Opinion

Although cases of COVID-19 in children is reported to be low, we are seeing a surge in Wisconsin with a 27.6% positivity rate reported on Sept. 27. Numerous other states across the country are reporting similar jumps of 10% or more.

According to the Wisconsin Department of Health Services as of Sept. 20, 2020, there were 10,644 cumulative cases in persons aged less than 18 years. This rise in cases is consistent with a return to school and sports. This cumulative case load amounts to 836.7/100, 000 cases. This population may not experience the level of illness seen in the older populations with hospitalization rates of only 3% under the age of 9 years and 13% of those age 10- 19-years, yet exposing older family and members of the community is driving the death rates. The combined influenza and COVID-19 season may greatly impact hospitalization rates of young and old. Additionally, we may see a surge in pediatric cancer rates and autoimmune diseases secondary to these trends.

I believe the overall number of adolescents with COVID-19 is underreported. Teens admit to a lack of understanding of symptoms. Many do not realize they have COVID-19 until someone points out the symptoms they describe such as a loss of taste or smell are COVID-19 symptoms. Others report they do not report symptoms to prevent quarantine. Additionally, others endorse ridicule from peers if they have tested positive and contract tracing identifies others potentially exposed and forced to sit out of sports because of quarantine. They have been bullied into amnesia when contract tracers call to prevent identifying others at school or in the community. All these behaviors proliferate the spread of disease within the community and will continue to drive both exposures and death rates.

Teens in high schools require increased education of the symptoms of COVID-19, promotion of the flu vaccine, and knowledge of the impact they can have on preventing the spread of viruses.

Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee. She is a member of the Pediatric News editorial advisory board. She said she had no relevant financial disclosures. Email her at [email protected].

Reference

COVID-19: Wisconsin Cases, Wisconsin Department of Health Services. Accessed 2020 Sep 27.

Although cases of COVID-19 in children is reported to be low, we are seeing a surge in Wisconsin with a 27.6% positivity rate reported on Sept. 27. Numerous other states across the country are reporting similar jumps of 10% or more.

According to the Wisconsin Department of Health Services as of Sept. 20, 2020, there were 10,644 cumulative cases in persons aged less than 18 years. This rise in cases is consistent with a return to school and sports. This cumulative case load amounts to 836.7/100, 000 cases. This population may not experience the level of illness seen in the older populations with hospitalization rates of only 3% under the age of 9 years and 13% of those age 10- 19-years, yet exposing older family and members of the community is driving the death rates. The combined influenza and COVID-19 season may greatly impact hospitalization rates of young and old. Additionally, we may see a surge in pediatric cancer rates and autoimmune diseases secondary to these trends.

I believe the overall number of adolescents with COVID-19 is underreported. Teens admit to a lack of understanding of symptoms. Many do not realize they have COVID-19 until someone points out the symptoms they describe such as a loss of taste or smell are COVID-19 symptoms. Others report they do not report symptoms to prevent quarantine. Additionally, others endorse ridicule from peers if they have tested positive and contract tracing identifies others potentially exposed and forced to sit out of sports because of quarantine. They have been bullied into amnesia when contract tracers call to prevent identifying others at school or in the community. All these behaviors proliferate the spread of disease within the community and will continue to drive both exposures and death rates.

Teens in high schools require increased education of the symptoms of COVID-19, promotion of the flu vaccine, and knowledge of the impact they can have on preventing the spread of viruses.

Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee. She is a member of the Pediatric News editorial advisory board. She said she had no relevant financial disclosures. Email her at [email protected].

Reference

COVID-19: Wisconsin Cases, Wisconsin Department of Health Services. Accessed 2020 Sep 27.

Although cases of COVID-19 in children is reported to be low, we are seeing a surge in Wisconsin with a 27.6% positivity rate reported on Sept. 27. Numerous other states across the country are reporting similar jumps of 10% or more.

According to the Wisconsin Department of Health Services as of Sept. 20, 2020, there were 10,644 cumulative cases in persons aged less than 18 years. This rise in cases is consistent with a return to school and sports. This cumulative case load amounts to 836.7/100, 000 cases. This population may not experience the level of illness seen in the older populations with hospitalization rates of only 3% under the age of 9 years and 13% of those age 10- 19-years, yet exposing older family and members of the community is driving the death rates. The combined influenza and COVID-19 season may greatly impact hospitalization rates of young and old. Additionally, we may see a surge in pediatric cancer rates and autoimmune diseases secondary to these trends.

I believe the overall number of adolescents with COVID-19 is underreported. Teens admit to a lack of understanding of symptoms. Many do not realize they have COVID-19 until someone points out the symptoms they describe such as a loss of taste or smell are COVID-19 symptoms. Others report they do not report symptoms to prevent quarantine. Additionally, others endorse ridicule from peers if they have tested positive and contract tracing identifies others potentially exposed and forced to sit out of sports because of quarantine. They have been bullied into amnesia when contract tracers call to prevent identifying others at school or in the community. All these behaviors proliferate the spread of disease within the community and will continue to drive both exposures and death rates.

Teens in high schools require increased education of the symptoms of COVID-19, promotion of the flu vaccine, and knowledge of the impact they can have on preventing the spread of viruses.

Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee. She is a member of the Pediatric News editorial advisory board. She said she had no relevant financial disclosures. Email her at [email protected].

Reference

COVID-19: Wisconsin Cases, Wisconsin Department of Health Services. Accessed 2020 Sep 27.

I remember New Year’s Day 2020, full of hope and wonderment of what the year would bring. I was coming into the Society of Hospital Medicine as the incoming President, taking the 2020 reins in the organization’s 20th year. It would be a year of transitioning to a new CEO, reinvigorating our membership engagement efforts, and renewing a strategic plan for forward progress into the next decade. It would be a year chock full of travel, speaking engagements, and meetings with thousands of hospitalists around the globe.

What I didn’t know is that we would soon face the grim reality that the long-voiced concern of infectious disease experts and epidemiologists would come true. That our colleagues and friends and families would be infected, hospitalized, and die from this new disease, for which there were no good, effective treatments. That our ability to come together as a nation to implement basic infection control and epidemiologic practices would be fractured, uncoordinated, and ineffective. That within 6 months of the first case on U.S. soil, we would witness 5,270,000 people being infected from the disease, and 167,000 dying from it. And that the stunning toll of the disease would ripple into every nook and cranny of our society, from the economy to the fabric of our families and to the mental and physical health of all of our citizens.

However, what I couldn’t have known on this past New Year’s Day is how incredibly resilient and innovative our hospital medicine society and community would be to not only endure this new way of working and living, but also to find ways to improve upon how we care for all patients, despite COVID-19. What I couldn’t have known is how hospitalists would pivot to new arenas of care settings, including the EDs, ICUs, “COVID units,” and telehealth – flawlessly and seamlessly filling care gaps that would otherwise be catastrophically unfilled.

What I couldn’t have known is how we would be willing to come back into work, day after day, to care for our patients, despite the risks to ourselves and our families. What I couldn’t have known is how hospitalists would come together as a community to network and share knowledge in unprecedented ways, both humbly and proactively – knowing that we would not have all the answers but that we probably had better answers than most. What I couldn’t have known is that the SHM staff would pivot our entire SHM team away from previous “staple” offerings (e.g., live meetings) to virtual learning and network opportunities, which would be attended at rates higher than ever seen before, including live webinars, HMX exchanges, and e-learnings. What I couldn’t have known is that we would figure out, in a matter of weeks, what treatments were and were not effective for our patients and get those treatments to them despite the difficulties. And what I couldn’t have known is how much prouder I would be, more than ever before, to tell people: “I am a hospitalist.”

I took my son to the dentist recently, and when we were just about to leave, the dentist asked: “What do you do for a living?” and I stated: “I am a hospitalist.” He slowly breathed in and replied: “Oh … wow … you have really seen things …” Yes, we have.

So, is 2020 shaping up as expected? Absolutely not! But I am more inspired, humbled, and motivated than ever to proudly serve SHM with more energy and enthusiasm than I would have dreamed on New Year’s Day. And even if we can’t see each other in person (as we so naively planned), through virtual meetings (national, regional, and chapter), webinars, social media, and other listening modes, we will still be able to connect as a community and share ideas and issues as we muddle through the remainder of 2020 and beyond. We need each other more than ever before, and I am so proud to be a part of this SHM family.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

I remember New Year’s Day 2020, full of hope and wonderment of what the year would bring. I was coming into the Society of Hospital Medicine as the incoming President, taking the 2020 reins in the organization’s 20th year. It would be a year of transitioning to a new CEO, reinvigorating our membership engagement efforts, and renewing a strategic plan for forward progress into the next decade. It would be a year chock full of travel, speaking engagements, and meetings with thousands of hospitalists around the globe.

What I didn’t know is that we would soon face the grim reality that the long-voiced concern of infectious disease experts and epidemiologists would come true. That our colleagues and friends and families would be infected, hospitalized, and die from this new disease, for which there were no good, effective treatments. That our ability to come together as a nation to implement basic infection control and epidemiologic practices would be fractured, uncoordinated, and ineffective. That within 6 months of the first case on U.S. soil, we would witness 5,270,000 people being infected from the disease, and 167,000 dying from it. And that the stunning toll of the disease would ripple into every nook and cranny of our society, from the economy to the fabric of our families and to the mental and physical health of all of our citizens.

However, what I couldn’t have known on this past New Year’s Day is how incredibly resilient and innovative our hospital medicine society and community would be to not only endure this new way of working and living, but also to find ways to improve upon how we care for all patients, despite COVID-19. What I couldn’t have known is how hospitalists would pivot to new arenas of care settings, including the EDs, ICUs, “COVID units,” and telehealth – flawlessly and seamlessly filling care gaps that would otherwise be catastrophically unfilled.

What I couldn’t have known is how we would be willing to come back into work, day after day, to care for our patients, despite the risks to ourselves and our families. What I couldn’t have known is how hospitalists would come together as a community to network and share knowledge in unprecedented ways, both humbly and proactively – knowing that we would not have all the answers but that we probably had better answers than most. What I couldn’t have known is that the SHM staff would pivot our entire SHM team away from previous “staple” offerings (e.g., live meetings) to virtual learning and network opportunities, which would be attended at rates higher than ever seen before, including live webinars, HMX exchanges, and e-learnings. What I couldn’t have known is that we would figure out, in a matter of weeks, what treatments were and were not effective for our patients and get those treatments to them despite the difficulties. And what I couldn’t have known is how much prouder I would be, more than ever before, to tell people: “I am a hospitalist.”

I took my son to the dentist recently, and when we were just about to leave, the dentist asked: “What do you do for a living?” and I stated: “I am a hospitalist.” He slowly breathed in and replied: “Oh … wow … you have really seen things …” Yes, we have.

So, is 2020 shaping up as expected? Absolutely not! But I am more inspired, humbled, and motivated than ever to proudly serve SHM with more energy and enthusiasm than I would have dreamed on New Year’s Day. And even if we can’t see each other in person (as we so naively planned), through virtual meetings (national, regional, and chapter), webinars, social media, and other listening modes, we will still be able to connect as a community and share ideas and issues as we muddle through the remainder of 2020 and beyond. We need each other more than ever before, and I am so proud to be a part of this SHM family.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

I remember New Year’s Day 2020, full of hope and wonderment of what the year would bring. I was coming into the Society of Hospital Medicine as the incoming President, taking the 2020 reins in the organization’s 20th year. It would be a year of transitioning to a new CEO, reinvigorating our membership engagement efforts, and renewing a strategic plan for forward progress into the next decade. It would be a year chock full of travel, speaking engagements, and meetings with thousands of hospitalists around the globe.

What I didn’t know is that we would soon face the grim reality that the long-voiced concern of infectious disease experts and epidemiologists would come true. That our colleagues and friends and families would be infected, hospitalized, and die from this new disease, for which there were no good, effective treatments. That our ability to come together as a nation to implement basic infection control and epidemiologic practices would be fractured, uncoordinated, and ineffective. That within 6 months of the first case on U.S. soil, we would witness 5,270,000 people being infected from the disease, and 167,000 dying from it. And that the stunning toll of the disease would ripple into every nook and cranny of our society, from the economy to the fabric of our families and to the mental and physical health of all of our citizens.

However, what I couldn’t have known on this past New Year’s Day is how incredibly resilient and innovative our hospital medicine society and community would be to not only endure this new way of working and living, but also to find ways to improve upon how we care for all patients, despite COVID-19. What I couldn’t have known is how hospitalists would pivot to new arenas of care settings, including the EDs, ICUs, “COVID units,” and telehealth – flawlessly and seamlessly filling care gaps that would otherwise be catastrophically unfilled.

What I couldn’t have known is how we would be willing to come back into work, day after day, to care for our patients, despite the risks to ourselves and our families. What I couldn’t have known is how hospitalists would come together as a community to network and share knowledge in unprecedented ways, both humbly and proactively – knowing that we would not have all the answers but that we probably had better answers than most. What I couldn’t have known is that the SHM staff would pivot our entire SHM team away from previous “staple” offerings (e.g., live meetings) to virtual learning and network opportunities, which would be attended at rates higher than ever seen before, including live webinars, HMX exchanges, and e-learnings. What I couldn’t have known is that we would figure out, in a matter of weeks, what treatments were and were not effective for our patients and get those treatments to them despite the difficulties. And what I couldn’t have known is how much prouder I would be, more than ever before, to tell people: “I am a hospitalist.”

I took my son to the dentist recently, and when we were just about to leave, the dentist asked: “What do you do for a living?” and I stated: “I am a hospitalist.” He slowly breathed in and replied: “Oh … wow … you have really seen things …” Yes, we have.

So, is 2020 shaping up as expected? Absolutely not! But I am more inspired, humbled, and motivated than ever to proudly serve SHM with more energy and enthusiasm than I would have dreamed on New Year’s Day. And even if we can’t see each other in person (as we so naively planned), through virtual meetings (national, regional, and chapter), webinars, social media, and other listening modes, we will still be able to connect as a community and share ideas and issues as we muddle through the remainder of 2020 and beyond. We need each other more than ever before, and I am so proud to be a part of this SHM family.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

Editor’s Note: This transcript from the October 7 episode of Psychcast and the October 8 episode of Blood & Cancer has been edited for clarity.

David Henry, MD: Welcome to this episode of Blood And Cancer. I’m your host, Dr. David Henry, and I’m joined today by another host in the MDedge family, Dr. Lorenzo Norris, who is the host of MDedge Psychcast on MDedge.com or wherever you get your podcasts. He is associate dean of student affairs and administration at the George Washington School of Medicine in Washington, DC. Dr. Norris, thank you so much for taking the time to do this today.

Dr. Norris: CBT in a nutshell -- how you think influences greatly your emotions, which influences your behavior. Very simple and very powerful. With breast cancer, as an example, patients are dealing with a great deal of stress. They are literally fighting for their lives.

And that’s going to allow you to actually think about or to screen for patients that you’re going to need to refer for treatment. So if you have a patient with advanced cancer, as an example, and you use the PHQ-2 or PHQ-9, then that’s going to give you a very evidence-based avenue in which to refer for treatment. Now you may be asking yourself, maybe I don’t want to use a PHQ-2 or 9, or I’m in a community practice or a private practice, I just don’t have the bandwidth to process this.

