had left him earlier, his family was distraught that no one had bothered to check on a dying man.

Nearly one year later, a coroner's report into Figiel's death confirms that he died in a hospital ER that was so overloaded that other patients in the waiting room on Feb. 3 were not seen or treated until late afternoon the next day.

Coroner Jean Brochu's report concluded that Figiel's chances of survival would have improved had the severity of his condition been detected earlier.

But only after Figiel stopped breathing in the hallway did medical staff come to his side with a blood-pressure device and a thermometer.

His family had been banging desperately on the window of the triage unit for attention. Figiel was having problems breathing. No one opened the door, his daughter Della recalled.

The hospital ER was operating at 180 per cent capacity that day; there was a 16-hour wait to be seen.

Figiel's death was one of several last year related to overcrowding in hospital emergency rooms.

A year later, these chaotic conditions haven't improved much, according to the Montreal Health and Social Services Agency, which yesterday recorded ERs were at 151 per cent of capacity.

Although Montreal's emergency rooms are equipped to handle 512 patients on stretchers, yesterday's tally reached 801 patients.

The overflow included 98 patients stuck on ER gurneys longer than 48 hours.

The problem seems to affect Montreal-area emergency rooms more than regional facilities, said Karine Rivard, spokesperson for Quebec Health Minister Yves Bolduc, who suggested a link to the seasonal explosion of flu and gastroenteritis cases.

But the Montreal health agency's assistant executive director, Louise Massicotte, said the cyclic jump in flu and gastro cases is not responsible for the current situation.

Most of the people calling on the emergency rooms rather than their own doctors or walk-in clinics do not need to be hospitalized for seasonal illnesses, Massicotte said.

"Clearly it's busier, but it's not increasing the number of hospitalizations," she said.

Instead, Massicotte blamed a jump in the number of ambulances in recent months -up by 30 to 40 a day -to Montreal's hospitals, a phenomenon linked to the aging of the population, she said.

"That brings an important increase in traffic," she said, which added to the traditional holiday service reduction and the usual closures of hospital beds.

Many of those coming by ambulance need several medical consultations before there's a decision to admit them to the hospital, she said.

"Indeed, we hope that there will never be a 48-hour wait," Massicotte said.

But this week, Montreal hospitals saw an average jump of 15 per cent from the same period last year in waits of 48 hours, Massicotte said.

It takes a few days into the new year to stabilize the ER situation as hospitals resume normal activities and medical clinics and doctor's offices reopen, she said.

Massicotte would not comment on the coroner's report in Figiel's case, but said that patients coming to the ERs are seen by medical staff according to priority, called triage, and that emergency

patients do get seen before more benign cases.

"Staff dif ferentiates between influenza and heart attack," she said.

Maisonneuve-Rosemont Hospital officials were not available to comment.

Figiel's family, however, says it is not any farther ahead than last year.

"As far as (the hospital) is concerned, they did everything possible ... everything that they could," Della Figiel said recalling a meeting with health officials after the coroner's report was filed.

"It's very disturbing. We're not getting the services required or the care, it's just been awful. Saying you're overloaded is not an answer."

Figiel has hired a lawyer because the hospital has refused to release her father's health records. The family is considering legal action.

Stock volatility as a risk factor for coronary heart disease death — Eur Heart J

Aims The volatility of financial markets may cause substantial emotional and physical stress among investors. We hypothesize that this may have adverse effects on cardiovascular health. The Chinese stock markets were extremely volatile between 2006 and 2008. We, therefore, examined the relationship between daily change of the Shanghai Stock Exchange (SSE) Composite Index (referred as the Index) and coronary heart disease (CHD) deaths from 1 January 2006 to 31 December 2008 in Shanghai, the financial capital of China.

Methods and results Daily death and stock performance data were collected from the Shanghai Center for Disease Control and Prevention and SSE, respectively. Data were analysed with over-dispersed generalized linear Poisson models, controlling for long-term and seasonal trends of CHD mortality, day of the week, Index closing value, weather conditions, and air pollution levels. We observed a U-shaped relationship between the Index change and CHD deaths: both rising and falling of the Index were associated with more deaths and the fewest deaths coincided with little or no change of the index. We also examined the absolute daily change of the Index in relation to CHD deaths: in a 1-day lag model, each 100-point change of the Index corresponded to 5.17% (95% confidence interval: 1.71, 8.63%) increase in CHD deaths. Further analysis showed that the association was stronger for out-of-hospital CHD death than for in-hospital death.

