Life Space
Physicians Lindsey and Kirsten are back with a new topic. They discuss the concept of life space, the area in which one conducts life activities. Studies have demonstrated that larger life space positively affects health. Lindsey and Kirsten discuss the benefits of a larger life space and explore how to obtain these benefits even when life space is limited.
Physical Therapy for Shoulders
In this episode we discuss shoulder pathology including impingement, adhesive capsulitis, arthritis of the shoulder, and rotator cuff injuries with physical therapist Lindsey Sandbeck. We review what to expect from a PT evaluation, as well as non-operative and post-operative physical therapy. Lindsey provides insight into strategies to optimize recovery from shoulder injuries and surgery.
Dizziness
Dizziness can come in different forms: vertigo, lightheadedness, disequilibrium.
Vertigo: False movement, room spinning. Feels as if you are moving when you are not.
Benign Paroxysmal Positional Vertigo: acute, occurs with certain movements, lasts seconds to minutes
Dix-Hallpike to diagnose
Vestibular rehab/physical therapy to treat - Epley Maneuver
Meniere’s Disease: vertigo, with hearing loss and ringing in ears
Labyrinthitis
Central vertigo: can be more worrisome, exam looks for signs of stroke or other pathology. May need brain imaging.
Lightheadedness: feeling like one could pass out, pre-syncope
Cardiac causes: arrhythmias, valve disease
Orthostatic hypotension
Disequilibrium: sense of imbalance
Changes in nerve sensation can contribute: peripheral neuropathy, knee replacements
Vision and auditory impairment can also contribute
Diagnosis: monofilament testing, vibration sensory testing, gait speed, get up and go test, Romberg test all help evaluate
Treatable causes: B12 deficiency, thyroid disease, uncontrolled diabetes, medications that can be stopped (older anti-histamines)
Treatment: Adaptations (change in glasses, hearing aids), practice balance - physical therapy, strengthening
Persistent Postural Perceptual Dizziness (PPPD): persistent dizziness that worsens with motion or upright position, present > 3 months
Often follows BPPV or labyrinthitis
Anxiety, depression often present concomitantly
Treatment: Evaluate medications, consider medication to help with anxiety, depression
Health Pearl: For people who have been fully vaccinated for COVID-19, we discuss CDC guidelines and ways to safely expand activities.
Episode 38 - All About Asthma
In this episode we discuss asthma. We review symptoms, diagnosis, and treatment. We also discuss triggers and how to minimize them. We talk about creating a home management plant, or asthma action plan, with your doctor. Finally, we talk about symptoms that indicate an asthma exacerbation and symptoms that might indicate a need for prompt evaluation.
Health pearl: try a low calorie Shrub for a refreshing alcohol free drink.
Episode 36 - Gut Health
In this episode we discuss a problem commonly encountered in our clinics, chronic diarrhea. We review various causes, and discuss how patients can help us determine the cause. We provide a basic overview of treatment of some types of chronic diarrhea.
Common Aches and Pains
Tendonitis: Inflammation of the tendons (attachment of muscle to bone). Elbow, ankles, wrist, overuse.
Treatment: rest, ice, NSAIDS. Physical Therapy can be necessary and helpful
Bursitis: fluid filled sacs in areas of friction that can become inflamed.
Common: Trochanteric Bursitis (hip), Anserine bursitis (medial knee), Olecranon Bursitis (elbow)
Treatment: Physical therapy, Steroid injections, Ice, NSAIDS, stretching
Arthritis: Pain in the joints
Osteoarthritis: wear and tear or degenerative joint disease. Knees, hips, Spine, hands, shoulders
Risks: age, obesity, family history, prior injury, occupation
Pain worsens with use
Treatment: scheduled Tylenol, NSAIDS if able, injections ultimate joint replacement
Topicals always worth a try
Inflammatory Arthritis: most common Rheumatoid Arthritis (autoimmune- immune system fighting itself at the joints)
AM stiffness lasts hours, red, warm swollen joints, symmetric- hands wrists, feet, knees
Treatment: prescription medication to avoid destruction/deformity in the future
Future: Gut microbiome and diets role in joint inflammation and pain?