So I want to go off of just my own patient interaction. What are things that I can cue on?

With a patient with cancer, there’s going to be roughly four things that we’re considering in terms of depressive spectrum disorders: Adjustment disorder with depressed mood, major depression, a mood disorder due to cancer itself, or substance-induced mood disorder.

For our audience I want you to concentrate on right now on adjustment disorder with depressed mood and major depression. Now when you look at the evidence, there are roughly nine things that some people like to think about in regard to depressive symptoms to key on. For all of us as health practitioners, these are the things I would like for you to focus on in particular:

1. Non-adherence with treatment for cancer.

2. Impairment of their social or occupational function.

3. Your patient becomes demoralized when they start to lose a little bit of confidence or hope.

When you have those three things, or any one of them, in an advanced stage of cancer, with or without a PHQ screening, you need to really think about how you’re going to refer this patient for treatment. So we can break this down into three different types of interventions. One, the biggest thing, is just to ask, “How are you feeling? What is your mood? Are you suffering from a clinical depression?” You know, take a little bit of inspiration from Dr. Henry. Just give it to people straight and just ask. That’s the biggest thing people don’t do. They don’t ask.

The next thing, if you want to use an evidence-based scale, use a PHQ-2...You would have to follow up, but you-- rather you’re practicing solo or in a group practice or whether you have, your nurse or PA -- they generally assist with that.

And then the third thing is, when you’re interacting with the patient, look for those three things that I talked about: Non-adherence with treatment, impairment of social or occupational function, and then demoralization.

And then the final thing I want to focus on, because you can’t talk about depression without talking about suicide or really significant distress. Obviously, you can ask and you should ask about suicide if that is in your wheelhouse, but to be perfectly frank, most oncologists are not going to-- or most people outside of psychiatrists aren’t going to necessarily just routinely ask that question.

But here’s what I would say. It’s an old one but it’s a good one: Listen to that little voice. Listen to that little voice, all right? Depending on the evidence that you look at, a lot of detecting suicide can be aided by a clinician listening to their own gut instincts. What I mean by that is, you feel a sense of distress. You feel a sense of lack of connection. You find yourself [saying], “Wait a minute, why do I want to call that patient and checkup? Why do I want to reach out?”

When you start to feel like this, you need to listen. More importantly, you need to stop and then you need to make sure that that patient has a referral in place.

Dr. Henry: So they’re just tuning out so badly, you’re really losing the connection, and that’s when your little voice talks to you.

Dr. Norris: Exactly. Well said, Dr. Henry. Well said.

Dr. Henry: In my long career, drug abuse, narcotics, and suicide have been extremely rare. I can think of one patient who was a drug abuser with cancer, or it turned out she was a drug abuser before she had cancer. And then suicide, really quite rare. I’m sure they occur, and we have to watch for them, as you say, but fortunately I’ve not seen that so much. Thanks to your comments, I want to be sure I’m watching and looking.

And the PHQ-2 and -9, I’m sure, with so many of us having electronic medical records, you can simply Google while you’re talking to the patient for those two questionnaires and say, oh, you know, how about you answer these two questions, these nine questions, and see how many points the patient gets and worry about referral or even medication yourself if it looks like an antidepressant is in order.

Dr. Norris: Absolutely. Absolutely.

Dr. Henry: Well, I think we’ve covered an awful lot of ground. I really want to thank you. Any get-away thoughts? We worry about the cognitive behavioral therapy. We worry about it, and we should listen to it and do it.

Practicing in the COVID era is stressful for all of us. I told Dr. Norris at the outset, if I broke down and started baring my soul, he wouldn’t be surprised. Fortunately, I’ve kept it together while talking to a psychiatrist.

And finally watch for clinically significant depression, either by your own questions, which you’ve outlined, or the PHQ-2 and -9.

Really appreciate your thoughts today. Lorenzo, thanks so much for taking the time to do this today.


To hear the entire conversation, go to mdedge.com/podcasts or listen wherever you find your podcasts. David Henry, MD, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He is editor in chief of MDedge Hematology-Oncology and the host of the Blood & Cancer podcast. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.

Lorenzo Norris, MD, is host of the MDedge Psychcast, editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Lorenzo Norris has no conflicts.

Editor’s Note: This transcript from the October 7 episode of Psychcast and the October 8 episode of Blood & Cancer has been edited for clarity.

David Henry, MD: Welcome to this episode of Blood And Cancer. I’m your host, Dr. David Henry, and I’m joined today by another host in the MDedge family, Dr. Lorenzo Norris, who is the host of MDedge Psychcast on MDedge.com or wherever you get your podcasts. He is associate dean of student affairs and administration at the George Washington School of Medicine in Washington, DC. Dr. Norris, thank you so much for taking the time to do this today.

Dr. Norris: CBT in a nutshell -- how you think influences greatly your emotions, which influences your behavior. Very simple and very powerful. With breast cancer, as an example, patients are dealing with a great deal of stress. They are literally fighting for their lives.

And that’s going to allow you to actually think about or to screen for patients that you’re going to need to refer for treatment. So if you have a patient with advanced cancer, as an example, and you use the PHQ-2 or PHQ-9, then that’s going to give you a very evidence-based avenue in which to refer for treatment. Now you may be asking yourself, maybe I don’t want to use a PHQ-2 or 9, or I’m in a community practice or a private practice, I just don’t have the bandwidth to process this.

So I want to go off of just my own patient interaction. What are things that I can cue on?

With a patient with cancer, there’s going to be roughly four things that we’re considering in terms of depressive spectrum disorders: Adjustment disorder with depressed mood, major depression, a mood disorder due to cancer itself, or substance-induced mood disorder.

For our audience I want you to concentrate on right now on adjustment disorder with depressed mood and major depression. Now when you look at the evidence, there are roughly nine things that some people like to think about in regard to depressive symptoms to key on. For all of us as health practitioners, these are the things I would like for you to focus on in particular:

1. Non-adherence with treatment for cancer.

2. Impairment of their social or occupational function.

3. Your patient becomes demoralized when they start to lose a little bit of confidence or hope.

When you have those three things, or any one of them, in an advanced stage of cancer, with or without a PHQ screening, you need to really think about how you’re going to refer this patient for treatment. So we can break this down into three different types of interventions. One, the biggest thing, is just to ask, “How are you feeling? What is your mood? Are you suffering from a clinical depression?” You know, take a little bit of inspiration from Dr. Henry. Just give it to people straight and just ask. That’s the biggest thing people don’t do. They don’t ask.

The next thing, if you want to use an evidence-based scale, use a PHQ-2...You would have to follow up, but you-- rather you’re practicing solo or in a group practice or whether you have, your nurse or PA -- they generally assist with that.

And then the third thing is, when you’re interacting with the patient, look for those three things that I talked about: Non-adherence with treatment, impairment of social or occupational function, and then demoralization.

And then the final thing I want to focus on, because you can’t talk about depression without talking about suicide or really significant distress. Obviously, you can ask and you should ask about suicide if that is in your wheelhouse, but to be perfectly frank, most oncologists are not going to-- or most people outside of psychiatrists aren’t going to necessarily just routinely ask that question.

But here’s what I would say. It’s an old one but it’s a good one: Listen to that little voice. Listen to that little voice, all right? Depending on the evidence that you look at, a lot of detecting suicide can be aided by a clinician listening to their own gut instincts. What I mean by that is, you feel a sense of distress. You feel a sense of lack of connection. You find yourself [saying], “Wait a minute, why do I want to call that patient and checkup? Why do I want to reach out?”

When you start to feel like this, you need to listen. More importantly, you need to stop and then you need to make sure that that patient has a referral in place.

Dr. Henry: So they’re just tuning out so badly, you’re really losing the connection, and that’s when your little voice talks to you.

Dr. Norris: Exactly. Well said, Dr. Henry. Well said.

Dr. Henry: In my long career, drug abuse, narcotics, and suicide have been extremely rare. I can think of one patient who was a drug abuser with cancer, or it turned out she was a drug abuser before she had cancer. And then suicide, really quite rare. I’m sure they occur, and we have to watch for them, as you say, but fortunately I’ve not seen that so much. Thanks to your comments, I want to be sure I’m watching and looking.

And the PHQ-2 and -9, I’m sure, with so many of us having electronic medical records, you can simply Google while you’re talking to the patient for those two questionnaires and say, oh, you know, how about you answer these two questions, these nine questions, and see how many points the patient gets and worry about referral or even medication yourself if it looks like an antidepressant is in order.

Dr. Norris: Absolutely. Absolutely.

Dr. Henry: Well, I think we’ve covered an awful lot of ground. I really want to thank you. Any get-away thoughts? We worry about the cognitive behavioral therapy. We worry about it, and we should listen to it and do it.

Practicing in the COVID era is stressful for all of us. I told Dr. Norris at the outset, if I broke down and started baring my soul, he wouldn’t be surprised. Fortunately, I’ve kept it together while talking to a psychiatrist.

And finally watch for clinically significant depression, either by your own questions, which you’ve outlined, or the PHQ-2 and -9.

Really appreciate your thoughts today. Lorenzo, thanks so much for taking the time to do this today.


To hear the entire conversation, go to mdedge.com/podcasts or listen wherever you find your podcasts. David Henry, MD, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He is editor in chief of MDedge Hematology-Oncology and the host of the Blood & Cancer podcast. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.

Lorenzo Norris, MD, is host of the MDedge Psychcast, editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Lorenzo Norris has no conflicts.

Editor’s Note: This transcript from the October 7 episode of Psychcast and the October 8 episode of Blood & Cancer has been edited for clarity.

David Henry, MD: Welcome to this episode of Blood And Cancer. I’m your host, Dr. David Henry, and I’m joined today by another host in the MDedge family, Dr. Lorenzo Norris, who is the host of MDedge Psychcast on MDedge.com or wherever you get your podcasts. He is associate dean of student affairs and administration at the George Washington School of Medicine in Washington, DC. Dr. Norris, thank you so much for taking the time to do this today.

Dr. Norris: CBT in a nutshell -- how you think influences greatly your emotions, which influences your behavior. Very simple and very powerful. With breast cancer, as an example, patients are dealing with a great deal of stress. They are literally fighting for their lives.

And that’s going to allow you to actually think about or to screen for patients that you’re going to need to refer for treatment. So if you have a patient with advanced cancer, as an example, and you use the PHQ-2 or PHQ-9, then that’s going to give you a very evidence-based avenue in which to refer for treatment. Now you may be asking yourself, maybe I don’t want to use a PHQ-2 or 9, or I’m in a community practice or a private practice, I just don’t have the bandwidth to process this.

So I want to go off of just my own patient interaction. What are things that I can cue on?

With a patient with cancer, there’s going to be roughly four things that we’re considering in terms of depressive spectrum disorders: Adjustment disorder with depressed mood, major depression, a mood disorder due to cancer itself, or substance-induced mood disorder.

For our audience I want you to concentrate on right now on adjustment disorder with depressed mood and major depression. Now when you look at the evidence, there are roughly nine things that some people like to think about in regard to depressive symptoms to key on. For all of us as health practitioners, these are the things I would like for you to focus on in particular:

1. Non-adherence with treatment for cancer.

2. Impairment of their social or occupational function.

3. Your patient becomes demoralized when they start to lose a little bit of confidence or hope.

When you have those three things, or any one of them, in an advanced stage of cancer, with or without a PHQ screening, you need to really think about how you’re going to refer this patient for treatment. So we can break this down into three different types of interventions. One, the biggest thing, is just to ask, “How are you feeling? What is your mood? Are you suffering from a clinical depression?” You know, take a little bit of inspiration from Dr. Henry. Just give it to people straight and just ask. That’s the biggest thing people don’t do. They don’t ask.

The next thing, if you want to use an evidence-based scale, use a PHQ-2...You would have to follow up, but you-- rather you’re practicing solo or in a group practice or whether you have, your nurse or PA -- they generally assist with that.

And then the third thing is, when you’re interacting with the patient, look for those three things that I talked about: Non-adherence with treatment, impairment of social or occupational function, and then demoralization.

And then the final thing I want to focus on, because you can’t talk about depression without talking about suicide or really significant distress. Obviously, you can ask and you should ask about suicide if that is in your wheelhouse, but to be perfectly frank, most oncologists are not going to-- or most people outside of psychiatrists aren’t going to necessarily just routinely ask that question.

But here’s what I would say. It’s an old one but it’s a good one: Listen to that little voice. Listen to that little voice, all right? Depending on the evidence that you look at, a lot of detecting suicide can be aided by a clinician listening to their own gut instincts. What I mean by that is, you feel a sense of distress. You feel a sense of lack of connection. You find yourself [saying], “Wait a minute, why do I want to call that patient and checkup? Why do I want to reach out?”

When you start to feel like this, you need to listen. More importantly, you need to stop and then you need to make sure that that patient has a referral in place.

Dr. Henry: So they’re just tuning out so badly, you’re really losing the connection, and that’s when your little voice talks to you.

Dr. Norris: Exactly. Well said, Dr. Henry. Well said.

Dr. Henry: In my long career, drug abuse, narcotics, and suicide have been extremely rare. I can think of one patient who was a drug abuser with cancer, or it turned out she was a drug abuser before she had cancer. And then suicide, really quite rare. I’m sure they occur, and we have to watch for them, as you say, but fortunately I’ve not seen that so much. Thanks to your comments, I want to be sure I’m watching and looking.

And the PHQ-2 and -9, I’m sure, with so many of us having electronic medical records, you can simply Google while you’re talking to the patient for those two questionnaires and say, oh, you know, how about you answer these two questions, these nine questions, and see how many points the patient gets and worry about referral or even medication yourself if it looks like an antidepressant is in order.

Dr. Norris: Absolutely. Absolutely.

Dr. Henry: Well, I think we’ve covered an awful lot of ground. I really want to thank you. Any get-away thoughts? We worry about the cognitive behavioral therapy. We worry about it, and we should listen to it and do it.

Practicing in the COVID era is stressful for all of us. I told Dr. Norris at the outset, if I broke down and started baring my soul, he wouldn’t be surprised. Fortunately, I’ve kept it together while talking to a psychiatrist.

And finally watch for clinically significant depression, either by your own questions, which you’ve outlined, or the PHQ-2 and -9.

Really appreciate your thoughts today. Lorenzo, thanks so much for taking the time to do this today.


To hear the entire conversation, go to mdedge.com/podcasts or listen wherever you find your podcasts. David Henry, MD, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He is editor in chief of MDedge Hematology-Oncology and the host of the Blood & Cancer podcast. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.

Lorenzo Norris, MD, is host of the MDedge Psychcast, editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Lorenzo Norris has no conflicts.

“Diabetes drugs may cure dementia.”

How many of you saw that headline (or similar) earlier this year, before the pandemic took over the news?

My patients sure did. And their families. And people who aren’t my patients but found my name in the phone book after reading the headline. Of course, all of them wanted to be put on diabetes drugs to cure or prevent dementia, like the headline said.

The key word in the headline, though, is “may,” which promises nothing. Not only that, but if you actually read the story you quickly learn that the study was done in people who have diabetes, and lowers the risk of dementia.