Conclusion We found that CHD deaths fluctuated with daily stock changes in Shanghai, suggesting that stock volatility may adversely affect cardiovascular health.

Tuesday, January 4, 2011

Fido’s No Doctor. Neither Is Whiskers. -

A dog or cat owner spends roughly $10,000 on the care and feeding of his pet over its lifetime. (Dogs cost more per year, but cats make up for it by living longer.) What does he get for this investment?

Surveys indicate that what most pet owners mainly want is companionship, unconditional love and a play pal. In recent years, however, we have also begun to regard pets as furry physicians and four-legged psychotherapists.

The idea that domestic animals are beneficial to human health and happiness has been fueled by books like "The Healing Power of Pets: Harnessing the Amazing Ability of Pets to Make and Keep People Happy and Healthy," by the veterinarian Marty Becker, and by news reports claiming that having a dog helps you live longer or that swimming with dolphins can cure autism, bad backs, attention deficit disorder and even cancer. But is there any truth to these claims?

The task of distinguishing hype from reality on this question falls to anthrozoology, the new science of human-animal relationships. In 1980, Erika Friedmann, a scientist at the University of Pennsylvania, found the first evidence that animals might provide medical benefits: a survey of 92 heart attack victims revealed that those who had pets were nearly five times more likely to be alive a year later than those without them.

Since then, research has shown that stroking an animal lowers blood pressure, that AIDS patients living with pets are less depressed and that pet owners have lower cholesterol levels, sleep more soundly, exercise more and take fewer sick days than non-pet owners. Indeed, I have a stack of articles in my office supporting the hypothesis that pets are healthy for us.

Unfortunately, however, I also have another stack of articles, almost as high, showing that pets have either no long-term effects or have even adverse effects on physical and mental health.

A 2006 survey of Americans by the Pew Research Center, for instance, reported that living with a pet did not make people any happier. Similarly, a 2000 Australian study of mortality rates found no evidence that pet owners lived any longer than anyone else. And last year Dutch researchers concluded that companion animals had no effect on their owners' physical or mental well-being. Worse, in 2006, epidemiologists in Finland reported that pet owners were more likely than non-pet owners to suffer from sciatica, kidney disease, arthritis, migraines, panic attacks, high blood pressure and depression.

This pattern of mixed results also holds true for the widely heralded notion that animals can cure various physical afflictions. For example, a study of people with chronic fatigue syndrome found that while pet owners believed that interacting with their pets relieved their symptoms, objective analysis revealed that they were just as tired, stressed, worried and unhappy as sufferers in a control group who had no pets. Similarly, a clinical trial of cancer patients undergoing radiation therapy found that interacting with therapy dogs did no more to enhance the participants' morale than reading a book did.

As for the presumed curative powers of swimming with dolphins, researchers at Emory University who reviewed the dolphin therapy studies concluded that every one purporting to document positive health effects was methodologically flawed.

Don't get me wrong. I don't mean to disparage animal companionship; pets are central to my life, too. But the truth is that we know little about how pets could affect us biologically, or why a health benefit accrues to some people but not others. Answering these questions will require the same rigorous methods that scientists use to test the effectiveness of drugs and medical procedures.

Despite the importance of pets in our lives, researchers in the health and behavioral sciences have, until recently, largely neglected the study of human-animal relationships. But this is changing. In 2008, the National Institutes of Health (in conjunction with Mars, the corporate giant whose products include pet food) began a multimillion-dollar research initiative that will eventually help separate fact from wishful thinking on how pets influence human health and happiness.

No doubt, the talk in some medical circles of prescribing puppies and kittens for the chronically ill is well intentioned. But until the research is complete, pet lovers should probably keep taking their Lipitor and Prozac.

Hal Herzog, a professor of psychology at Western Carolina University, is the author of "Some We Love, Some We Hate, Some We Eat: Why It's So Hard To Think Straight About Animals."