Health Pearl: Anti-inflammatory diet limit processed food, sugar, simple carbohydrates
Episode 34: the 4M’s
4M’s to discuss with your physician: Medications, Mobility, Mentation, Matters Most (what Matters Most)
Help shape patient-centered care
Reduce hospitalizations, decrease the need for care
Mobility - evaluate yearly
Measures:
Gait speed is one measure (slower than 1 m/s increased risk of falling, increased risk of hospitalization)
Timed get up and go
Balance evaluation by physical therapy
Getting up from chair without using arms
Next step:
Home exercise program (NIH healthy aging)
Physical therapy
Multi-disciplinary falls and stability clinic
Driving
- Multiple falls indicate increased risk for driving safety issues
Everyday movement is important to maintain mobility
Home exercises, Youtube exercises
Medications
Beer’s list - potentially inappropriate medications for older adults due to risk of side effects
Examples include benadryl, benzodiazepines, narcotic pain medications, some seizure medications
Need to look at benefits versus side effects
Evaluate for “prescribing cascades” - one medication is used to treat a side effect of another medication, and then another medication is used to treat side effects of that medication.
Polypharmacy - more than 6 medications is polypharmacy. More medications = more side effects and medication interactions. Deprescribing can help with this.
Goals of care can help determine which medications are adding value
Matters Most
It’s important to discuss what’s important and what makes life worth living, then delve deeper.
“What could you live without and still feel you have good quality of life?” Focuses on quality of life rather than just quantity
Patients can bring this topic up by bringing in an Advance Care Directive or Polst form, or mentioning this as a goal of the visit
Evolves depending on stage of life
Mentation
Assessment of memory and cognition, as well as mood
Generally we evaluate cognition when family brings up a concern or clinician notices a change
Can be done as part of Medicare Wellness Exam
Depression and anxiety can look like physical symptoms and cognitive changes in older population
Next steps if a concern is present:
Evaluate medications, which can impact cognition and mood
Obtain more information from screening tests, family members
Consider referral for further testing; this isn’t required to make a diagnosis
Neuropsych testing can distinguish between depression, anxiety, dementia
References
NIH National Institute on Aging
POLST: Portable Medical Orders
Health pearl: Get your influenza vaccines! They’re very important this year.
Everything Doc Show Notes: Genetic Counseling
Special guest: Allison Hutchinson a certified genetic counselor. Has worked at Sanford Imaginetics for the last 2 years. Her focus is working with teams to offer genomic and pharmacogenomics education to providers, patients, and the public. She is part of a research collaborative investigating whether these education interventions have been successful and how to continuously improve. Prior to this Allison was a high school science teacher for over a decade. She enjoys listening to podcasts in her spare time!
Quote: “Teaching should always start the discussion and never end it.”
Genetic Counselor: Advanced healthcare providers with training in genetics and counseling.
Education includes semester in classroom, year in clinic, research throughout
Certified
Who should see a genetic counselor?
Those with rare genetic diseases in family
Family history of related cancers in 2 or more people on same side, often earlier onset
Help interpreting consumer driven testing
Cardiovascular diseases: arrhythmias with sudden cardiac death, familial hypercholesterolemia
Pretest counseling is important! Think about all possible outcomes of genetic testing and what you might do with range of results.
How to prepare?
Come with information about family members: cause of death, age of death, chronic diseases, so pedigree can be developed.