While there could, possibly, maybe, be something interesting underlying the finding, it could also be as simple as controlling your vascular risk factors, which is good for you.

Of course, the lay public rarely reads past the first few paragraphs. To the nonmedical reader, the cure has been found, and they want it. Where’s the phone?

I’m sure this is good for business in the lay press. People see the headline and don’t bother to read the story but they immediately forward it to friends, family, Facebook and Twitter groups ... That’s a lot of clicks and advertising.

The study might genuinely mean something, but that’s a big “might.” A lot of common drugs have been hyped as being treatments for dementia – statins, ibuprofen, estrogen patches, to name a few – only to quietly die in larger controlled trials. But that part of the research never seems to make the news, only the first small, preliminary, results.

People want us to find answers. Isn’t that what doctors and scientists are supposed to do? I understand that. But by the same token, it’s generally not that easy. And if we try to explain the difficulty, then we’re often accused of being part of “them,” some secretive group trying to hide inexpensive miracle cures from the public to keep Big Pharma in business.

The real truth is that a lot of things initially seem to be good (or bad) and these things change like the seasons. Everyone should be on daily aspirin, oops, maybe not. Saccharine causes bladder cancer, wait, I take that back. And so on.

While diabetes treatments may indeed lower the risk of dementia in patients who have diabetes, people too often extrapolate that to everyone, and wishfully think the headline says “does cure” instead of “may cure.”

I have nothing against research. Everything we have now came from it. But preliminary results are just that – preliminary. Like many other things in this world, they have to be taken with a grain of salt.

Dr. Block has a solo neurology practice in Scottsdale, Arizona. He has no relevant disclosures.

“Diabetes drugs may cure dementia.”

How many of you saw that headline (or similar) earlier this year, before the pandemic took over the news?

My patients sure did. And their families. And people who aren’t my patients but found my name in the phone book after reading the headline. Of course, all of them wanted to be put on diabetes drugs to cure or prevent dementia, like the headline said.

The key word in the headline, though, is “may,” which promises nothing. Not only that, but if you actually read the story you quickly learn that the study was done in people who have diabetes, and lowers the risk of dementia.

While there could, possibly, maybe, be something interesting underlying the finding, it could also be as simple as controlling your vascular risk factors, which is good for you.

Of course, the lay public rarely reads past the first few paragraphs. To the nonmedical reader, the cure has been found, and they want it. Where’s the phone?

I’m sure this is good for business in the lay press. People see the headline and don’t bother to read the story but they immediately forward it to friends, family, Facebook and Twitter groups ... That’s a lot of clicks and advertising.

The study might genuinely mean something, but that’s a big “might.” A lot of common drugs have been hyped as being treatments for dementia – statins, ibuprofen, estrogen patches, to name a few – only to quietly die in larger controlled trials. But that part of the research never seems to make the news, only the first small, preliminary, results.

People want us to find answers. Isn’t that what doctors and scientists are supposed to do? I understand that. But by the same token, it’s generally not that easy. And if we try to explain the difficulty, then we’re often accused of being part of “them,” some secretive group trying to hide inexpensive miracle cures from the public to keep Big Pharma in business.

The real truth is that a lot of things initially seem to be good (or bad) and these things change like the seasons. Everyone should be on daily aspirin, oops, maybe not. Saccharine causes bladder cancer, wait, I take that back. And so on.

While diabetes treatments may indeed lower the risk of dementia in patients who have diabetes, people too often extrapolate that to everyone, and wishfully think the headline says “does cure” instead of “may cure.”

I have nothing against research. Everything we have now came from it. But preliminary results are just that – preliminary. Like many other things in this world, they have to be taken with a grain of salt.

Dr. Block has a solo neurology practice in Scottsdale, Arizona. He has no relevant disclosures.

“Diabetes drugs may cure dementia.”

How many of you saw that headline (or similar) earlier this year, before the pandemic took over the news?

My patients sure did. And their families. And people who aren’t my patients but found my name in the phone book after reading the headline. Of course, all of them wanted to be put on diabetes drugs to cure or prevent dementia, like the headline said.

The key word in the headline, though, is “may,” which promises nothing. Not only that, but if you actually read the story you quickly learn that the study was done in people who have diabetes, and lowers the risk of dementia.

While there could, possibly, maybe, be something interesting underlying the finding, it could also be as simple as controlling your vascular risk factors, which is good for you.

Of course, the lay public rarely reads past the first few paragraphs. To the nonmedical reader, the cure has been found, and they want it. Where’s the phone?

I’m sure this is good for business in the lay press. People see the headline and don’t bother to read the story but they immediately forward it to friends, family, Facebook and Twitter groups ... That’s a lot of clicks and advertising.

The study might genuinely mean something, but that’s a big “might.” A lot of common drugs have been hyped as being treatments for dementia – statins, ibuprofen, estrogen patches, to name a few – only to quietly die in larger controlled trials. But that part of the research never seems to make the news, only the first small, preliminary, results.

People want us to find answers. Isn’t that what doctors and scientists are supposed to do? I understand that. But by the same token, it’s generally not that easy. And if we try to explain the difficulty, then we’re often accused of being part of “them,” some secretive group trying to hide inexpensive miracle cures from the public to keep Big Pharma in business.

The real truth is that a lot of things initially seem to be good (or bad) and these things change like the seasons. Everyone should be on daily aspirin, oops, maybe not. Saccharine causes bladder cancer, wait, I take that back. And so on.

While diabetes treatments may indeed lower the risk of dementia in patients who have diabetes, people too often extrapolate that to everyone, and wishfully think the headline says “does cure” instead of “may cure.”

I have nothing against research. Everything we have now came from it. But preliminary results are just that – preliminary. Like many other things in this world, they have to be taken with a grain of salt.

Dr. Block has a solo neurology practice in Scottsdale, Arizona. He has no relevant disclosures.

An ADHD brain thrives with daily routines, and requires spontaneity and challenge to remain engaged in work, academics, relationships, and even leisure activities. ADHD is a performance issue and not one of intellectual understanding. It is not a problem of knowing what to do, but rather, difficulty doing it.

The COVID-19 pandemic has led to the loss of structure, with many parents working out of their homes alongside their children engaged in virtual learning. There has been a significant loss of impromptu events, since all activities outside of the house require proper planning and safety precautions.

To help normalize the struggles of the adult patient with ADHD during the pandemic, I have compiled a list of everything I want my adult ADHD patients and their family members to know so they don’t feel shame, guilt, or hopelessness when others’ coping strategies do not work for their ADHD brains.
 

Adult ADHD is a misnomer – and not just a disorder of inattention and hyperactivity

A better name for this often misconstrued disorder is inconsistent attention and motivation disorder with internal or external hyperactivity/impulsivity.

An ADHD brain vacillates between inattention and hyperfocus. It is not uncommon for individuals with ADHD to lose interest in a new television series when they become hyperfocused on finding the best pandemic-friendly toy for their 5-year-olds, which inevitably turns into a 3-hour Google rabbit-hole search.

These same individuals with ADHD may have low motivation for mundane household chores but become highly motivated when their nonessential Amazon purchases arrive. They may even go as far as pulling an all-nighter to have an electric toy jeep built and ready for the youngster by morning.

Adults with ADHD can also exhibit hyperactive symptoms, such as physical restlessness with fidgeting, and an internal restlessness with anxious and repetitive thoughts that affect their ability to unwind, relax, and even sleep. Impulsivity in adults with ADHD can present as rushing through tasks that one finds uninteresting or unimportant, interrupting others on a Zoom work call, or impulse buying an expensive hot tub instead of a more affordable on their spouse agreed to.
 

ADHD is a risk factor for contracting COVID-19

Untreated ADHD can increase one’s risk of contracting COVID-19. Israeli researchers published a study in the Journal of Attention Disorders showing that individuals with ADHD are 52% more likely to test positive for COVID-19, compared with those without ADHD, because of risk-taking behaviors, impulsivity, and carelessness. However, individuals whose ADHD symptoms are treated with stimulant medication do not increase their risk of contracting COVID-19, the researchers wrote.

ADHD might be noticed in family members

ADHD is a neurodevelopmental disorder that affects the development of the brain. We know that structural, functional, and chemical differences affect our patients’ ability to regulate attention, motivation, impulses, and emotions. ADHD tends to run in families and is highly genetic. Since spending more time with family members during the pandemic, patients might even recognize ADHD symptoms in siblings, children, and one or both of parents. A child who has ADHD has a 25% chance of having a parent with ADHD.

Strengths and attributes are related to ADHD

Your ability to thrive in new, stressful, and challenging situations is an ADHD attribute that will be beneficial during the pandemic. Creativity, great problem-solving skills, and ability to be flexible will be admired and helpful to our patients with ADHD and others during these uncertain times.

Those with ADHD might be highly sensitive to their environments

As previously mentioned, ADHD is a misnomer and not just a disorder of inattention but also too much attention. Unfortunately, this hyperfocused attention is usually on the wrong things. Those with ADHD might find it difficult to filter and process sensory information correctly and, therefore, can be easily distracted by auditory, visual, tactile, and olfactory stimuli. The change to working at home during the pandemic might make it hard to ignore children’s voices, the uncomfortable new mask bought after losing yet another mask over the weekend, and the smell of cookies emanating from the kitchen. This increased sensitivity may affect one’s emotions.

Heightened emotions are expected during the pandemic and even more so among adults with ADHD. The inability of adults with ADHD to properly filter information can also affect emotional stimuli. These intense emotions, coupled with impulsive behaviors, can cause disagreements with partners, lack of patience with children, and conflict with colleagues. When individuals with ADHD feel attacked or invalidated, they can become emotionally dysregulated and “vomit” their pent up feelings.
 

ADHD may affect interpersonal relationships

ADHD symptoms of inattention and impulsivity can affect the ability to connect with friends and family. When one is easily distracted by the pandemic’s chaos, it is harder to be mindful and emotionally and physically connected to one’s partner, which also disrupts their sex life and intimacy.

ADHD sensory integration issues can make people sensitive to particular touches, smells, and sensory information. A gentle touch from one’s partner might be annoying during the pandemic, since other senses may already be overstimulated by the loud sounds of children screaming, the visual and auditory distractions of a neighbor mowing the lawn, and the sun beating down because one forgot to get blinds in the home office before the pandemic.

These minor distractions that are usually insignificant to a non-ADHD brain can profoundly affect an ADHD brain since one must use valuable energy to tune out these unwanted disturbances.
 

Your brain uses a different motivational system than a non-ADHD brain

You have a deficiency in the neurotransmitter dopamine, which affects your motivational system. Your motivational system is based on what you find interesting, challenging, new, exciting, and urgent. Your non-ADHD partner, family members, friends, and colleagues motivate and accomplish their daily tasks differently from you and most likely use a system based on rewards and consequences.

Do not be surprised if you notice that your motivation is diminished during the pandemic because of less novelty and excitement in your life. The coronavirus’s chronic importance level may make everything else in your life not as essential and, therefore, less urgent, which indirectly also lowers your motivation.

Your non-ADHD partner may see that you can focus, prioritize, initiate, and complete tasks when you “choose” to, and confuse your inconsistent behaviors as being within your control. However, this lack of motivation for things that do not pique your interest, challenge you, and are not urgent is not voluntary. It is caused by a lack of neural connections in the area of the brain that controls motivation.
 

You can still have ADHD even though you were not diagnosed as a child or adolescent

Your symptoms of ADHD may not affect your level of functioning until you go away to college, obtain your first job, marry your partner, start a family, or even until a global pandemic alters every aspect of your daily life.

It is, therefore, never too late to get assessed and treated for ADHD. Stimulants are the first line of treatment for adult ADHD. Nonstimulants may also be prescribed if you do not tolerate the side effects of stimulants or have a history of certain medical conditions. These options include some antidepressants and high blood pressure medicines. Sometimes, just identifying the deficits of those with ADHD and how they may affect their performance at work, school, and interpersonal relationships can help the person living with ADHD. Many other any nonmedication types of effective treatment are available for adults with ADHD, including therapy, executive skills, and mindfulness training.

• ADHD focused cognitive-behavioral therapy can help one change your distorted, negative, and irrational thoughts about themselves, others, and situations and replace them with more realistic and rational thoughts that allow for helpful and adaptive behaviors.
• Executive skills training is a type of ADHD treatment that focuses on developing effective systems, routines, improving time management, organization, planning, productivity, and emotional self-regulation.
• Mindfulness meditation training is an additional treatment for adult ADHD. Mindfulness training teaches skills to focus on the present moment and become aware of one’s thoughts, emotions, and actions without judgment. The goal is to learn to accept your ADHD deficits and all that is out of your control while remaining mindful of your ADHD strengths and focusing on the daily choices within your control.

Silver linings of the pandemic

Numerous underserved and rural geographic areas lack adequate psychiatric care. Many primary care physicians and even some psychiatrists are uncomfortable diagnosing and treating attentional disorders because of a lack of proper training in medical school and fear related to the fact that the first-line treatment for adult ADHD is a controlled substance.

In response to the pandemic, the expansion of telepsychiatry services, state waivers that allow clinicians to practice across state lines, exemptions that enable the prescribing of controlled substances without an in-person medical evaluation, and the acceptance of employees working from home during the COVID-19 pandemic have increased the accessibility of adult ADHD psychiatric assessments and treatment.

It is hoped that when the COVID-19 pandemic is behind us, many of the benefits that have emerged, such as the growth of telepsychiatry, changes in state licensure and prescriber regulations, and reduced work commutes will continue into our postpandemic lives.
 

Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.

An ADHD brain thrives with daily routines, and requires spontaneity and challenge to remain engaged in work, academics, relationships, and even leisure activities. ADHD is a performance issue and not one of intellectual understanding. It is not a problem of knowing what to do, but rather, difficulty doing it.

The COVID-19 pandemic has led to the loss of structure, with many parents working out of their homes alongside their children engaged in virtual learning. There has been a significant loss of impromptu events, since all activities outside of the house require proper planning and safety precautions.

To help normalize the struggles of the adult patient with ADHD during the pandemic, I have compiled a list of everything I want my adult ADHD patients and their family members to know so they don’t feel shame, guilt, or hopelessness when others’ coping strategies do not work for their ADHD brains.
 

Adult ADHD is a misnomer – and not just a disorder of inattention and hyperactivity

A better name for this often misconstrued disorder is inconsistent attention and motivation disorder with internal or external hyperactivity/impulsivity.

An ADHD brain vacillates between inattention and hyperfocus. It is not uncommon for individuals with ADHD to lose interest in a new television series when they become hyperfocused on finding the best pandemic-friendly toy for their 5-year-olds, which inevitably turns into a 3-hour Google rabbit-hole search.

These same individuals with ADHD may have low motivation for mundane household chores but become highly motivated when their nonessential Amazon purchases arrive. They may even go as far as pulling an all-nighter to have an electric toy jeep built and ready for the youngster by morning.

Adults with ADHD can also exhibit hyperactive symptoms, such as physical restlessness with fidgeting, and an internal restlessness with anxious and repetitive thoughts that affect their ability to unwind, relax, and even sleep. Impulsivity in adults with ADHD can present as rushing through tasks that one finds uninteresting or unimportant, interrupting others on a Zoom work call, or impulse buying an expensive hot tub instead of a more affordable on their spouse agreed to.
 