Sunday, January 2, 2011

Meet the Twiblings -

Midway on our life's journey, I found myself in dark woods, the right road lost. I've actually never read "The Inferno," but I found that line in my mind every morning when I woke to do my hormone injection and especially on the darkest mornings — the ones when I went into the clinic to have my unpregnant blood drawn to confirm another I.V.F. cycle's failure. Of course, I had considered my life ruined many times before — other medical and romantic crises — but I was always wrong. This issue, though — childlessness — really did seem different. My two closest girlfriends chose not to have children and didn't regret it, and I envied them, but I didn't know how to feel as they did. No one gets everything they want in life, but to be childless felt like being deprived of something essential: the primal human experience. When I was 39 and single, I was in northern Uganda, and a woman there asked about my children. I said I didn't have any, and she solemnly told me that she would pray to God to remove my curse. Instead of shrugging it off, I thanked her.

I was 41 when, after a gazillion not-quite-right relationships and a broken engagement, I met Michael, the man I would marry. He was five years younger; socially, it didn't seem like an important age difference, but in terms of fertility, it turned out to be. I was haunted by the thought that if we didn't have children — even though he loved me and even though that love might blind him to the truth — in some sense marrying me would have turned out to be a mistake. Raising children was a crucial part of his vision of what he wanted to do with his life, and if he had married someone his age, she probably would have been fertile.

"I'm not comfortable with it," our doctor said when I begged him to let us do a fifth round of I.V.F. "When a doctor offers you a treatment, there is an expectation that that treatment could work."

"It could work," I said. "I don't mind doing the treatments. I just want to keep trying."

"Realistically, you need to consider other ways to have a family," he said.

But it seemed to me that there were no other good options. I had friends who spent all of their money trying to adopt, only to have things fall through again and again — birth mothers who changed their minds, foreign programs that were discontinued. I researched adoption in China but discovered that the criteria excluded us. When Michael's parents adopted his sister in the 1970s, there was an abundance of babies in the United States in need of homes, but the widespread use of birth control and abortion, among other factors, has caused the supply of infants available for adoption in the subsequent three decades to plummet to a fraction of what it was then. Knowing that, I was still taken aback by how discouraging one adoption agency was about our prospects for "competing" against other couples. "Most birth mothers do prefer younger women," the woman informed me. "But you'll get a letter from your doctor, certifying you are in excellent health for the social worker anyway."

"Right," I said, thinking about the arthritic condition that caused the chronic pain I had been struggling with for many years.

I found another doctor and persuaded him to let us try a fifth round. All you have to do is not die, I told the embryos once again, but once again they all did. After a failed sixth round, I was told I had a new medical problem that would pose risks to a fetus's health, and I began to consider whether the embryos might have been right about the merits of my body as their greenhouse. Should I scrap my problem-ridden body entirely and try third-party reproduction? I felt a pang at the idea of excluding myself — of having no role at all in gestating or creating the child. But that pang was checked by disappointment in my body and a longing not to be limited by its limitations.

I consulted with a perinatologist, a high-risk pregnancy specialist. "Is your goal to have the experience of being pregnant or is your goal to have the best chance of having a healthy baby?" he asked. "If you really want a healthy baby, get a surrogate and an egg donor." In that instant, I made up my mind. Of course that was my goal — and compared with that goal, all other desires seemed not only secondary, but also trivial, even narcissistic.

I began researching surrogacy and egg donation — corresponding with gestational carriers on surrogacy Web sites and talking to agencies. The process seemed so daunting and alienating — inviting all these strangers into our bedroom, creating relationships with unknown conventions and risks, giving others extraordinary power. In the story of what happens when a man and a woman love each other very much, they don't need strangers to lend them their gametes. Having children was one of life's great acts of self-definition. How could we turn the most intimate thing a couple could do — coupling — into a ménage à trois, let alone à quatre or cinq?