Help write letters to family
Most insurances cover but varies check with your insurance
For more information about Genetic Counseling visit:
https://imagenetics.sanfordhealth.org/
https://www.aboutgeneticcounselors.org/
https://www.augie.edu/academics/graduatepeducation/master-science-genetic-counseling
The Dark Side of Isolation During COVID-19
In this episode, we discuss the unintended isolation that results from social distancing and quarantine measures, especially in the elderly. We review complications of isolation, including frailty, sarcopenia, depression, cognitive changes, and increased suicidality. We also review measures to help mitigate these adverse consequences, and discuss how everyone can help.
We explain which outings are safe and whether gathering during the summer can be safe. We review precautions that should be taken when out.
Health pearl: Find someone who could benefit from a safe, social distancing outing and do something fun together!
Resources:
Search “Adopt a Grandparent” to find a program near you.
Nacional Suicide Prevention Lifeline: (800) 273-8255, https://suicidepreventionlifeline.org
Mental Health During the Pandemic
Child and Adolescent Psychiatrist Dr. Stefanie Hanisch joins us to discuss mental health, especially that of youth, during the current pandemic.
Dr. Hanisch was born and raised in South Africa. She attended medical school at the University of Pretoria, South Africa, before obtaining her fellowship in Child and Adolescent Psychiatry at Baylor College of Medicine in Houston, TX. She served as Chief Resident before moving to Fargo, ND. She has been in her current practice since 2007 and currently serves as her Department Chair in addition to having faculty appointment at the UND School of Medicine. Dr. Hanisch is married and has two sons. She enjoys traveling with her family and is an accomplished runner.
In this episode, we talk about mental health (with a focus on youth) during the pandemic. We discuss the following points:
How kids might respond differently based on their age and developmental level
How to talk with kids about their feelings and fears.
Validation of feelings
Spend time with the fear, and then transition to constructive thinking (what you can do about the situation)
The value of parental role modeling
How to maintain health for all during the pandemic
When to seek help: WHEN NEEDS OUTWEIGH RESOURCES
Available resources include:
Your primary care provider
Emergency department
Health Pearl: take time to relax and destress. There are many great resources for this, including the following:
Headspace app
Ahway Island Podcast (for youth)
Calm app
Youtube Meditation
Peloton app - meditation, yoga, family work outs
Episode 30 COVID-19: A Marathon, Not a Sprint
Recorded Sunday April 5, 2020
Today we are joined by Infectious Disease expert Dr. Dubert Guerrero to discuss COVID-19. Dr. Guerrero is a practicing Infectious Disease Physician at Sanford Health. He graduated from the University of the Philippines and completed his training in Internal Medicine at Akron General Medical Center. He went on to complete an Infectious Disease fellowship at Case Western Reserve University in Cleveland, Ohio. Dr. Guerrero is married and has three children.
In this episode, we discuss common questions related to the current coronavirus pandemic, including
- What is social distancing?
- Is social distancing effective?
- Is it important to sanitize groceries and other items coming into one’s home?
- What can we expect to see over the next several months regarding COVID-19 cases?
- When can we expect to see vaccines and/or treatments for the virus?
Health pearl: take care of your mental health. You can do this by taking time for yourself every day, including exercise and mindfulness/meditation in your daily life.
Resources:
Center for Disease Control and Prevention
Your state health department
Your Questions Answered
This week we spend a few minutes summarizing key information about COVID 19.
The remainder of the episode is devoted to your questions, including topics ranging from which diet is best to how can you tell if your doctor is a good one.
Resources
COVID 19:
https://www.cdc.gov/coronavirus/2019-nCoV/index.html
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
Your state health department
Episode 28 Pharmacogenomics with Dr. Natasha Petry, PharmD, BCACP
Natasha has a bachelor’s degree in Microbiology and graduated with a Doctor of Pharmacy in 2012 from North Dakota State University in Fargo, ND. She completed a post graduate Pharmacy Practice Residency at Trinity Health in Minot, ND and joined the faculty at NDSU as an Assistant Professor with a clinical appointment at Sanford Health. She is a board-certified Ambulatory Care Pharmacist and began working in the area of Pharmacogenomics in 2014. She is an affiliate member of the NIH funded Implementing GeNomics In practice (IGNITE) network. She currently works as a Pharmacogenetics Clinical Pharmacist for Sanford Imagenetics. In addition, she is pursuing a Master of Public Health degree. Natasha is a wife, mother to 2 beautiful girls, and enjoys attending sporting events.