ADHD is a risk factor for contracting COVID-19

Untreated ADHD can increase one’s risk of contracting COVID-19. Israeli researchers published a study in the Journal of Attention Disorders showing that individuals with ADHD are 52% more likely to test positive for COVID-19, compared with those without ADHD, because of risk-taking behaviors, impulsivity, and carelessness. However, individuals whose ADHD symptoms are treated with stimulant medication do not increase their risk of contracting COVID-19, the researchers wrote.

ADHD might be noticed in family members

ADHD is a neurodevelopmental disorder that affects the development of the brain. We know that structural, functional, and chemical differences affect our patients’ ability to regulate attention, motivation, impulses, and emotions. ADHD tends to run in families and is highly genetic. Since spending more time with family members during the pandemic, patients might even recognize ADHD symptoms in siblings, children, and one or both of parents. A child who has ADHD has a 25% chance of having a parent with ADHD.

Strengths and attributes are related to ADHD

Your ability to thrive in new, stressful, and challenging situations is an ADHD attribute that will be beneficial during the pandemic. Creativity, great problem-solving skills, and ability to be flexible will be admired and helpful to our patients with ADHD and others during these uncertain times.

Those with ADHD might be highly sensitive to their environments

As previously mentioned, ADHD is a misnomer and not just a disorder of inattention but also too much attention. Unfortunately, this hyperfocused attention is usually on the wrong things. Those with ADHD might find it difficult to filter and process sensory information correctly and, therefore, can be easily distracted by auditory, visual, tactile, and olfactory stimuli. The change to working at home during the pandemic might make it hard to ignore children’s voices, the uncomfortable new mask bought after losing yet another mask over the weekend, and the smell of cookies emanating from the kitchen. This increased sensitivity may affect one’s emotions.

Heightened emotions are expected during the pandemic and even more so among adults with ADHD. The inability of adults with ADHD to properly filter information can also affect emotional stimuli. These intense emotions, coupled with impulsive behaviors, can cause disagreements with partners, lack of patience with children, and conflict with colleagues. When individuals with ADHD feel attacked or invalidated, they can become emotionally dysregulated and “vomit” their pent up feelings.
 

ADHD may affect interpersonal relationships

ADHD symptoms of inattention and impulsivity can affect the ability to connect with friends and family. When one is easily distracted by the pandemic’s chaos, it is harder to be mindful and emotionally and physically connected to one’s partner, which also disrupts their sex life and intimacy.

ADHD sensory integration issues can make people sensitive to particular touches, smells, and sensory information. A gentle touch from one’s partner might be annoying during the pandemic, since other senses may already be overstimulated by the loud sounds of children screaming, the visual and auditory distractions of a neighbor mowing the lawn, and the sun beating down because one forgot to get blinds in the home office before the pandemic.

These minor distractions that are usually insignificant to a non-ADHD brain can profoundly affect an ADHD brain since one must use valuable energy to tune out these unwanted disturbances.
 

Your brain uses a different motivational system than a non-ADHD brain

You have a deficiency in the neurotransmitter dopamine, which affects your motivational system. Your motivational system is based on what you find interesting, challenging, new, exciting, and urgent. Your non-ADHD partner, family members, friends, and colleagues motivate and accomplish their daily tasks differently from you and most likely use a system based on rewards and consequences.

Do not be surprised if you notice that your motivation is diminished during the pandemic because of less novelty and excitement in your life. The coronavirus’s chronic importance level may make everything else in your life not as essential and, therefore, less urgent, which indirectly also lowers your motivation.

Your non-ADHD partner may see that you can focus, prioritize, initiate, and complete tasks when you “choose” to, and confuse your inconsistent behaviors as being within your control. However, this lack of motivation for things that do not pique your interest, challenge you, and are not urgent is not voluntary. It is caused by a lack of neural connections in the area of the brain that controls motivation.
 

You can still have ADHD even though you were not diagnosed as a child or adolescent

Your symptoms of ADHD may not affect your level of functioning until you go away to college, obtain your first job, marry your partner, start a family, or even until a global pandemic alters every aspect of your daily life.

It is, therefore, never too late to get assessed and treated for ADHD. Stimulants are the first line of treatment for adult ADHD. Nonstimulants may also be prescribed if you do not tolerate the side effects of stimulants or have a history of certain medical conditions. These options include some antidepressants and high blood pressure medicines. Sometimes, just identifying the deficits of those with ADHD and how they may affect their performance at work, school, and interpersonal relationships can help the person living with ADHD. Many other any nonmedication types of effective treatment are available for adults with ADHD, including therapy, executive skills, and mindfulness training.

• ADHD focused cognitive-behavioral therapy can help one change your distorted, negative, and irrational thoughts about themselves, others, and situations and replace them with more realistic and rational thoughts that allow for helpful and adaptive behaviors.
• Executive skills training is a type of ADHD treatment that focuses on developing effective systems, routines, improving time management, organization, planning, productivity, and emotional self-regulation.
• Mindfulness meditation training is an additional treatment for adult ADHD. Mindfulness training teaches skills to focus on the present moment and become aware of one’s thoughts, emotions, and actions without judgment. The goal is to learn to accept your ADHD deficits and all that is out of your control while remaining mindful of your ADHD strengths and focusing on the daily choices within your control.

Silver linings of the pandemic

Numerous underserved and rural geographic areas lack adequate psychiatric care. Many primary care physicians and even some psychiatrists are uncomfortable diagnosing and treating attentional disorders because of a lack of proper training in medical school and fear related to the fact that the first-line treatment for adult ADHD is a controlled substance.

In response to the pandemic, the expansion of telepsychiatry services, state waivers that allow clinicians to practice across state lines, exemptions that enable the prescribing of controlled substances without an in-person medical evaluation, and the acceptance of employees working from home during the COVID-19 pandemic have increased the accessibility of adult ADHD psychiatric assessments and treatment.

It is hoped that when the COVID-19 pandemic is behind us, many of the benefits that have emerged, such as the growth of telepsychiatry, changes in state licensure and prescriber regulations, and reduced work commutes will continue into our postpandemic lives.
 

Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.

An ADHD brain thrives with daily routines, and requires spontaneity and challenge to remain engaged in work, academics, relationships, and even leisure activities. ADHD is a performance issue and not one of intellectual understanding. It is not a problem of knowing what to do, but rather, difficulty doing it.

The COVID-19 pandemic has led to the loss of structure, with many parents working out of their homes alongside their children engaged in virtual learning. There has been a significant loss of impromptu events, since all activities outside of the house require proper planning and safety precautions.

To help normalize the struggles of the adult patient with ADHD during the pandemic, I have compiled a list of everything I want my adult ADHD patients and their family members to know so they don’t feel shame, guilt, or hopelessness when others’ coping strategies do not work for their ADHD brains.
 

Adult ADHD is a misnomer – and not just a disorder of inattention and hyperactivity

A better name for this often misconstrued disorder is inconsistent attention and motivation disorder with internal or external hyperactivity/impulsivity.

An ADHD brain vacillates between inattention and hyperfocus. It is not uncommon for individuals with ADHD to lose interest in a new television series when they become hyperfocused on finding the best pandemic-friendly toy for their 5-year-olds, which inevitably turns into a 3-hour Google rabbit-hole search.

These same individuals with ADHD may have low motivation for mundane household chores but become highly motivated when their nonessential Amazon purchases arrive. They may even go as far as pulling an all-nighter to have an electric toy jeep built and ready for the youngster by morning.

Adults with ADHD can also exhibit hyperactive symptoms, such as physical restlessness with fidgeting, and an internal restlessness with anxious and repetitive thoughts that affect their ability to unwind, relax, and even sleep. Impulsivity in adults with ADHD can present as rushing through tasks that one finds uninteresting or unimportant, interrupting others on a Zoom work call, or impulse buying an expensive hot tub instead of a more affordable on their spouse agreed to.
 

ADHD is a risk factor for contracting COVID-19

Untreated ADHD can increase one’s risk of contracting COVID-19. Israeli researchers published a study in the Journal of Attention Disorders showing that individuals with ADHD are 52% more likely to test positive for COVID-19, compared with those without ADHD, because of risk-taking behaviors, impulsivity, and carelessness. However, individuals whose ADHD symptoms are treated with stimulant medication do not increase their risk of contracting COVID-19, the researchers wrote.

ADHD might be noticed in family members

ADHD is a neurodevelopmental disorder that affects the development of the brain. We know that structural, functional, and chemical differences affect our patients’ ability to regulate attention, motivation, impulses, and emotions. ADHD tends to run in families and is highly genetic. Since spending more time with family members during the pandemic, patients might even recognize ADHD symptoms in siblings, children, and one or both of parents. A child who has ADHD has a 25% chance of having a parent with ADHD.

Strengths and attributes are related to ADHD

Your ability to thrive in new, stressful, and challenging situations is an ADHD attribute that will be beneficial during the pandemic. Creativity, great problem-solving skills, and ability to be flexible will be admired and helpful to our patients with ADHD and others during these uncertain times.

Those with ADHD might be highly sensitive to their environments

As previously mentioned, ADHD is a misnomer and not just a disorder of inattention but also too much attention. Unfortunately, this hyperfocused attention is usually on the wrong things. Those with ADHD might find it difficult to filter and process sensory information correctly and, therefore, can be easily distracted by auditory, visual, tactile, and olfactory stimuli. The change to working at home during the pandemic might make it hard to ignore children’s voices, the uncomfortable new mask bought after losing yet another mask over the weekend, and the smell of cookies emanating from the kitchen. This increased sensitivity may affect one’s emotions.

Heightened emotions are expected during the pandemic and even more so among adults with ADHD. The inability of adults with ADHD to properly filter information can also affect emotional stimuli. These intense emotions, coupled with impulsive behaviors, can cause disagreements with partners, lack of patience with children, and conflict with colleagues. When individuals with ADHD feel attacked or invalidated, they can become emotionally dysregulated and “vomit” their pent up feelings.
 

ADHD may affect interpersonal relationships

ADHD symptoms of inattention and impulsivity can affect the ability to connect with friends and family. When one is easily distracted by the pandemic’s chaos, it is harder to be mindful and emotionally and physically connected to one’s partner, which also disrupts their sex life and intimacy.

ADHD sensory integration issues can make people sensitive to particular touches, smells, and sensory information. A gentle touch from one’s partner might be annoying during the pandemic, since other senses may already be overstimulated by the loud sounds of children screaming, the visual and auditory distractions of a neighbor mowing the lawn, and the sun beating down because one forgot to get blinds in the home office before the pandemic.

These minor distractions that are usually insignificant to a non-ADHD brain can profoundly affect an ADHD brain since one must use valuable energy to tune out these unwanted disturbances.
 

Your brain uses a different motivational system than a non-ADHD brain

You have a deficiency in the neurotransmitter dopamine, which affects your motivational system. Your motivational system is based on what you find interesting, challenging, new, exciting, and urgent. Your non-ADHD partner, family members, friends, and colleagues motivate and accomplish their daily tasks differently from you and most likely use a system based on rewards and consequences.

Do not be surprised if you notice that your motivation is diminished during the pandemic because of less novelty and excitement in your life. The coronavirus’s chronic importance level may make everything else in your life not as essential and, therefore, less urgent, which indirectly also lowers your motivation.

Your non-ADHD partner may see that you can focus, prioritize, initiate, and complete tasks when you “choose” to, and confuse your inconsistent behaviors as being within your control. However, this lack of motivation for things that do not pique your interest, challenge you, and are not urgent is not voluntary. It is caused by a lack of neural connections in the area of the brain that controls motivation.
 

You can still have ADHD even though you were not diagnosed as a child or adolescent

Your symptoms of ADHD may not affect your level of functioning until you go away to college, obtain your first job, marry your partner, start a family, or even until a global pandemic alters every aspect of your daily life.

It is, therefore, never too late to get assessed and treated for ADHD. Stimulants are the first line of treatment for adult ADHD. Nonstimulants may also be prescribed if you do not tolerate the side effects of stimulants or have a history of certain medical conditions. These options include some antidepressants and high blood pressure medicines. Sometimes, just identifying the deficits of those with ADHD and how they may affect their performance at work, school, and interpersonal relationships can help the person living with ADHD. Many other any nonmedication types of effective treatment are available for adults with ADHD, including therapy, executive skills, and mindfulness training.

• ADHD focused cognitive-behavioral therapy can help one change your distorted, negative, and irrational thoughts about themselves, others, and situations and replace them with more realistic and rational thoughts that allow for helpful and adaptive behaviors.
• Executive skills training is a type of ADHD treatment that focuses on developing effective systems, routines, improving time management, organization, planning, productivity, and emotional self-regulation.
• Mindfulness meditation training is an additional treatment for adult ADHD. Mindfulness training teaches skills to focus on the present moment and become aware of one’s thoughts, emotions, and actions without judgment. The goal is to learn to accept your ADHD deficits and all that is out of your control while remaining mindful of your ADHD strengths and focusing on the daily choices within your control.

Silver linings of the pandemic

Numerous underserved and rural geographic areas lack adequate psychiatric care. Many primary care physicians and even some psychiatrists are uncomfortable diagnosing and treating attentional disorders because of a lack of proper training in medical school and fear related to the fact that the first-line treatment for adult ADHD is a controlled substance.

In response to the pandemic, the expansion of telepsychiatry services, state waivers that allow clinicians to practice across state lines, exemptions that enable the prescribing of controlled substances without an in-person medical evaluation, and the acceptance of employees working from home during the COVID-19 pandemic have increased the accessibility of adult ADHD psychiatric assessments and treatment.

It is hoped that when the COVID-19 pandemic is behind us, many of the benefits that have emerged, such as the growth of telepsychiatry, changes in state licensure and prescriber regulations, and reduced work commutes will continue into our postpandemic lives.
 

Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.

Successful athletes exhibit positive mental health. This mental health is directly related to athletic success and high levels of performance.¹ Mental skills are as important as natural physical ability and mechanical skills in the sport of tennis.

Research has shown that tennis is 85% mental and that players spend 80% of their time on the court handling emotions. Some players look good in practice when they are not under pressure but cannot win matches (they have the physical skill level to win) because they cannot handle their own emotions during the duress of a match. They are affected by anger, fear, stress, poor concentration, and other internal elements that interfere with their ability to perform at an optimal level. Competitors may also be affected by external factors such as the sun, wind, an opponent, and so on, and may use these situations as an excuse not to win.

Players normally practice physical skills but rarely practice cognitive techniques. Regardless of level of play – pro, collegiate, junior, or club – practicing mental skills will greatly improve the players’ arsenal of weapons, giving them an edge in matches and making them the best players they can be. Mental health professionals also can use these strategies to help motivate athletes who compete in other sports – and in other competitive endeavors.

Visualization is the formation of a mental image of something of your choice. Visualization imagery techniques can be used by players to calm themselves before playing a match so their emotions are not wasted on trying to quiet the minds and quell stress. Implementing the following visualization techniques will reduce a player’s anxiety during the match, allowing the player to direct energy toward optimal mental and physical performance on the court.