There were so many ways the journey could go astray. The Internet was filled with stories of predatory egg-donation and surrogacy agencies. The legal status of surrogacy is varied. In a number of states, the status is unclear or surrogacy is prohibited. There were several cases of surrogacy in recent years in which the surrogate succeeded in keeping the baby despite an absence of any genetic connection. Even if everything went perfectly, it was hugely expensive. Of course, the cost of surrogacy is dwarfed by the cost of actually raising a child, to say nothing, for example, of a college education, but considering what baby-making usually costs — nothing — it took our breath away. We were able to afford it because of a financial deus ex machina. Just when the I.V.F. bills were mounting, the software company that Michael co-founded was acquired by a large company. But there was still something disquieting about choosing to spend so much — and having an option that many infertile people did not have.

We were also unsettled to discover how many people disapprove of surrogacy and egg donation. There are objections to it on the right, on religious grounds, as violating the natural order and the trinity of father-mother-baby, or as being part of a slippery slope that would lead to abominations like human cloning. There are objections on the left by those who say that surrogacy is exploitative and degrading for the women, irrespective of what the women who become surrogates say about it. (Some people believe only paid surrogacy is exploitative but unpaid surrogacy is fine.) I read articles and court decisions and took notes on the arguments, but in the end they mainly seemed to boil down to the fact that it is new. Because of the central social importance of the family, changes that affect it are often initially condemned as strange, unnatural, evil or dangerous. Using anesthesia in childbirth was controversial after anesthesia's invention. Had not God condemned Eve to bring forth children in pain? Birth control was once condemned, but it is now widely accepted. Once outlawed, abortion is now legal and supported by a majority of Americans within certain limits.

Reproductive technology fills an important — and growing — need. Gay couples are increasingly choosing to have families. Eight percent of women between 40 and 44 identify themselves as involuntarily childless or hoping to become pregnant, according to a Pew report. Most women in that age bracket will be able to become pregnant only by using donor eggs. Although we could handle negative reactions, it was upsetting to think that our children would have to deal with them. Still, we didn't want fear of other people's opinions to influence such an important and personal decision, and we hoped we would raise children who could stand up for themselves.

More ...

Alzheimer’s Therapy Focuses on Care -

Margaret Nance was, to put it mildly, a difficult case. Agitated, combative, often reluctant to eat, she would hit staff members and fellow residents at nursing homes, several of which kicked her out. But when Beatitudes nursing home agreed to an urgent plea to accept her, all that changed.

Disregarding typical nursing-home rules, Beatitudes allowed Ms. Nance, 96 and afflicted with Alzheimer's, to sleep, be bathed and dine whenever she wanted, even at 2 a.m. She could eat anything, too, no matter how unhealthy, including unlimited chocolate.

And she was given a baby doll, a move that seemed so jarring that a supervisor initially objected until she saw how calm Ms. Nance became when she rocked, caressed and fed her "baby," often agreeing to eat herself after the doll "ate" several spoonfuls.

Dementia patients at Beatitudes are allowed practically anything that brings comfort, even an alcoholic "nip at night," said Tena Alonzo, director of research. "Whatever your vice is, we're your folks," she said.

Once, Ms. Alonzo said: "The state tried to cite us for having chocolate on the nursing chart. They were like, 'It's not a medication.' Yes, it is. It's better than Xanax."

It is an unusual posture for a nursing home, but Beatitudes is actually following some of the latest science. Research suggests that creating positive emotional experiences for Alzheimer's patients diminishes distress and behavior problems.

In fact, science is weighing in on many aspects of taking care of dementia patients, applying evidence-based research to what used to be considered subjective and ad hoc.

With virtually no effective medical treatment for Alzheimer's yet, most dementia therapy is the caregiving performed by families and nursing homes. Some 11 million people care for Alzheimer's-afflicted relatives at home. In nursing homes, two-thirds of residents have some dementia.

Caregiving is considered so crucial that several federal and state agencies, including the Department of Veterans Affairs, are adopting research-tested programs to support and train caregivers. This month, the Senate Special Committee on Aging held a forum about Alzheimer's caregiving.

"There's actually better evidence and more significant results in caregiver interventions than there is in anything to treat this disease so far," said Lisa P. Gwyther, education director for the Bryan Alzheimer's Disease Research Center at Duke University.