Pharmacogenomics: The genetics of how people metabolize (break down) medications. Genetic information can help guide the use of medication dosing and medication choice. Genetics looks at the enzymes that break down medications. Can help determine efficacy or utility, safety and/or dosing
Still limited but growing rapidly- another “tool in the toolbox”
Genetics does not change in a lifetime
Cost can be limiting
Currently useful in prescribing antidepressants, some pain medications, cholesterol medications (statins), clopidogrel (Plavix), warfarin
Limitations:
No standardization in lab testing regarding which allele variants are tested
Cost
Limited actionable results that impact a finite number of medications
Genetic testing collected through blood, saliva, cells from the cheeks depending on lab used
Variable insurance coverage: preemptive testing not likely covered, reactive is being covered more often
Direct to consumer testing vs. laboratory (health system) derived testing
Need Medical Geneticists and Pharmacists to help interpret information
Health Pearl: Try out meal delivery kits for improved health
Resource list: https://imaginetics.sandordhealth.org
https://www.genome.gov/FAQ/Pharmacogenomics
https://ghr.nlm.nih.gov/primer/genomicresearch/pharmacogenomics
https://www.yourgenome.org/facts/what-is-pharmacogenomics
https://nigms.nih.gov/education/pages/factsheet-pharmacogenomics.aspx
https://www.cdc.gov/genomics/disease/pharma.htm
https://pharmgkb.org/page/pharmacogenomics
https://www.pharmkb/page/iAmACitizen
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Episode 27: Sugar and Metabolic Syndrome
In this episode we discuss the impact of sugar on metabolism and the adverse effects of sugar loads on various organ systems.
Metabolic syndrome: dysregulation of normal metabolism. It can lead to damage of many organs. Increases risk of diabetes, high blood pressure, excess body fat (especially central obesity), abnormal cholesterol. This increases risk for heart attack and stroke. Can also lead to fatty liver disease.
High fructose loads cause cellular inflammation. Fructose loads trigger a metabolic pathway that stimulates increased consumption of food and storage of energy. This is beneficial for animals that hibernate or don’t have access to as much food during winter, but not for humans. Fructose also depletes energy on a cellular level.
The more concentrated the sugar load, the more it stimulates increased food consumption and storage. Because of this, sugary beverages such as soda, sports drinks, and juice should be avoided.
Foods to limit/avoid to help improve metabolism:
Juice and soda, sports drinks, or other beverages with added sugar.
Potatoes
Bread
Chips
Rice
Dried fruit
Fruits (limit, don’t avoid) - some have more sugar than others (grapes are high in sugar, low in fiber)
Beer and wine
Foods/beverages that promote healthy metabolism:
Water
Vegetables
For fruit consumption, eating berries, kiwi, other low sugar fruits is better
Resources:
Peter Attia, MD episode 87: Rick Johnson, MD: Fructose - the common link in high blood pressure, insulin resistance, T2D, & obesity? https://peterattiamd.com/rickjohnson/
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Warning Signs of Heart Attack and Stroke
Heart Attack: Occurs with decreased blood supply to the heart muscle.
Symptoms:
Chest pressure, like elephant sitting on chest
Jaw Pain
Pain into left arm
Nausea/indigestion
Breaking into a sweat
Shortness of breath
Other warning signs: change or decrease in exercise tolerance
Stroke: Decreased blood supply to area of the brain
Symptoms:
Facial drooping/drooling
Arm or leg weakness/numbness
Speech difficulty
Acute imbalance or change in/lack of coordination
These symptoms are concerning enough to warrant evaluation in an EMERGENCY DEPARTMENT!