In advance of a match, encourage the player to learn and analyze the opponent’s strengths and weaknesses by watching the opponent play and/or from asking others. The night before the scheduled match, get the player to imagine how they will play points against their competitor. Play into the opponents’ vulnerabilities or first play to their strengths to expose shortcomings and – then attack their weakness. For example, if an opponent has a weak backhand, first play to the opponent’s forehand and, when the opponent is vulnerable, go into his backhand to get a short or weak ball – and attack. The following are specific strategies that mental health professionals who work with athletes can use to help them perform optimally.
 

Using visualization, shadowing

Visualize the correct way to hit a tennis stroke and repeat it over and over in your mind. On a tennis court or where ever you have adequate space, shadow a stroke by using a racket and repetitively performing the actual stroke without hitting a ball. At home, practice relaxation and deep breathing techniques at night before going to sleep. Put yourself in a relaxed state and visualize repetitively striking the ball correctly. The next time you actually hit the stroke, you will produce a better shot.

Focusing on, staying in the here and now

The “here” means to focus on what is happening on your own court, not what is happening on the court next to you. Players may be affected by external factors, such as the sun, wind, and their opponent and may use these conditions or situations as an excuse if they do not win. Ignore background chatter and distractions, and be a horse with blinders. Be responsible for yourself and your own actions; manage what you can and realize that you cannot control the weather or actions of your opponent.

The “now” refers to staying present and focusing only on the current point. Do not think of past mistakes. If you are winning a match, do not think about celebrating while the match is still in play. If you are losing, do not start to write a script of excuses why you lost the match. Instead, just concentrate on the present, point by point. Focusing will allow you to understand what is true and important in the here and now. Focusing will help alleviate stress and better equip you to make quick decisions and be clear about your intended actions.
 

Set realistic and achievable goals

It is always good to have goals and dreams; however, you as a player must understand the realities of your current level of play. Know your level; don’t be grandiose and think you are able to beat Rafael Nadal. Having an unrealistic attitude will result in frustration and poor performance during a match. Instead, set achievable, and realistic short- and long-term goals for yourself, which will aid in your overall tennis development. After the match is over, reflect upon and evaluate the points – and your overall performance.

Don’t devalue yourself if you lose a match. Do not feel too low from a loss or too high from a win. When you have a match loss, use it as an opportunity to learn from your mistakes and to improve by working on your weaknesses in future practice until you feel confident enough to use your new skills in a tournament.
 

Stay positive

Do not tie up your self-esteem as a person with your match outcome; in otherwords, separate feelings of self-worth from your match results. Cultivate an optimistic attitude and talk positively to yourself, strive to improve, and maintain positive self-esteem in practice and in matches. During practice, allocate 110% effort, and focus on the process, not the outcome. Arrange your practice matches so that one-third of them are against players of your same level, one-third against players worse than you, and one-third against players better than yourself.

Deal with adversity

It is important to be able to deal with external pressures going on in your life such as conflicts related to family, peers, school, work, and relationships. Deal with and manage this discord before your match so you can maintain control of your emotions and can give 100% effort on the court.

Learn mental techniques

Many athletes may have difficulty teaching themselves cognitive skills and would benefit from a few sessions with a sports psychologist/psychiatrist to understand and learn the techniques. Once the tactics are understood and learned, players can apply them to training and ultimately to their tournament arsenal, allowing them to play to their ultimate potential.

References

1. Morgan WP. Selected psychological factors limiting performance: A mental health model. In Clarke DH and Eckert HM (eds.), Limits of Human Performance. Champaign, Ill.: Human Kinetics Publishers, 1985.

Dr. Cohen had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present and served as captain of the tennis team at the University of Pennsylvania, Philadelphia. Dr. Cohen, who was ranked No. 1 in tennis in the middle states section and in the country in various categories and times, was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012. Dr. Cohen has no conflicts of interest.

Ms. Cohen, Dr. Cohen’s daughter, was No. 1 ranked in the United States in junior tennis and No. 4 in the world. In addition, Ms. Cohen was ranked among the top 100 players in the world by the professional World Tennis Association. She also was the No. 2 college player in United States, and an All-American at the University of Miami. She holds a master’s in sports psychology, and presently works as a sports psychologist and tennis professional in Philadelphia. Ms. Cohen has no conflicts of interest.

Successful athletes exhibit positive mental health. This mental health is directly related to athletic success and high levels of performance.¹ Mental skills are as important as natural physical ability and mechanical skills in the sport of tennis.

Research has shown that tennis is 85% mental and that players spend 80% of their time on the court handling emotions. Some players look good in practice when they are not under pressure but cannot win matches (they have the physical skill level to win) because they cannot handle their own emotions during the duress of a match. They are affected by anger, fear, stress, poor concentration, and other internal elements that interfere with their ability to perform at an optimal level. Competitors may also be affected by external factors such as the sun, wind, an opponent, and so on, and may use these situations as an excuse not to win.

Players normally practice physical skills but rarely practice cognitive techniques. Regardless of level of play – pro, collegiate, junior, or club – practicing mental skills will greatly improve the players’ arsenal of weapons, giving them an edge in matches and making them the best players they can be. Mental health professionals also can use these strategies to help motivate athletes who compete in other sports – and in other competitive endeavors.

Visualization is the formation of a mental image of something of your choice. Visualization imagery techniques can be used by players to calm themselves before playing a match so their emotions are not wasted on trying to quiet the minds and quell stress. Implementing the following visualization techniques will reduce a player’s anxiety during the match, allowing the player to direct energy toward optimal mental and physical performance on the court.

In advance of a match, encourage the player to learn and analyze the opponent’s strengths and weaknesses by watching the opponent play and/or from asking others. The night before the scheduled match, get the player to imagine how they will play points against their competitor. Play into the opponents’ vulnerabilities or first play to their strengths to expose shortcomings and – then attack their weakness. For example, if an opponent has a weak backhand, first play to the opponent’s forehand and, when the opponent is vulnerable, go into his backhand to get a short or weak ball – and attack. The following are specific strategies that mental health professionals who work with athletes can use to help them perform optimally.
 

Using visualization, shadowing

Visualize the correct way to hit a tennis stroke and repeat it over and over in your mind. On a tennis court or where ever you have adequate space, shadow a stroke by using a racket and repetitively performing the actual stroke without hitting a ball. At home, practice relaxation and deep breathing techniques at night before going to sleep. Put yourself in a relaxed state and visualize repetitively striking the ball correctly. The next time you actually hit the stroke, you will produce a better shot.

Focusing on, staying in the here and now

The “here” means to focus on what is happening on your own court, not what is happening on the court next to you. Players may be affected by external factors, such as the sun, wind, and their opponent and may use these conditions or situations as an excuse if they do not win. Ignore background chatter and distractions, and be a horse with blinders. Be responsible for yourself and your own actions; manage what you can and realize that you cannot control the weather or actions of your opponent.

The “now” refers to staying present and focusing only on the current point. Do not think of past mistakes. If you are winning a match, do not think about celebrating while the match is still in play. If you are losing, do not start to write a script of excuses why you lost the match. Instead, just concentrate on the present, point by point. Focusing will allow you to understand what is true and important in the here and now. Focusing will help alleviate stress and better equip you to make quick decisions and be clear about your intended actions.
 

Set realistic and achievable goals

It is always good to have goals and dreams; however, you as a player must understand the realities of your current level of play. Know your level; don’t be grandiose and think you are able to beat Rafael Nadal. Having an unrealistic attitude will result in frustration and poor performance during a match. Instead, set achievable, and realistic short- and long-term goals for yourself, which will aid in your overall tennis development. After the match is over, reflect upon and evaluate the points – and your overall performance.

Don’t devalue yourself if you lose a match. Do not feel too low from a loss or too high from a win. When you have a match loss, use it as an opportunity to learn from your mistakes and to improve by working on your weaknesses in future practice until you feel confident enough to use your new skills in a tournament.
 

Stay positive

Do not tie up your self-esteem as a person with your match outcome; in otherwords, separate feelings of self-worth from your match results. Cultivate an optimistic attitude and talk positively to yourself, strive to improve, and maintain positive self-esteem in practice and in matches. During practice, allocate 110% effort, and focus on the process, not the outcome. Arrange your practice matches so that one-third of them are against players of your same level, one-third against players worse than you, and one-third against players better than yourself.

Deal with adversity

It is important to be able to deal with external pressures going on in your life such as conflicts related to family, peers, school, work, and relationships. Deal with and manage this discord before your match so you can maintain control of your emotions and can give 100% effort on the court.

Learn mental techniques

Many athletes may have difficulty teaching themselves cognitive skills and would benefit from a few sessions with a sports psychologist/psychiatrist to understand and learn the techniques. Once the tactics are understood and learned, players can apply them to training and ultimately to their tournament arsenal, allowing them to play to their ultimate potential.

References

1. Morgan WP. Selected psychological factors limiting performance: A mental health model. In Clarke DH and Eckert HM (eds.), Limits of Human Performance. Champaign, Ill.: Human Kinetics Publishers, 1985.

Dr. Cohen had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present and served as captain of the tennis team at the University of Pennsylvania, Philadelphia. Dr. Cohen, who was ranked No. 1 in tennis in the middle states section and in the country in various categories and times, was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012. Dr. Cohen has no conflicts of interest.

Ms. Cohen, Dr. Cohen’s daughter, was No. 1 ranked in the United States in junior tennis and No. 4 in the world. In addition, Ms. Cohen was ranked among the top 100 players in the world by the professional World Tennis Association. She also was the No. 2 college player in United States, and an All-American at the University of Miami. She holds a master’s in sports psychology, and presently works as a sports psychologist and tennis professional in Philadelphia. Ms. Cohen has no conflicts of interest.

Successful athletes exhibit positive mental health. This mental health is directly related to athletic success and high levels of performance.¹ Mental skills are as important as natural physical ability and mechanical skills in the sport of tennis.

Research has shown that tennis is 85% mental and that players spend 80% of their time on the court handling emotions. Some players look good in practice when they are not under pressure but cannot win matches (they have the physical skill level to win) because they cannot handle their own emotions during the duress of a match. They are affected by anger, fear, stress, poor concentration, and other internal elements that interfere with their ability to perform at an optimal level. Competitors may also be affected by external factors such as the sun, wind, an opponent, and so on, and may use these situations as an excuse not to win.

Players normally practice physical skills but rarely practice cognitive techniques. Regardless of level of play – pro, collegiate, junior, or club – practicing mental skills will greatly improve the players’ arsenal of weapons, giving them an edge in matches and making them the best players they can be. Mental health professionals also can use these strategies to help motivate athletes who compete in other sports – and in other competitive endeavors.

Visualization is the formation of a mental image of something of your choice. Visualization imagery techniques can be used by players to calm themselves before playing a match so their emotions are not wasted on trying to quiet the minds and quell stress. Implementing the following visualization techniques will reduce a player’s anxiety during the match, allowing the player to direct energy toward optimal mental and physical performance on the court.

In advance of a match, encourage the player to learn and analyze the opponent’s strengths and weaknesses by watching the opponent play and/or from asking others. The night before the scheduled match, get the player to imagine how they will play points against their competitor. Play into the opponents’ vulnerabilities or first play to their strengths to expose shortcomings and – then attack their weakness. For example, if an opponent has a weak backhand, first play to the opponent’s forehand and, when the opponent is vulnerable, go into his backhand to get a short or weak ball – and attack. The following are specific strategies that mental health professionals who work with athletes can use to help them perform optimally.
 

Using visualization, shadowing

Visualize the correct way to hit a tennis stroke and repeat it over and over in your mind. On a tennis court or where ever you have adequate space, shadow a stroke by using a racket and repetitively performing the actual stroke without hitting a ball. At home, practice relaxation and deep breathing techniques at night before going to sleep. Put yourself in a relaxed state and visualize repetitively striking the ball correctly. The next time you actually hit the stroke, you will produce a better shot.

Focusing on, staying in the here and now

The “here” means to focus on what is happening on your own court, not what is happening on the court next to you. Players may be affected by external factors, such as the sun, wind, and their opponent and may use these conditions or situations as an excuse if they do not win. Ignore background chatter and distractions, and be a horse with blinders. Be responsible for yourself and your own actions; manage what you can and realize that you cannot control the weather or actions of your opponent.

The “now” refers to staying present and focusing only on the current point. Do not think of past mistakes. If you are winning a match, do not think about celebrating while the match is still in play. If you are losing, do not start to write a script of excuses why you lost the match. Instead, just concentrate on the present, point by point. Focusing will allow you to understand what is true and important in the here and now. Focusing will help alleviate stress and better equip you to make quick decisions and be clear about your intended actions.
 

Set realistic and achievable goals

It is always good to have goals and dreams; however, you as a player must understand the realities of your current level of play. Know your level; don’t be grandiose and think you are able to beat Rafael Nadal. Having an unrealistic attitude will result in frustration and poor performance during a match. Instead, set achievable, and realistic short- and long-term goals for yourself, which will aid in your overall tennis development. After the match is over, reflect upon and evaluate the points – and your overall performance.

Don’t devalue yourself if you lose a match. Do not feel too low from a loss or too high from a win. When you have a match loss, use it as an opportunity to learn from your mistakes and to improve by working on your weaknesses in future practice until you feel confident enough to use your new skills in a tournament.
 

Stay positive

Do not tie up your self-esteem as a person with your match outcome; in otherwords, separate feelings of self-worth from your match results. Cultivate an optimistic attitude and talk positively to yourself, strive to improve, and maintain positive self-esteem in practice and in matches. During practice, allocate 110% effort, and focus on the process, not the outcome. Arrange your practice matches so that one-third of them are against players of your same level, one-third against players worse than you, and one-third against players better than yourself.

Deal with adversity

It is important to be able to deal with external pressures going on in your life such as conflicts related to family, peers, school, work, and relationships. Deal with and manage this discord before your match so you can maintain control of your emotions and can give 100% effort on the court.

Learn mental techniques

Many athletes may have difficulty teaching themselves cognitive skills and would benefit from a few sessions with a sports psychologist/psychiatrist to understand and learn the techniques. Once the tactics are understood and learned, players can apply them to training and ultimately to their tournament arsenal, allowing them to play to their ultimate potential.

References

1. Morgan WP. Selected psychological factors limiting performance: A mental health model. In Clarke DH and Eckert HM (eds.), Limits of Human Performance. Champaign, Ill.: Human Kinetics Publishers, 1985.

Dr. Cohen had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present and served as captain of the tennis team at the University of Pennsylvania, Philadelphia. Dr. Cohen, who was ranked No. 1 in tennis in the middle states section and in the country in various categories and times, was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012. Dr. Cohen has no conflicts of interest.

Ms. Cohen, Dr. Cohen’s daughter, was No. 1 ranked in the United States in junior tennis and No. 4 in the world. In addition, Ms. Cohen was ranked among the top 100 players in the world by the professional World Tennis Association. She also was the No. 2 college player in United States, and an All-American at the University of Miami. She holds a master’s in sports psychology, and presently works as a sports psychologist and tennis professional in Philadelphia. Ms. Cohen has no conflicts of interest.