The National Institute on Aging and the Administration on Aging are now financing caregiving studies on "things that just kind of make the life of an Alzheimer's patient and his or her caregiver less burdensome," said Sidney M. Stahl, chief of the Individual Behavioral Processes branch of the Institute on Aging. "At least initially, these seem to be good nonpharmacological techniques."

Techniques include using food, scheduling, art, music and exercise to generate positive emotions; engaging patients in activities that salvage fragments of their skills; and helping caregivers be more accepting and competent.

Changing the Mood

Some efforts involve stopping anti-anxiety or antipsychotic drugs, used to quell hallucinations or aggression, but potentially harmful to dementia patients, who can be especially sensitive to side effects. Instead, some experts recommend primarily giving drugs for pain or depression, addressing what might be making patients unhappy.

Others recommend making cosmetic changes to rooms and buildings to affect behavior or mood.

study in The Journal of the American Medical Association found that brightening lights in dementia facilities decreased depression, cognitive deterioration and loss of functional abilities. Increased light bolsters circadian rhythms and helps patients see better so they can be more active, said Elizabeth C. Brawley, a dementia care design expert not involved in the study, adding, "If I could change one thing in these places it would be the lighting."

Several German nursing homes have fake bus stops outside to keep patients from wandering; they wait for nonexistent buses until they forget where they wanted to go, or agree to come inside.

And Beatitudes installed a rectangle of black carpet in front of the dementia unit's fourth-floor elevators because residents appear to interpret it as a cliff or hole, no longer darting into elevators and wandering away.

"They'll walk right along the edge but don't want to step in the black," said Ms. Alonzo, who finds it less unsettling than methods some facilities use, bracelets that trigger alarms when residents exit. "People with dementia have visual-spatial problems. We've actually had some people so wary of it that when we have to get them on the elevator to take them somewhere, we put down a white towel or something to cover it up."

When elevator doors open, Beatitudes staff members stand casually in front, distracting residents with "over-the-top" hellos, she said: "We look like Cheshire cats," but "who's going to want to get on the elevator when here's this lovely smiling person greeting you? It gets through to the emotional brain."

New research suggests emotion persists after cognition deteriorates. In a University of Iowa study, people with brain damage producing Alzheimer's-like amnesia viewed film clips evoking tears and sadness ("Sophie's Choice," "Steel Magnolias"), or laughter and happiness (Bill Cosby, "America's Funniest Home Videos").

Six minutes later, participants had trouble recalling the clips. But 30 minutes later, emotion evaluations showed they still felt sad or happy, often more than participants with normal memories. The more memory-impaired patients retained stronger emotions.

Justin Feinstein, the lead author, an advanced neuropsychology doctoral student, said the results, being studied with Alzheimer's patients at Iowa and Harvard, suggest behavioral problems could stem from sadness or anxiety that patients cannot explain.

"Because you don't have a memory, there's this general free-floating state of distress and you can't really figure out why," Mr. Feinstein said. Similarly, happy emotions, even from socializing with patients, "could linger well beyond the memories that actually caused them."

One program for dementia patients cared for by relatives at home creates specific activities related to something they once enjoyed: arranging flowers, filling photo albums, snapping beans.

"A gentleman who loved fishing could still set up a tackle box, so we gave him a plastic tackle box" to set up every day, said the program's developer, Laura N. Gitlin, a sociologist at Thomas Jefferson University in Philadelphia and newly appointed director of the Center on Aging and Health at Johns Hopkins University.

After four months, patients seemed happier and more active, and showed fewer behavior problems, especially repetitive questioning and shadowing, following caregivers around. And that gave caregivers breaks, important because studies suggest that "what's good for the caregiver is good for the patient," Professor Gwyther said.

Aiding the Caregiver

In fact, reducing caregiver stress is considered significant enough in dementia care that federal and state health agencies are adopting programs giving caregivers education and emotional support.

One, led by Mary S. Mittelman, a New York University dementia expert, found that when people who cared for demented spouses were given six counseling sessions as well as counselors whom they could call in a crisis, it helped them handle caregiving better and delayed by 18 months placing patients in nursing homes.

"The patient did not have fewer symptoms," Dr. Mittelman said. "It was the caregiver's reaction that changed."