Health Pearl: Read book Being Mortal by Atul Gawande or watch PBS documentary of the same name https://www.pbs.org/video/frontline-being-mortal/
A Pain in the Back
80% of the population will present to primary care with low back pain. Most of the time low back pain isn’t a signal of a worrisome underlying condition/ dangerous, though it can affect quality of life and become chronic.
Definitions:
Acute back pain: new back pain that has been present less than 4 weeks
Subacute back pain: back pain present for more than 4 and less than 12 weeks
Chronic back pain: back pain present for more than 12 weeks
Most of the time it will improve.
Symptoms:
Pain across the low back, may shoot down the leg or to other locations
Muscle spasm with stiffness
Difficulty urinating or moving bowels*
Weakness, foot drop*
Numbness, tingling
Tenderness over the spine
*More concerning symptoms
Causes:
Nonspecific - a definitive diagnosis is not obtained or needed
Injury/twisting/pulling
Osteoarthritis / degenerative disc disease
“Slipped disc” or disc herniation
Compression fractures
Radiculopathy (inflammation of the nerves)
Spinal stenosis (narrowing around the spinal cord)
Ankylosing spondylitis (auto-immune condition)
Scoliosis
Depression can increase pain sensations
Foot issues - flat feet, poor arch support can contribute
Kidney stones
Shingles
Intra-abdominal conditions (pancreatitis, gall bladder disease)
Less common, more worrisome causes: cauda equina syndrome, spinal infection, malignancy
Evaluation:
Office visit for history and exam, usually no X-rays or other imaging at the first appointment unless trauma occurred. Clinician can rule out worrisome symptoms
Management:
Physical therapy
Heat, ice
Acetaminophen, NSAIDs (ibuprofen, naproxen, etc) if approved by your clinician, muscle relaxants
Stretching, massage, rest
Exercise, strengthening supporting muscles - needs to be ongoing
Weight loss when indicated
Injections from pain clinic or spine clinic
Topical products (Biofreeze), lidocaine patches
Narcotic pain medications are not usually indicated. If they are, it would be for 3 days or less. Narcotics have no role in management of chronic pain.
Medications to help with nerve pain: duloxetine, gabapentin, pregabalin
Health pearl: book recommendation - Mayo Clinic Guide to Stress Free Living by Amit Sood.
Episode 7: Living Well with Dementia
Dementia - changes in memory and thinking that are beyond what is normal for age. It is progressive (worsens over time).
Treatment can slow progression of dementia, but there is no cure. It is felt that regular exercise, following a healthy diet such as the Mediterranean diet, and staying socially and cognitively engaged can help prevent dementia. Controlling chronic diseases such as high blood pressure, high cholesterol, and diabetes can also help with prevention.
Today we are joined by Deb Kaul, the owner of geriatric consulting service “Dignity Care” and one of the Co-founders of “Memory Café of the Red River Valley.” Deb has a bachelors degree in Business Administration from UND and a BSN from the University of Mary. She also has a Master’s certificate in Geriatric Care Management from the University of Florida. Deb considers the lessons she learned while caring for her parents - both of whom lived with dementia, the most valuable education she has ever received.
Deb provides recommendations for living with and caring for people living with dementia:
Keeping the diagnosis of dementia a secret from the person with dementia robs the individual of their autonomy. It also perpetuates the stigma related to dementia.
It is possible to live well with dementia.
Our responses to the diagnosis impact how a person responds to the disease. If they are diminished and de-humanized, they lose hope.
How to engage with a person living with memory loss: Greet them with a compliment or information that reminds them about their life. Tell them their story (“That is a beautiful/handsome sweater.” or “You did such a great job raising your children.”) Avoid quizzing them (“Did ___ come to visit you this morning?”)