While anxiety was at the top of my list of emotional states that generated office visits in my pediatric practice, depression always ran a close second. Not infrequently, patients would report symptoms that suggested they were harboring both morbidities.

LumineImages/iStock/Getty Images

Although some families appear to be prone to depression, I’m not aware that a definable genetic basis has been discovered. Like me, you may have wondered what factors determine whether an individual will become depressed or merely be unhappy when things aren’t going well. We all have known people who have weathered disappointment and life-altering calamities without even a hint of being depressed. On the other hand you probably have met numerous patients and acquaintances who have become significantly depressed as the result of simply worrying that some disaster might befall them.

Is this variable vulnerability to depression the result of some as yet undiscovered neurotransmitter? Or are there certain lifestyle features that make individuals more prone to depression? Or ... could it be both? In other words are there behaviors that can tweak a person’s telomeres in such a way that triggers a biochemical cascade that results in depression?

A recent paper in the American Journal of Psychiatry doesn’t drill down through the genetic and biochemical strata, but it does suggest that there are “modifiable” behaviors that may contribute to depression. The researchers based at Harvard Medical School in Boston accessed a database of more than 100,000 adults in the United Kingdom. With use of a two-stage method that included a strategy similar to that employed for identifying genetic risk factors for disease, the researchers scanned a large number of factors that they considered modifiable, searching for those that might be associated with the development of depression.

Not surprisingly, they discovered that those respondents who more frequently confided in others and more frequently visited with family and friends were less likely to become depressed. Of course, this protective effect of social connection can cut both ways during the pandemic. During this pandemic if those people you confide in are not currently in your “bubble,” you may have a problem. This may explain why, despite warnings of their dangers, bars continue to be so attractive. It’s probably not just the alcohol but it’s the bartenders and patrons who are willing to listen that patrons seek out. It would be helpful if more people felt comfortable sharing their feelings with members of their family bubble. But you and I know that many families don’t come even close to matching the Brady Bunch image of a functionality.

Somewhat surprisingly to the Harvard researchers was their finding that time watching television also was a significant risk factor for the development of depression. Their data did not allow them to determine whether this observation was linked to the sedentary nature of television watching or the content of the shows being viewed. I suspect that content is not the problem. But in addition to being a sedentary activity, television watching often is isolating. When television was first introduced to the mass market, families grouped around the household’s lone set, much as families did back when radios became popular. In their infancy radio listening and television viewing were social activities rich with discussion and shared emotions.

However, as televisions became less expensive and no longer required large pieces of furniture to house them, television viewing became a more solitary and individual activity. Televisions became obligatory furnishings of every bedroom, and parents and children could withdraw to their own spaces and be entertained free of any opportunity or obligation to interact with the rest of family.

This new research into the risk factors for depression suggests that again we should be strongly discouraging parents from allowing their children to have a television or electronic viewing device in their bedrooms without any way of monitoring their usage. At least among children, television watching should be a modifiable behavior.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

While anxiety was at the top of my list of emotional states that generated office visits in my pediatric practice, depression always ran a close second. Not infrequently, patients would report symptoms that suggested they were harboring both morbidities.

LumineImages/iStock/Getty Images

Although some families appear to be prone to depression, I’m not aware that a definable genetic basis has been discovered. Like me, you may have wondered what factors determine whether an individual will become depressed or merely be unhappy when things aren’t going well. We all have known people who have weathered disappointment and life-altering calamities without even a hint of being depressed. On the other hand you probably have met numerous patients and acquaintances who have become significantly depressed as the result of simply worrying that some disaster might befall them.

Is this variable vulnerability to depression the result of some as yet undiscovered neurotransmitter? Or are there certain lifestyle features that make individuals more prone to depression? Or ... could it be both? In other words are there behaviors that can tweak a person’s telomeres in such a way that triggers a biochemical cascade that results in depression?

A recent paper in the American Journal of Psychiatry doesn’t drill down through the genetic and biochemical strata, but it does suggest that there are “modifiable” behaviors that may contribute to depression. The researchers based at Harvard Medical School in Boston accessed a database of more than 100,000 adults in the United Kingdom. With use of a two-stage method that included a strategy similar to that employed for identifying genetic risk factors for disease, the researchers scanned a large number of factors that they considered modifiable, searching for those that might be associated with the development of depression.

Not surprisingly, they discovered that those respondents who more frequently confided in others and more frequently visited with family and friends were less likely to become depressed. Of course, this protective effect of social connection can cut both ways during the pandemic. During this pandemic if those people you confide in are not currently in your “bubble,” you may have a problem. This may explain why, despite warnings of their dangers, bars continue to be so attractive. It’s probably not just the alcohol but it’s the bartenders and patrons who are willing to listen that patrons seek out. It would be helpful if more people felt comfortable sharing their feelings with members of their family bubble. But you and I know that many families don’t come even close to matching the Brady Bunch image of a functionality.

Somewhat surprisingly to the Harvard researchers was their finding that time watching television also was a significant risk factor for the development of depression. Their data did not allow them to determine whether this observation was linked to the sedentary nature of television watching or the content of the shows being viewed. I suspect that content is not the problem. But in addition to being a sedentary activity, television watching often is isolating. When television was first introduced to the mass market, families grouped around the household’s lone set, much as families did back when radios became popular. In their infancy radio listening and television viewing were social activities rich with discussion and shared emotions.

However, as televisions became less expensive and no longer required large pieces of furniture to house them, television viewing became a more solitary and individual activity. Televisions became obligatory furnishings of every bedroom, and parents and children could withdraw to their own spaces and be entertained free of any opportunity or obligation to interact with the rest of family.

This new research into the risk factors for depression suggests that again we should be strongly discouraging parents from allowing their children to have a television or electronic viewing device in their bedrooms without any way of monitoring their usage. At least among children, television watching should be a modifiable behavior.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

While anxiety was at the top of my list of emotional states that generated office visits in my pediatric practice, depression always ran a close second. Not infrequently, patients would report symptoms that suggested they were harboring both morbidities.

LumineImages/iStock/Getty Images

Although some families appear to be prone to depression, I’m not aware that a definable genetic basis has been discovered. Like me, you may have wondered what factors determine whether an individual will become depressed or merely be unhappy when things aren’t going well. We all have known people who have weathered disappointment and life-altering calamities without even a hint of being depressed. On the other hand you probably have met numerous patients and acquaintances who have become significantly depressed as the result of simply worrying that some disaster might befall them.

Is this variable vulnerability to depression the result of some as yet undiscovered neurotransmitter? Or are there certain lifestyle features that make individuals more prone to depression? Or ... could it be both? In other words are there behaviors that can tweak a person’s telomeres in such a way that triggers a biochemical cascade that results in depression?

A recent paper in the American Journal of Psychiatry doesn’t drill down through the genetic and biochemical strata, but it does suggest that there are “modifiable” behaviors that may contribute to depression. The researchers based at Harvard Medical School in Boston accessed a database of more than 100,000 adults in the United Kingdom. With use of a two-stage method that included a strategy similar to that employed for identifying genetic risk factors for disease, the researchers scanned a large number of factors that they considered modifiable, searching for those that might be associated with the development of depression.

Not surprisingly, they discovered that those respondents who more frequently confided in others and more frequently visited with family and friends were less likely to become depressed. Of course, this protective effect of social connection can cut both ways during the pandemic. During this pandemic if those people you confide in are not currently in your “bubble,” you may have a problem. This may explain why, despite warnings of their dangers, bars continue to be so attractive. It’s probably not just the alcohol but it’s the bartenders and patrons who are willing to listen that patrons seek out. It would be helpful if more people felt comfortable sharing their feelings with members of their family bubble. But you and I know that many families don’t come even close to matching the Brady Bunch image of a functionality.

Somewhat surprisingly to the Harvard researchers was their finding that time watching television also was a significant risk factor for the development of depression. Their data did not allow them to determine whether this observation was linked to the sedentary nature of television watching or the content of the shows being viewed. I suspect that content is not the problem. But in addition to being a sedentary activity, television watching often is isolating. When television was first introduced to the mass market, families grouped around the household’s lone set, much as families did back when radios became popular. In their infancy radio listening and television viewing were social activities rich with discussion and shared emotions.

However, as televisions became less expensive and no longer required large pieces of furniture to house them, television viewing became a more solitary and individual activity. Televisions became obligatory furnishings of every bedroom, and parents and children could withdraw to their own spaces and be entertained free of any opportunity or obligation to interact with the rest of family.

This new research into the risk factors for depression suggests that again we should be strongly discouraging parents from allowing their children to have a television or electronic viewing device in their bedrooms without any way of monitoring their usage. At least among children, television watching should be a modifiable behavior.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Breast cancer in women remains one of the most common types of cancer in the United States, affecting about one in eight women¹ over the course of their lifetime. Despite its pervasiveness, the 5-year survival rate for women with breast cancer remains high, estimated at around 90%² based on data from 2010-2016, in large part because of early detection and treatment through screening. However, many organizations disagree on when to start and how often to screen women at average risk.

Important to discussions about breast cancer screening is the trend that many women delay childbirth until their 30s and 40s. In 2018 the birth rate increased for women ages 35-44, and the mean age of first birth increased from the prior year across all racial and ethnic groups.³ Therefore, ob.gyns. may need to consider that their patients not only may have increased risk of developing breast cancer based on age alone – women aged 35-44 have four times greater risk of disease than women aged 20-34² – but that the pregnancy itself may further exacerbate risk in older women. A 2019 pooled analysis found that women who were older at first birth had a greater chance of developing breast cancer compared with women with no children.⁴

In addition, ob.gyns. should consider that their patients may have received a breast cancer diagnosis prior to initiation or completion of their family plans or that their patients are cancer survivors – in 2013-2017, breast cancer was the most common form of cancer in adolescents and young adults.⁵ Thus, practitioners should be prepared to discuss not only options for fertility preservation but the evidence regarding cancer recurrence after pregnancy.

We have invited Dr. Katherine Tkaczuk, professor of medicine at the University of Maryland School of Medicine* and director of the breast evaluation and treatment program at the Marlene and Stewart Greenebaum Comprehensive Cancer Center, to discuss the vital role of screening in the shared decision-making process of breast cancer prevention.
 

Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore,* as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].

Correction, 1/8/21: *An earlier version of this article misstated the university affiliations for Dr. Tkaczuk and Dr. Reece.

References

1. U.S. Breast Cancer Statistics. breastcancer.org.

2. “Cancer Stat Facts: Female Breast Cancer,” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.

3. Martin JA et al. “Births: Final Data for 2018.” National Vital Statistics Reports. 2019 Nov 27;68(13):1-46.

4. Nichols HB et al. Ann Intern Med. 2019 Jan;170(1):22-30.

5. “Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15-39),” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
 

Breast cancer in women remains one of the most common types of cancer in the United States, affecting about one in eight women¹ over the course of their lifetime. Despite its pervasiveness, the 5-year survival rate for women with breast cancer remains high, estimated at around 90%² based on data from 2010-2016, in large part because of early detection and treatment through screening. However, many organizations disagree on when to start and how often to screen women at average risk.

Important to discussions about breast cancer screening is the trend that many women delay childbirth until their 30s and 40s. In 2018 the birth rate increased for women ages 35-44, and the mean age of first birth increased from the prior year across all racial and ethnic groups.³ Therefore, ob.gyns. may need to consider that their patients not only may have increased risk of developing breast cancer based on age alone – women aged 35-44 have four times greater risk of disease than women aged 20-34² – but that the pregnancy itself may further exacerbate risk in older women. A 2019 pooled analysis found that women who were older at first birth had a greater chance of developing breast cancer compared with women with no children.⁴

In addition, ob.gyns. should consider that their patients may have received a breast cancer diagnosis prior to initiation or completion of their family plans or that their patients are cancer survivors – in 2013-2017, breast cancer was the most common form of cancer in adolescents and young adults.⁵ Thus, practitioners should be prepared to discuss not only options for fertility preservation but the evidence regarding cancer recurrence after pregnancy.

We have invited Dr. Katherine Tkaczuk, professor of medicine at the University of Maryland School of Medicine* and director of the breast evaluation and treatment program at the Marlene and Stewart Greenebaum Comprehensive Cancer Center, to discuss the vital role of screening in the shared decision-making process of breast cancer prevention.
 

Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore,* as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].

Correction, 1/8/21: *An earlier version of this article misstated the university affiliations for Dr. Tkaczuk and Dr. Reece.

References

1. U.S. Breast Cancer Statistics. breastcancer.org.

2. “Cancer Stat Facts: Female Breast Cancer,” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.

3. Martin JA et al. “Births: Final Data for 2018.” National Vital Statistics Reports. 2019 Nov 27;68(13):1-46.

4. Nichols HB et al. Ann Intern Med. 2019 Jan;170(1):22-30.

5. “Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15-39),” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
 

Breast cancer in women remains one of the most common types of cancer in the United States, affecting about one in eight women¹ over the course of their lifetime. Despite its pervasiveness, the 5-year survival rate for women with breast cancer remains high, estimated at around 90%² based on data from 2010-2016, in large part because of early detection and treatment through screening. However, many organizations disagree on when to start and how often to screen women at average risk.

Important to discussions about breast cancer screening is the trend that many women delay childbirth until their 30s and 40s. In 2018 the birth rate increased for women ages 35-44, and the mean age of first birth increased from the prior year across all racial and ethnic groups.³ Therefore, ob.gyns. may need to consider that their patients not only may have increased risk of developing breast cancer based on age alone – women aged 35-44 have four times greater risk of disease than women aged 20-34² – but that the pregnancy itself may further exacerbate risk in older women. A 2019 pooled analysis found that women who were older at first birth had a greater chance of developing breast cancer compared with women with no children.⁴

In addition, ob.gyns. should consider that their patients may have received a breast cancer diagnosis prior to initiation or completion of their family plans or that their patients are cancer survivors – in 2013-2017, breast cancer was the most common form of cancer in adolescents and young adults.⁵ Thus, practitioners should be prepared to discuss not only options for fertility preservation but the evidence regarding cancer recurrence after pregnancy.

We have invited Dr. Katherine Tkaczuk, professor of medicine at the University of Maryland School of Medicine* and director of the breast evaluation and treatment program at the Marlene and Stewart Greenebaum Comprehensive Cancer Center, to discuss the vital role of screening in the shared decision-making process of breast cancer prevention.
 

Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland, Baltimore,* as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].

Correction, 1/8/21: *An earlier version of this article misstated the university affiliations for Dr. Tkaczuk and Dr. Reece.

References

1. U.S. Breast Cancer Statistics. breastcancer.org.

2. “Cancer Stat Facts: Female Breast Cancer,” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.

3. Martin JA et al. “Births: Final Data for 2018.” National Vital Statistics Reports. 2019 Nov 27;68(13):1-46.

4. Nichols HB et al. Ann Intern Med. 2019 Jan;170(1):22-30.

5. “Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15-39),” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.
 