The Veterans Affairs Department is adopting another program, Resources for Enhancing Alzheimer's Caregiver Health, providing 12 counseling sessions and 5 telephone support group sessions. Studies showed that these measures reduced hospital visits and helped family caregivers manage dementia behaviors.

"Investing in caregiver services and support is very worthwhile," saving money and letting patients remain home, said Deborah Amdur, chief consultant for care management and social work at the Veterans Affairs Department.

Beatitudes, which takes about 30 moderate to severe dementia sufferers, introduced its program 12 years ago, focusing on individualized care.

"In the old days," Ms. Alonzo said, "we would find out more about somebody from their obituary than we did when they were alive."

The dementia floor was named Vermillion Cliffs, after colorfully layered rock formations formed by centuries of erosion, implying that, "although weathered, although tested by dementia, people are beautiful" and "have certain strengths," said Peggy Mullan, the president of Beatitudes.

The facility itself is institutional-looking, dowdy and "extremely outdated," Ms. Mullan said.

"It's ugly," said Jan Dougherty, director of family and community services at Banner Alzheimer's Institute in Phoenix. But "they're probably doing some of the best work" and "virtually have no sundowning," she said, referring to agitated, delusional behavior common with Alzheimer's, especially during afternoon and evening.

Beatitudes eliminated anything potentially considered restraining, from deep-seated wheelchairs that hinder standing up to bedrails (some beds are lowered and protected by mats). It drastically reduced antipsychotics and medications considered primarily for "staff convenience," focusing on relieving pain, Ms. Alonzo said.

It encouraged keeping residents out of diapers if possible, taking them to the toilet to preserve feelings of independence. Some staff members resisted, Ms. Alonzo said, but now "like it because it saves time" and difficult diaper changes.

Family members like Nancy Mendelsohn, whose mother, Rose Taran, was kicked out of facilities for screaming and calling 911, appreciate it. "The last place just put her in diapers, and she was not incontinent at all," Ms. Mendelsohn said.

Ms. Alonzo declined to pay workers more to adopt the additional skills or night work, saying, "We want people to work here because it's your bag."

Finding Favorite Things

For behavior management, Beatitudes plumbs residents' biographies, soothing one woman, Ruth Ann Clapper, by dabbing on White Shoulders perfume, which her biographical survey indicated she had worn before becoming ill. Food became available constantly, a canny move, Ms. Dougherty said, because people with dementia might be "too distracted" to eat during group mealtimes, and later "be acting out when what they actually need is food."

Realizing that nutritious, low-salt, low-fat, doctor-recommended foods might actually discourage people from eating, Ms. Alonzo began carrying chocolate in her pocket. "For God's sake," Ms. Mullan said, "if you like bacon, you can have bacon here."

Comforting food improves behavior and mood because it "sends messages they can still understand: 'it feels good, therefore I must be in a place where I'm loved,' " Ms. Dougherty said.

Now, when Maribeth Gallagher, Beatitudes' dementia program director, learns someone's favorite foods, "I'm going to pop that on your tongue, and you're going to go 'yum,' " she said. "Isn't that better than an injection?"

Beatitudes also changed activity programming. Instead of group events like bingo, in which few residents could actually participate, staff members, including housekeepers, conduct one-on-one activities: block-building, coloring, simply conversing. State regulators initially objected, saying, "Where's your big group, and what you're doing isn't right and doesn't follow regulations," Ms. Alonzo said.

Ms. Mullan said, "I don't think we ever got cited, but it was a huge fight to make sure we didn't."

These days, hundreds of Arizona physicians, medical students, and staff members at other nursing homes have received Beatitudes' training, and several Illinois nursing homes are adopting it. The program, which received an awardfrom an industry association, the American Association of Homes and Services for the Aging, also appears to save money.

Arlene Washington's family moved her to Beatitudes recently, pulling her from another nursing home because of what they considered inattentive and "improper care," said her husband, William. Mrs. Washington, 86, was heavily medicated, tube fed and unable to communicate, "like she had no life in her," said Sharon Hibbert, a friend.