For caregivers: Communicate about what’s occurring. Allow the person with memory loss to set goals for themselves. Avoid arguments with people living with dementia. They lose the ability to rationalize and reason, and it’s our job as caregivers to think creatively to solve problems. Caregivers can apologize, redirect, distract to work around conflicts or disagreements “Live their truth.” People with dementia are living in the present moment, so living with them in their truth/reality can help them and reduce conflicts. Engage trustworthy friends to build a village of support around them. People living with dementia should continue to have opportunities to make friends and maintain some independence. Communicate goals with physicians and other medical providers. Continue to pursue joy in life (both caregiver and person living with dementia).
Available resources:
“What the Hell Happened to my Brain?” by Kate Swaffer. The author’s diagnosis resulted in “prescribed disengagement” by her physician. She was told to “get her affairs in order” when diagnosed at age 49. She challenged these ideas and has achieved incredible things while living with dementia.
The Dementia Alliance International (DAI) - https://www.dementiaallianceinternational.org/
Alzheimer’s Association - https://www.alz.org/
Memory Cafe - free socialization and support for people with mild to moderate memory loss and their caregivers
Episode 23: Resolve to do your Advance Care Plan
We are joined by guest Gail Christopher to discuss Advance Care Planning. Gail is a nurse with over 40 years of experience in clinical nursing, surgery, utilization management, wellness coordination, and long term care among other things. In 2003 she obtained an MSN from UND with a focus on Nursing Administration. She works for Sanford Health in Fargo as the lead with the Advance Care Planning Team. In April 2019 she became a Certified Sacred Passage End of Life Doula through the Conscious Dying Institute in Boulder, CO. She has worked much of her career with the geriatric population and has a special interest in this area. She is a lifelong North Dakota native, and has 3 children and 5 grandchildren.
Advance care planning definition: formerly known as healthcare directive. Process of defining your goals and wishes for healthcare, especially if you’re unable to make those wishes known at some time in the future.
Barriers include
- Good health (feeling it doesn’t apply)
- Feeling their families already know wishes
- Misconception that it’s only for elderly
- Fear of facing mortality
- Mistrust of others’ ability to follow directive
Steps of completing an advance care directive
- Who do you want as an agent to speak on your behalf?
- Document your wishes
- Communicate with your family about your wishes so they can advocate for you
- Communicate with your PCP about your wishes. Your PCP can help maintain perspective and advocate for you
It’s important and can be helpful to think about how you want the end of your life to look.
Questions in advance care planning can include:
Where you want to die and how you would want that to look
What matters most to you? What makes life worth living?
Specific medical treatments that you would or would not want (including cost of certain treatments) - CPR, artificial nutrition, respiration, etc
Burial vs cremation vs donation
Organ donation
Autopsy
Once completed, advance care plans should be updated every 10 years or sooner if there are other major changes in health (new diagnoses, decline in health, death or change in the agent)
End of life can be a beautiful experience rather than something to fear.
Consults can be arranged with an advance care planning team. Local Sanford phone number: (701) 234-6980 to schedule an appointment or obtain advance care planning documents.
Resources:
https://www.cdc.gov/aging/pdf/acp-resources-public.pdf
Health Pearl: Butternut Squash Wild Rice Stew
Winter Colds
Most of the time caused by viral infections (no benefit from antibiotics) as opposed to bacterial infections. Symptoms include nasal congestion, headache, sinus pressure, face pain.
Control symptoms with humidifier, nasal washes/rinses, steroid nasal sprays, guaifenesin for thinning of mucous, Tylenol, and time. Often more than 2 weeks to see resolution of symptoms and can be up to 4-6 weeks.
Health Pearl: Try to begin active traditions like a Turkey trot during the holidays. Okay to indulge for 1 day. Be sure to drink water as this helps keep you full. ***Additional information: Prevention is key! Remember to wash your hands often during cold and flu season. Cover your mouth with the bend of your elbow when coughing or sneezing. Stay home from work or school when sick.