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Kales H.C.,University of Michigan | Kales H.C.,Center for Clinical Management Research | Kales H.C.,Geriatric Research | Gitlin L.N.,Johns Hopkins University | And 2 more authors.
Journal of the American Geriatrics Society | Year: 2014

Noncognitive neuropsychiatric symptoms (NPS) of dementia (aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, disinhibition) affect individuals with dementia nearly universally across dementia stages and etiologies. NPS are associated with poor outcomes for individuals with dementia and caregivers, including excess morbidity and mortality, greater healthcare use, and earlier nursing home placement, as well as caregiver stress, depression, and difficulty with employment. Although the Food and Drug Administration has not approved pharmacotherapy for NPS, psychotropic medications are frequently used to manage these symptoms, but in the few cases of proven pharmacological efficacy, significant risk of adverse effects may offset benefits. There is evidence of efficacy and limited potential for adverse effects of nonpharmacological treatments, typically considered first line, but their uptake as preferred treatments remains inadequate in real-world clinical settings. Thus, the field currently finds itself in a predicament in terms of management of these difficult symptoms. It was in this context that the University of Michigan Program for Positive Aging, working in collaboration with the Johns Hopkins Alzheimer's Disease Research Center and Center for Innovative Care in Aging sponsored and convened a multidisciplinary expert panel in Detroit, Michigan, in fall 2011 with three objectives: to define critical elements of care for NPS in dementia; to construct an approach describing the sequential and iterative steps of managing NPS in real-world clinical settings that can be used as a basis for integrating nonpharmacological and pharmacological approaches; and to discuss how the approach generated could be implemented in research and clinical care. © Published 2014. This article is a U.S. Government work and is in the public domain in the U.S.A.


Gitlin L.N.,Johns Hopkins University | Kales H.C.,University of Michigan | Kales H.C.,Center for Clinical Management Research | Lyketsos C.G.,Johns Hopkins Bayview Medical Center
JAMA - Journal of the American Medical Association | Year: 2012

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behavior scan accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, andresult in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case,we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction. ©2012 American Medical Association. All rights reserved.


Fagerlin A.,Center for Clinical Management Research | Fagerlin A.,University of Michigan | Zikmund-Fisher B.J.,University of Michigan | Ubel P.A.,Duke University
Journal of the National Cancer Institute | Year: 2011

With increasing frequency, patients are being asked to make complex decisions about cancer screening, prevention, and treatment. These decisions are fraught with emotion and cognitive difficulty simultaneously. Many Americans have low numeracy skills making the cognitive demands even greater whenever, as is often the case, patients are presented with risk statistics and asked to make comparisons between the risks and benefits of multiple options and to make informed medical decisions. In this commentary, we highlight 10 Methods that have been empirically shown to improve patients' understanding of risk and benefit information and/or their decision making. The Methods range from presenting absolute risks using frequencies (rather than presenting relative risks) to using a risk format that clarifies how treatment changes risks from preexisting baseline levels to using plain language. We then provide recommendations for how health-care providers and health educators can best to communicate this complex medical information to patients, including using plain language, pictographs, and absolute risks instead of relative risks. © 2011 The Author.


Sun G.H.,University of Michigan | Sun G.H.,Center for Clinical Management Research | Peress L.,University of Michigan | Pynnonen M.A.,University of Michigan
Otolaryngology - Head and Neck Surgery (United States) | Year: 2014

Objective. This study compared postoperative technical, quality-of-life, and cost outcomes following either robotic or open thyroidectomy for thyroid nodules and cancer. Data Sources. PubMed, Ovid MEDLINE, EMBASE, ISI Web of Science, and the Cochrane Central Register of Controlled Trials. Review Methods. We examined relevant controlled trials, comparative effectiveness studies, and cohort studies for eligible publications. We calculated the pooled relative risk for key postoperative complications, mean differences for operative time, and standardized mean differences for length of stay (LOS) using random effects models. Quality-of-life outcomes were summarized in narrative form. Results. The meta-analysis comprised 11 studies with 726 patients undergoing robotic transaxillary or axillo-breast thyroidectomy and 1205 undergoing open thyroidectomy. There were no eligible cost-related studies. Mean operative time for robotic thyroidectomy exceeded open thyroidectomy by 76.7 minutes, while no significant difference in LOS was identified. There were no significant differences in hematoma, seroma, recurrent laryngeal nerve injury, hypocalcemia, or chyle leak rates. The systematic review included 12 studies. Voice, swallowing, pain, and paresthesia outcomes showed no significant differences between the 2 approaches. The robotic cohort reported higher cosmetic satisfaction scores, although followup periods did not exceed 3 months and no validated questionnaires were used. Conclusions. Transaxillary and axillo-breast robotic and open thyroidectomy demonstrate similar complication rates, but robotic approaches may introduce the risk of new complications and require longer operative times. Robotic thyroidectomy appears to improve cosmetic outcomes, although longer follow-up periods and use of validated instruments are needed to more rigorously examine this effect. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2014.


Sun G.H.,University of Michigan | Sun G.H.,Center for Clinical Management Research
Otolaryngology - Head and Neck Surgery (United States) | Year: 2012

The ubiquity of the Internet has led to the widespread availability of health-related information to the public, and the subsequent empowerment of patients has fundamentally altered the patient-physician relationship. Among several concerns of physicians is the possibility that patients may be misinformed by information obtained from the Internet. One opportunity for health care providers to address this problem exists within Internet-based patient education materials (IPEMs). According to recent research in Otolaryngology-Head and Neck Surgery, IPEMs found within professional otolaryngology websites are written at the 8th- to 18th-grade reading comprehension level, essentially unchanged over the past 3 years. This greatly exceeds the fourth- to sixth-grade reading level recommended by the National Institutes of Health. Benefits, strategies, and challenges to improving the readability of IPEMs are discussed. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2012.

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