At Beatitudes, Dr. Gillian Hamilton, administrative medical director, said she found Mrs. Washington "very sedated," took her off antipsychotics, then gradually stopped using the feeding tube. Now Mrs. Washington eats so well she no longer needs the insulin she was receiving. During a recent visit, she was alert, even singing a hymn.

That afternoon, Ms. Nance, in her wheelchair, happily held her baby doll, which she named Benjamin, and commented about raising her sons decades ago.

Ms. Alonzo had at first considered the doll an "undignified" and demeaning security blanket. But Ms. Gallagher explained that "for a lot of people who are parents, what gives them joy is caring for children."

"I was able," Ms. Gallagher said, "to find Margaret's strength."

Ms. Gallagher said she learned when approaching Ms. Nance to "look at her baby doll, and once I connect with the doll, I can look at her."

She squatted down, complimented Benjamin's shoes, and said, "You're the best mom I know."

Ms. Nance nodded earnestly.

"It's good to know," Ms. Nance said, "that somebody knows that you care."

Smarter Than You Think - When Computers Keep Watch -

Hundreds of correctional officers from prisons across America descended last spring on a shuttered penitentiary in West Virginia for annual training exercises.

Some officers played the role of prisoners, acting like gang members and stirring up trouble, including a mock riot. The latest in prison gear got a workout — body armor, shields, riot helmets, smoke bombs, gas masks. And, at this year's drill, computers that could see the action.

Perched above the prison yard, five cameras tracked the play-acting prisoners, and artificial-intelligence software analyzed the images to recognize faces, gestures and patterns of group behavior. When two groups of inmates moved toward each other, the experimental computer system sent an alert — a text message — to a corrections officer that warned of a potential incident and gave the location.

The computers cannot do anything more than officers who constantly watch surveillance monitors under ideal conditions. But in practice, officers are often distracted. When shifts change, an observation that is worth passing along may be forgotten. But machines do not blink or forget. They are tireless assistants.

The enthusiasm for such systems extends well beyond the nation's prisons. High-resolution, low-cost cameras are proliferating, found in products like smartphones and laptop computers. The cost of storing images is dropping, and new software algorithms for mining, matching and scrutinizing the flood of visual data are progressing swiftly.

A computer-vision system can watch a hospital room and remind doctors and nurses to wash their hands, or warn of restless patients who are in danger of falling out of bed. It can, through a computer-equipped mirror, read a man's face to detect his heart rate and other vital signs. It can analyze a woman's expressions as she watches a movie trailer or shops online, and help marketers tailor their offerings accordingly. Computer vision can also be used at shopping malls, schoolyards, subway platforms, office complexes and stadiums.

All of which could be helpful — or alarming.

"Machines will definitely be able to observe us and understand us better," said Hartmut Neven, a computer scientist and vision expert at Google. "Where that leads is uncertain."

Google has been both at the forefront of the technology's development and a source of the anxiety surrounding it. Its Street View service, which lets Internet users zoom in from above on a particular location, faced privacy complaints. Google will blur out people's homes at their request.

Google has also introduced an application called Goggles, which allows people to take a picture with a smartphone and search the Internet for matching images. The company's executives decided to exclude a facial-recognition feature, which they feared might be used to find personal information on people who did not know that they were being photographed.

Despite such qualms, computer vision is moving into the mainstream. With this technological evolution, scientists predict, people will increasingly be surrounded by machines that can not only see but also reason about what they are seeing, in their own limited way.

The uses, noted Frances Scott, an expert in surveillance technologies at the National Institute of Justice, the Justice Department's research agency, could allow the authorities to spot a terrorist, identify a lost child or locate anAlzheimer's patient who has wandered off.

The future of law enforcement, national security and military operations will most likely rely on observant machines. A few months ago, the Defense Advanced Research Projects Agency, the Pentagon's research arm, awarded the first round of grants in a five-year research program called the Mind's Eye. Its goal is to develop machines that can recognize, analyze and communicate what they see. Mounted on small robots or drones, these smart machines could replace human scouts. "These things, in a sense, could be team members," said James Donlon, the program's manager.