Screening mammography has contributed to the lowering of mortality from breast cancer by facilitating earlier diagnosis and a lower stage at diagnosis. With more effective treatment options for women who are diagnosed with lower-stage breast cancer, the current 5-year survival rate has risen to 90% – significantly higher than the 5-year survival rate of 75% in 1975.¹

Courtesy Dr. Katherine Tkaczuk

Women who are at much higher risk for developing breast cancer – mainly because of family history, certain genetic mutations, or a history of radiation therapy to the chest – will benefit the most from earlier and more frequent screening mammography as well as enhanced screening with non-x-ray methods of breast imaging. It is important that ob.gyns. help to identify these women.

However, the majority of women who are screened with mammography are at “average risk,” with a lifetime risk for developing breast cancer of 12.9%, based on 2015-2017 data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program (SEER).¹ The median age at diagnosis of breast cancer in the U.S. is 62 years,¹ and advancing age is the most important risk factor for these women.

A 20% relative risk reduction in breast cancer mortality with screening mammography has been demonstrated both in systematic reviews of randomized and observational studies² and in a meta-analysis of 11 randomized trials comparing screening and no screening.³ Even though the majority of randomized trials were done in the age of film mammography, experts believe that we still see at least a 20% reduction today.

Among average-risk women, those aged 50-74 with a life expectancy of at least 10 years will benefit the most from regular screening. According to the 2016 screening guideline of the United States Preventive Services Task Force (USPSTF), relative risk reductions in breast cancer mortality from mammography screening, by age group, are 0.88 (confidence interval, 0.73-1.003) for ages 39-49; 0.86 (CI, 0.68-0.97) for ages 50-59; 0.67 (CI, 0.55-0.91) for ages 60-69; and 0.80 (CI, 0.51 to 1.28) for ages 70-74.²

For women aged 40-49 years, most of the guidelines in the United States recommend individualized screening every 1 or 2 years – screening that is guided by shared decision-making that takes into account each woman’s values regarding relative harms and benefits. This is because their risk of developing breast cancer is relatively low while the risk of false-positive results can be higher.

A few exceptions include guidelines by the National Comprehensive Cancer Network (NCCN) and the American College of Radiology, which recommend annual screening mammography starting at age 40 years for all average-risk women. In our program, we adhere to these latter recommendations and advise annual digital 3-D mammograms starting at age 40 and continuing until age 74, or longer if the woman is otherwise healthy with a life expectancy greater than 10 years.
 

Screening and overdiagnosis

Overdiagnosis – the diagnosis of cancers that may not actually cause mortality or may not even have become apparent without screening – is a concern for all women undergoing routine screening for breast cancer. There is significant uncertainty about its frequency, however.

Research cited by the USPSTF suggests that as many as one in five women diagnosed with breast cancer over approximately 10 years will be overdiagnosed. Other modeling studies have estimated one in eight overdiagnoses, for women aged 50-75 years specifically. By the more conservative estimate, according to the USPSTF, one breast cancer death will be prevented for every 2-3 cases of unnecessary treatment.²

Ductal carcinoma in situ is confined to the mammary ductal-lobular system and lacks the classic characteristics of cancer. Technically, it should not metastasize. But we do not know with certainty which cases of DCIS will or will not progress to invasive cancer. Therefore these women often are offered surgical approaches mirroring invasive cancer treatments (lumpectomy with radiation or even mastectomy in some cases), while for some, such treatments may be unnecessary.
 

Screening younger women (40-49)

Shared decision-making is always important for breast cancer screening, but in our program we routinely recommend annual screening in average-risk women starting at age 40 for several reasons. For one, younger women may present with more aggressive types of breast cancer such as triple-negative breast cancer. These are much less common than hormone-receptor positive breast cancers – they represent 15%-20% of all breast cancers – but they are faster growing and may develop in the interim if women are screened less often (at 2-year intervals).

In addition, finding an invasive breast cancer early is almost always beneficial. Earlier diagnosis (lower stage at diagnosis) is associated with increased breast cancer-specific and overall survival, as well as less-aggressive treatment approaches.

As a medical oncologist who treats women with breast cancer, I see these benefits firsthand. With earlier diagnosis, we are more likely to offer less aggressive surgical approaches such as partial mastectomy (lumpectomy) and sentinel lymph node biopsy as opposed to total mastectomy with axillary lymph node dissection, the latter of which is more likely to be associated with lymphedema and which can lead to postmastectomy chest wall pain syndromes.

We also are able to use less aggressive radiation therapy approaches such as partial breast radiation, and less aggressive breast cancer–specific systemic treatments for women with a lower stage of breast cancer at diagnosis. In some cases, adjuvant or neoadjuvant chemotherapy may not be needed – and when it is necessary, shorter courses of chemotherapy or targeted chemotherapeutic regimens may be offered. This means lower systemic toxicities, both early and late, such as less cytopenias, risk of infections, mucositis, hair loss, cardiotoxicity, secondary malignancies/leukemia, and peripheral sensory neuropathy.

It is important to note that Black women in the United States have the highest death rate from breast cancer – 27.3 per 100,000 per year, versus 19.6 per 100,000 per year for White women¹ – and that younger Black women appear to have a higher risk of developing triple-negative breast cancer, a more aggressive type of breast cancer. The higher breast cancer mortality in Black women is likely multifactorial and may be attributed partly to disparities in health care and partly to tumor biology. The case for annual screening in this population thus seems especially strong.
 

Screening modalities

Digital 3-D mammography, or digital breast tomosynthesis (DBT), is widely considered to be a more sensitive screening tool than conventional digital mammography alone. The NCCN recommends DBT for women with an average risk of developing breast cancer starting at age 40,^4,5 and the USPSTF, while offering no recommendation on DBT as a primary screening method (“insufficient evidence”), says that DBT appears to increase cancer detection rates.² So, I do routinely recommend it.

DBT may be especially beneficial for women with dense breast tissue (determined mammographically), who are most often premenopausal women – particularly non-Hispanic White women. Dense breast tissue itself can contribute to an increased risk of breast cancer – an approximately 20% higher relative risk in an average-risk woman with heterogeneously dense breast tissue, and an approximately 100% higher relative risk in a woman with extremely dense breasts⁶ – but unfortunately it affects the sensitivity and specificity of screening mammography.

I do not recommend routine supplemental screening with other methods (breast ultrasonography or MRI) for women at average risk of breast cancer who have dense breasts. MRI with gadolinium contrast is recommended as an adjunct to mammography for women who have a lifetime risk of developing breast cancer of more than 20%-25% (e.g., women with known BRCA1/2 mutations or radiation to breast tissue), and can be done annually at the same time as the screening mammogram is done. Some clinicians and patients prefer to alternate these two tests – one every 6 months.

Screening breast MRI is more sensitive but less specific than mammography; combining the two screening modalities leads to overall increased sensitivity and specificity in high-risk populations.
 

Risk assessment

Identifying higher-risk women who need to be sent to a genetic counselor is critically important. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer, or who have an ancestry associated with BRCA1/2 gene mutations, be assessed with a brief familial risk assessment tool such as the Pedigree Assessment Tool. This and other validated tools have been evaluated by the USPSTF and can be used to guide referrals to genetic counseling for more definitive risk assessment.⁷

These tools are different from general breast cancer risk assessment models, such as the NCI’s Breast Cancer Risk Assessment Tool,⁸ which are designed to calculate the 5-year and lifetime risk of developing invasive breast cancer for an average-risk woman but not to identify BRCA-related cancer risk. (The NCI’s tool is based on the Gail model, which has been widely used over the years.)

The general risk assessment models use a women’s personal medical and reproductive history as well as the history of breast cancer among her first-degree relatives to estimate her risk.
 

Dr. Tkaczuk reported that she has no disclosures.

References

1. “Cancer Stat Facts: Female Breast Cancer.” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.

2. Siu AL et al. Ann Intern Med. 2016 Feb 16. doi: 10.7326/M15-2886.

3. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov 17;380(9855):1778-86.

4. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network.

5. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Risk Reduction. National Comprehensive Cancer Network.

6. Ziv E et al. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2090-5.

7. USPSTF. JAMA. 2019;322(7):652-65.

8. The Breast Cancer Risk Assessment Tool. National Cancer Institute.
 

Screening mammography has contributed to the lowering of mortality from breast cancer by facilitating earlier diagnosis and a lower stage at diagnosis. With more effective treatment options for women who are diagnosed with lower-stage breast cancer, the current 5-year survival rate has risen to 90% – significantly higher than the 5-year survival rate of 75% in 1975.¹

Courtesy Dr. Katherine Tkaczuk

Women who are at much higher risk for developing breast cancer – mainly because of family history, certain genetic mutations, or a history of radiation therapy to the chest – will benefit the most from earlier and more frequent screening mammography as well as enhanced screening with non-x-ray methods of breast imaging. It is important that ob.gyns. help to identify these women.

However, the majority of women who are screened with mammography are at “average risk,” with a lifetime risk for developing breast cancer of 12.9%, based on 2015-2017 data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program (SEER).¹ The median age at diagnosis of breast cancer in the U.S. is 62 years,¹ and advancing age is the most important risk factor for these women.

A 20% relative risk reduction in breast cancer mortality with screening mammography has been demonstrated both in systematic reviews of randomized and observational studies² and in a meta-analysis of 11 randomized trials comparing screening and no screening.³ Even though the majority of randomized trials were done in the age of film mammography, experts believe that we still see at least a 20% reduction today.

Among average-risk women, those aged 50-74 with a life expectancy of at least 10 years will benefit the most from regular screening. According to the 2016 screening guideline of the United States Preventive Services Task Force (USPSTF), relative risk reductions in breast cancer mortality from mammography screening, by age group, are 0.88 (confidence interval, 0.73-1.003) for ages 39-49; 0.86 (CI, 0.68-0.97) for ages 50-59; 0.67 (CI, 0.55-0.91) for ages 60-69; and 0.80 (CI, 0.51 to 1.28) for ages 70-74.²

For women aged 40-49 years, most of the guidelines in the United States recommend individualized screening every 1 or 2 years – screening that is guided by shared decision-making that takes into account each woman’s values regarding relative harms and benefits. This is because their risk of developing breast cancer is relatively low while the risk of false-positive results can be higher.

A few exceptions include guidelines by the National Comprehensive Cancer Network (NCCN) and the American College of Radiology, which recommend annual screening mammography starting at age 40 years for all average-risk women. In our program, we adhere to these latter recommendations and advise annual digital 3-D mammograms starting at age 40 and continuing until age 74, or longer if the woman is otherwise healthy with a life expectancy greater than 10 years.
 

Screening and overdiagnosis

Overdiagnosis – the diagnosis of cancers that may not actually cause mortality or may not even have become apparent without screening – is a concern for all women undergoing routine screening for breast cancer. There is significant uncertainty about its frequency, however.

Research cited by the USPSTF suggests that as many as one in five women diagnosed with breast cancer over approximately 10 years will be overdiagnosed. Other modeling studies have estimated one in eight overdiagnoses, for women aged 50-75 years specifically. By the more conservative estimate, according to the USPSTF, one breast cancer death will be prevented for every 2-3 cases of unnecessary treatment.²

Ductal carcinoma in situ is confined to the mammary ductal-lobular system and lacks the classic characteristics of cancer. Technically, it should not metastasize. But we do not know with certainty which cases of DCIS will or will not progress to invasive cancer. Therefore these women often are offered surgical approaches mirroring invasive cancer treatments (lumpectomy with radiation or even mastectomy in some cases), while for some, such treatments may be unnecessary.
 

Screening younger women (40-49)

Shared decision-making is always important for breast cancer screening, but in our program we routinely recommend annual screening in average-risk women starting at age 40 for several reasons. For one, younger women may present with more aggressive types of breast cancer such as triple-negative breast cancer. These are much less common than hormone-receptor positive breast cancers – they represent 15%-20% of all breast cancers – but they are faster growing and may develop in the interim if women are screened less often (at 2-year intervals).

In addition, finding an invasive breast cancer early is almost always beneficial. Earlier diagnosis (lower stage at diagnosis) is associated with increased breast cancer-specific and overall survival, as well as less-aggressive treatment approaches.

As a medical oncologist who treats women with breast cancer, I see these benefits firsthand. With earlier diagnosis, we are more likely to offer less aggressive surgical approaches such as partial mastectomy (lumpectomy) and sentinel lymph node biopsy as opposed to total mastectomy with axillary lymph node dissection, the latter of which is more likely to be associated with lymphedema and which can lead to postmastectomy chest wall pain syndromes.

We also are able to use less aggressive radiation therapy approaches such as partial breast radiation, and less aggressive breast cancer–specific systemic treatments for women with a lower stage of breast cancer at diagnosis. In some cases, adjuvant or neoadjuvant chemotherapy may not be needed – and when it is necessary, shorter courses of chemotherapy or targeted chemotherapeutic regimens may be offered. This means lower systemic toxicities, both early and late, such as less cytopenias, risk of infections, mucositis, hair loss, cardiotoxicity, secondary malignancies/leukemia, and peripheral sensory neuropathy.

It is important to note that Black women in the United States have the highest death rate from breast cancer – 27.3 per 100,000 per year, versus 19.6 per 100,000 per year for White women¹ – and that younger Black women appear to have a higher risk of developing triple-negative breast cancer, a more aggressive type of breast cancer. The higher breast cancer mortality in Black women is likely multifactorial and may be attributed partly to disparities in health care and partly to tumor biology. The case for annual screening in this population thus seems especially strong.
 

Screening modalities

Digital 3-D mammography, or digital breast tomosynthesis (DBT), is widely considered to be a more sensitive screening tool than conventional digital mammography alone. The NCCN recommends DBT for women with an average risk of developing breast cancer starting at age 40,^4,5 and the USPSTF, while offering no recommendation on DBT as a primary screening method (“insufficient evidence”), says that DBT appears to increase cancer detection rates.² So, I do routinely recommend it.

DBT may be especially beneficial for women with dense breast tissue (determined mammographically), who are most often premenopausal women – particularly non-Hispanic White women. Dense breast tissue itself can contribute to an increased risk of breast cancer – an approximately 20% higher relative risk in an average-risk woman with heterogeneously dense breast tissue, and an approximately 100% higher relative risk in a woman with extremely dense breasts⁶ – but unfortunately it affects the sensitivity and specificity of screening mammography.

I do not recommend routine supplemental screening with other methods (breast ultrasonography or MRI) for women at average risk of breast cancer who have dense breasts. MRI with gadolinium contrast is recommended as an adjunct to mammography for women who have a lifetime risk of developing breast cancer of more than 20%-25% (e.g., women with known BRCA1/2 mutations or radiation to breast tissue), and can be done annually at the same time as the screening mammogram is done. Some clinicians and patients prefer to alternate these two tests – one every 6 months.

Screening breast MRI is more sensitive but less specific than mammography; combining the two screening modalities leads to overall increased sensitivity and specificity in high-risk populations.
 

Risk assessment

Identifying higher-risk women who need to be sent to a genetic counselor is critically important. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer, or who have an ancestry associated with BRCA1/2 gene mutations, be assessed with a brief familial risk assessment tool such as the Pedigree Assessment Tool. This and other validated tools have been evaluated by the USPSTF and can be used to guide referrals to genetic counseling for more definitive risk assessment.⁷

These tools are different from general breast cancer risk assessment models, such as the NCI’s Breast Cancer Risk Assessment Tool,⁸ which are designed to calculate the 5-year and lifetime risk of developing invasive breast cancer for an average-risk woman but not to identify BRCA-related cancer risk. (The NCI’s tool is based on the Gail model, which has been widely used over the years.)