Millions of people now use products that show the progress that has been made in computer vision. In the last two years, the major online photo-sharing services — Picasa by Google, Windows Live Photo Gallery by Microsoft, Flickr by Yahoo and iPhoto by Apple — have all started using face recognition. A user puts a name to a face, and the service finds matches in other photographs. It is a popular tool for finding and organizing pictures.

Kinect, an add-on to Microsoft's Xbox 360 gaming console, is a striking advance for computer vision in the marketplace. It uses a digital camera and sensors to recognize people and gestures; it also understands voice commands. Players control the computer with waves of the hand, and then move to make their on-screen animated stand-ins — known as avatars — run, jump, swing and dance. Since Kinect was introduced in November, game reviewers have applauded, and sales are surging.

To Microsoft, Kinect is not just a game, but a step toward the future of computing. "It's a world where technology more fundamentally understands you, so you don't have to understand it," said Alex Kipman, an engineer on the team that designed Kinect.

'Please Wash Your Hands'

A nurse walks into a hospital room while scanning a clipboard. She greets the patient and washes her hands. She checks and records his heart rate and blood pressure, adjusts the intravenous drip, turns him over to look for bed sores, then heads for the door but does not wash her hands again, as protocol requires. "Pardon the interruption," declares a recorded women's voice, with a slight British accent. "Please wash your hands."

Three months ago, Bassett Medical Center in Cooperstown, N.Y., began an experiment with computer vision in a single hospital room. Three small cameras, mounted inconspicuously on the ceiling, monitor movements in Room 542, in a special care unit (a notch below intensive care) where patients are treated for conditions like severe pneumonia, heart attacks and strokes. The cameras track people going in and out of the room as well as the patient's movements in bed.

The first applications of the system, designed by scientists at General Electric, are immediate reminders and alerts. Doctors and nurses are supposed to wash their hands before and after touching a patient; lapses contribute significantly to hospital-acquired infections, research shows.

The camera over the bed delivers images to software that is programmed to recognize movements that indicate when a patient is in danger of falling out of bed. The system would send an alert to a nearby nurse.

If the results at Bassett prove to be encouraging, more features can be added, like software that analyzes facial expressions for signs of severe pain, the onset of delirium or other hints of distress, said Kunter Akbay, a G.E. scientist.

Hospitals have an incentive to adopt tools that improve patient safety. Medicare and Medicaid are adjusting reimbursement rates to penalize hospitals that do not work to prevent falls and pressure ulcers, and whose doctors and nurses do not wash their hands enough. But it is too early to say whether computer vision, like the system being tried out at Bassett, will prove to be cost-effective.

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Freakonomics Radio: You Say Repugnant, I Say ... Let's Do It! -

Some ideas are downright repugnant. Like …paying for human organs.

On the other hand, is it any less repugnant to let thousands of people die every year for want of a kidney that a lot of people might be willing to give up if they were able to be compensated?

Our new podcast ventures into the realm of repugnant ideas. (You can download/subscribe at iTunes, get the RSS feed or listen live via the link in box at right.) The fact is that the repugnance border shifts over time. Selling eggs or sperm, "renting" a womb — not long ago, all of this was considered way out of bounds. So was birth control and adoption. Go back a bit further in history: currency speculation, charging interest on loans, even selling life insurance — these practices, too, were almost universally felt to be repugnant.

Will the border shift for human organs as well? Should there be a legal market for organs? (At the moment, only Iran has one.) And if not, what should we be doing to help alleviate the massive world demand for transplantable organs, especially as the increase in diseases like diabetes continue to drive kidney failure?

Steve Levitt kicks off our journey through the repugnant by describing why economists can be useful in such conversations:

Economists are pretty much immune to repugnance. Either by birth or by training, economists have their mind open, or skewed in just such a way that instead of thinking about something in terms whether something it's right or wrong, they think about it in terms of whether it's efficient whether it makes sense…and many times the things that are most repugnant are the things that are quite efficient — but for other reasons, subtle reasons sometimes, are completely and utterly unacceptable.

The star of the podcast is Harvard economist Al Roth (the dean of repugnant ideas), who has thought a great deal about the organ problem. But more than that, he has actually done his part to help, helping to found the New England Program for Kidney Exchange

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