The general risk assessment models use a women’s personal medical and reproductive history as well as the history of breast cancer among her first-degree relatives to estimate her risk.
 

Dr. Tkaczuk reported that she has no disclosures.

References

1. “Cancer Stat Facts: Female Breast Cancer.” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.

2. Siu AL et al. Ann Intern Med. 2016 Feb 16. doi: 10.7326/M15-2886.

3. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov 17;380(9855):1778-86.

4. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network.

5. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Risk Reduction. National Comprehensive Cancer Network.

6. Ziv E et al. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2090-5.

7. USPSTF. JAMA. 2019;322(7):652-65.

8. The Breast Cancer Risk Assessment Tool. National Cancer Institute.
 

Screening mammography has contributed to the lowering of mortality from breast cancer by facilitating earlier diagnosis and a lower stage at diagnosis. With more effective treatment options for women who are diagnosed with lower-stage breast cancer, the current 5-year survival rate has risen to 90% – significantly higher than the 5-year survival rate of 75% in 1975.¹

Courtesy Dr. Katherine Tkaczuk

Women who are at much higher risk for developing breast cancer – mainly because of family history, certain genetic mutations, or a history of radiation therapy to the chest – will benefit the most from earlier and more frequent screening mammography as well as enhanced screening with non-x-ray methods of breast imaging. It is important that ob.gyns. help to identify these women.

However, the majority of women who are screened with mammography are at “average risk,” with a lifetime risk for developing breast cancer of 12.9%, based on 2015-2017 data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program (SEER).¹ The median age at diagnosis of breast cancer in the U.S. is 62 years,¹ and advancing age is the most important risk factor for these women.

A 20% relative risk reduction in breast cancer mortality with screening mammography has been demonstrated both in systematic reviews of randomized and observational studies² and in a meta-analysis of 11 randomized trials comparing screening and no screening.³ Even though the majority of randomized trials were done in the age of film mammography, experts believe that we still see at least a 20% reduction today.

Among average-risk women, those aged 50-74 with a life expectancy of at least 10 years will benefit the most from regular screening. According to the 2016 screening guideline of the United States Preventive Services Task Force (USPSTF), relative risk reductions in breast cancer mortality from mammography screening, by age group, are 0.88 (confidence interval, 0.73-1.003) for ages 39-49; 0.86 (CI, 0.68-0.97) for ages 50-59; 0.67 (CI, 0.55-0.91) for ages 60-69; and 0.80 (CI, 0.51 to 1.28) for ages 70-74.²

For women aged 40-49 years, most of the guidelines in the United States recommend individualized screening every 1 or 2 years – screening that is guided by shared decision-making that takes into account each woman’s values regarding relative harms and benefits. This is because their risk of developing breast cancer is relatively low while the risk of false-positive results can be higher.

A few exceptions include guidelines by the National Comprehensive Cancer Network (NCCN) and the American College of Radiology, which recommend annual screening mammography starting at age 40 years for all average-risk women. In our program, we adhere to these latter recommendations and advise annual digital 3-D mammograms starting at age 40 and continuing until age 74, or longer if the woman is otherwise healthy with a life expectancy greater than 10 years.
 

Screening and overdiagnosis

Overdiagnosis – the diagnosis of cancers that may not actually cause mortality or may not even have become apparent without screening – is a concern for all women undergoing routine screening for breast cancer. There is significant uncertainty about its frequency, however.

Research cited by the USPSTF suggests that as many as one in five women diagnosed with breast cancer over approximately 10 years will be overdiagnosed. Other modeling studies have estimated one in eight overdiagnoses, for women aged 50-75 years specifically. By the more conservative estimate, according to the USPSTF, one breast cancer death will be prevented for every 2-3 cases of unnecessary treatment.²

Ductal carcinoma in situ is confined to the mammary ductal-lobular system and lacks the classic characteristics of cancer. Technically, it should not metastasize. But we do not know with certainty which cases of DCIS will or will not progress to invasive cancer. Therefore these women often are offered surgical approaches mirroring invasive cancer treatments (lumpectomy with radiation or even mastectomy in some cases), while for some, such treatments may be unnecessary.
 

Screening younger women (40-49)

Shared decision-making is always important for breast cancer screening, but in our program we routinely recommend annual screening in average-risk women starting at age 40 for several reasons. For one, younger women may present with more aggressive types of breast cancer such as triple-negative breast cancer. These are much less common than hormone-receptor positive breast cancers – they represent 15%-20% of all breast cancers – but they are faster growing and may develop in the interim if women are screened less often (at 2-year intervals).

In addition, finding an invasive breast cancer early is almost always beneficial. Earlier diagnosis (lower stage at diagnosis) is associated with increased breast cancer-specific and overall survival, as well as less-aggressive treatment approaches.

As a medical oncologist who treats women with breast cancer, I see these benefits firsthand. With earlier diagnosis, we are more likely to offer less aggressive surgical approaches such as partial mastectomy (lumpectomy) and sentinel lymph node biopsy as opposed to total mastectomy with axillary lymph node dissection, the latter of which is more likely to be associated with lymphedema and which can lead to postmastectomy chest wall pain syndromes.

We also are able to use less aggressive radiation therapy approaches such as partial breast radiation, and less aggressive breast cancer–specific systemic treatments for women with a lower stage of breast cancer at diagnosis. In some cases, adjuvant or neoadjuvant chemotherapy may not be needed – and when it is necessary, shorter courses of chemotherapy or targeted chemotherapeutic regimens may be offered. This means lower systemic toxicities, both early and late, such as less cytopenias, risk of infections, mucositis, hair loss, cardiotoxicity, secondary malignancies/leukemia, and peripheral sensory neuropathy.

It is important to note that Black women in the United States have the highest death rate from breast cancer – 27.3 per 100,000 per year, versus 19.6 per 100,000 per year for White women¹ – and that younger Black women appear to have a higher risk of developing triple-negative breast cancer, a more aggressive type of breast cancer. The higher breast cancer mortality in Black women is likely multifactorial and may be attributed partly to disparities in health care and partly to tumor biology. The case for annual screening in this population thus seems especially strong.
 

Screening modalities

Digital 3-D mammography, or digital breast tomosynthesis (DBT), is widely considered to be a more sensitive screening tool than conventional digital mammography alone. The NCCN recommends DBT for women with an average risk of developing breast cancer starting at age 40,^4,5 and the USPSTF, while offering no recommendation on DBT as a primary screening method (“insufficient evidence”), says that DBT appears to increase cancer detection rates.² So, I do routinely recommend it.

DBT may be especially beneficial for women with dense breast tissue (determined mammographically), who are most often premenopausal women – particularly non-Hispanic White women. Dense breast tissue itself can contribute to an increased risk of breast cancer – an approximately 20% higher relative risk in an average-risk woman with heterogeneously dense breast tissue, and an approximately 100% higher relative risk in a woman with extremely dense breasts⁶ – but unfortunately it affects the sensitivity and specificity of screening mammography.

I do not recommend routine supplemental screening with other methods (breast ultrasonography or MRI) for women at average risk of breast cancer who have dense breasts. MRI with gadolinium contrast is recommended as an adjunct to mammography for women who have a lifetime risk of developing breast cancer of more than 20%-25% (e.g., women with known BRCA1/2 mutations or radiation to breast tissue), and can be done annually at the same time as the screening mammogram is done. Some clinicians and patients prefer to alternate these two tests – one every 6 months.

Screening breast MRI is more sensitive but less specific than mammography; combining the two screening modalities leads to overall increased sensitivity and specificity in high-risk populations.
 

Risk assessment

Identifying higher-risk women who need to be sent to a genetic counselor is critically important. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer, or who have an ancestry associated with BRCA1/2 gene mutations, be assessed with a brief familial risk assessment tool such as the Pedigree Assessment Tool. This and other validated tools have been evaluated by the USPSTF and can be used to guide referrals to genetic counseling for more definitive risk assessment.⁷

These tools are different from general breast cancer risk assessment models, such as the NCI’s Breast Cancer Risk Assessment Tool,⁸ which are designed to calculate the 5-year and lifetime risk of developing invasive breast cancer for an average-risk woman but not to identify BRCA-related cancer risk. (The NCI’s tool is based on the Gail model, which has been widely used over the years.)

The general risk assessment models use a women’s personal medical and reproductive history as well as the history of breast cancer among her first-degree relatives to estimate her risk.
 

Dr. Tkaczuk reported that she has no disclosures.

References

1. “Cancer Stat Facts: Female Breast Cancer.” Surveillance, Epidemiology, and End Results Program. National Cancer Institute.

2. Siu AL et al. Ann Intern Med. 2016 Feb 16. doi: 10.7326/M15-2886.

3. Independent UK Panel on Breast Cancer Screening. Lancet. 2012 Nov 17;380(9855):1778-86.

4. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network.

5. NCCN guidelines for Detection, Prevention, & Risk Reduction: Breast Cancer Risk Reduction. National Comprehensive Cancer Network.

6. Ziv E et al. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2090-5.

7. USPSTF. JAMA. 2019;322(7):652-65.

8. The Breast Cancer Risk Assessment Tool. National Cancer Institute.
 

I have been in practice for 31 years, so many of my patients are now in their 80s and 90s. Practices age with us, and I have been seeing many of these patients for 25-30 years. I have three rules I try to encourage my elderly patients follow, and I wanted to share them with you.

Absolutely, positively make sure you move!

Our older patients often have many reasons not to move, including pain from arthritis, deconditioning, muscle weakness, fatigue, and depression. “Keeping moving” is probably the most important thing a patient can do for their health.

Holme and Anderssen studied a large cohort of men for cardiovascular risk in 1972 and again in 2000. The surviving men were followed over an additional 12 years.¹ They found that 30 minutes of physical activity 6 days a week was associated with a 40% reduction in mortality. Sedentary men had a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active.

Stewart etal. studied the benefit of physical activity in people with stable coronary disease.² They concluded that, in patients with stable coronary heart disease, more physical activity was associated with lower mortality, and the largest benefit occurred in the sedentary patient groups and the highest cardiac risk groups.

Saint-Maurice et al. studied the effects of total daily step count and step intensity on mortality risk.³ They found that the risk of all-cause mortality decreases as the total number of daily steps increases, but that the speed of those steps did not make a difference. This is very encouraging data for our elderly patients. Moving is the secret, even if it may not be moving at a fast pace!
 

Never, ever get on a ladder!

This one should be part of every geriatric’s assessment and every Medicare wellness exam. I first experienced the horror of what can happen when elderly people climb when a 96-year-old healthy patient of mine fell off his roof and died. I never thought to tell him climbing on the roof was an awful idea.

Akland et al. looked at the epidemiology and outcomes of ladder-related falls that required ICU admission.⁴ Hospital mortality was 26%, and almost all of the mortalities occurred in older males in domestic falls, who died as a result of traumatic brain injury. Fewer than half of the survivors were living independently 1 year after the fall.

Valmuur et al. studied ladder related falls in Australia.⁵ They found that rates of ladder related falls requiring hospitalization rose from about 20/100,000 for men ages 15-29 years to 78/100,000 for men aged over 60 years. Of those who died from fall-related injury, 82% were over the age of 60, with more than 70% dying from head injuries.

Schaffarczyk et al. looked at the impact of nonoccupational falls from ladders in men aged over 50 years.⁶ The mean age of the patients in the study was 64 years (range, 50-85), with 27% suffering severe trauma. There was a striking impact on long-term function occurring in over half the study patients. The authors did interviews with patients in follow-up long after the falls and found that most never thought of themselves at risk for a fall, and after the experience of a bad fall, would never consider going on a ladder again. I think it is important for health care professionals to discuss the dangers of ladder use with our older patients, pointing out the higher risk of falling and the potential for the fall to be a life-changing or life-ending event.
 

Let them eat!

Many patients have a reduced appetite as they age. We work hard with our patients to choose a healthy diet throughout their lives, to help ward off obesity, treat hypertension, prevent or control diabetes, or provide heart health. Many patients just stop being interested in food, reduce intake, and may lose weight and muscle mass. When my patients pass the age of 85, I change my focus to encouraging them to eat for calories, socialization, and joy. I think the marginal benefits of more restrictive diets are small, compared with the benefits of helping your patients enjoy eating again. I ask patients what their very favorite foods are and encourage them to have them.

Pearl

Keep your patients eating and moving, except not onto a ladder!

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Holme I, Anderssen SA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med. 2015; 49:743-8.

2. Stewart RAH et al. Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol. 2017 Oct 3;70(14):1689-1700..

3. Saint-Maurice PF et al. Association of daily step count and step intensity with mortality among U.S. adults. JAMA 2020;323:1151-60.

4. Ackland HM et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury. 2016;47:1109-117.

5. Vallmuur K et al. Falls from ladders in Australia: comparing occupational and nonoccupational injuries across age groups. Aust N Z J Public Health. 2016 Dec;40(6):559-63.

6. Schaffarczyk K et al. Nonoccupational falls from ladders in men 50 years and over: Contributing factors and impact. Injury. 2020 Aug;51(8):1798-1804.

I have been in practice for 31 years, so many of my patients are now in their 80s and 90s. Practices age with us, and I have been seeing many of these patients for 25-30 years. I have three rules I try to encourage my elderly patients follow, and I wanted to share them with you.

Absolutely, positively make sure you move!

Our older patients often have many reasons not to move, including pain from arthritis, deconditioning, muscle weakness, fatigue, and depression. “Keeping moving” is probably the most important thing a patient can do for their health.

Holme and Anderssen studied a large cohort of men for cardiovascular risk in 1972 and again in 2000. The surviving men were followed over an additional 12 years.¹ They found that 30 minutes of physical activity 6 days a week was associated with a 40% reduction in mortality. Sedentary men had a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active.

Stewart etal. studied the benefit of physical activity in people with stable coronary disease.² They concluded that, in patients with stable coronary heart disease, more physical activity was associated with lower mortality, and the largest benefit occurred in the sedentary patient groups and the highest cardiac risk groups.

Saint-Maurice et al. studied the effects of total daily step count and step intensity on mortality risk.³ They found that the risk of all-cause mortality decreases as the total number of daily steps increases, but that the speed of those steps did not make a difference. This is very encouraging data for our elderly patients. Moving is the secret, even if it may not be moving at a fast pace!
 

Never, ever get on a ladder!

This one should be part of every geriatric’s assessment and every Medicare wellness exam. I first experienced the horror of what can happen when elderly people climb when a 96-year-old healthy patient of mine fell off his roof and died. I never thought to tell him climbing on the roof was an awful idea.

Akland et al. looked at the epidemiology and outcomes of ladder-related falls that required ICU admission.⁴ Hospital mortality was 26%, and almost all of the mortalities occurred in older males in domestic falls, who died as a result of traumatic brain injury. Fewer than half of the survivors were living independently 1 year after the fall.

Valmuur et al. studied ladder related falls in Australia.⁵ They found that rates of ladder related falls requiring hospitalization rose from about 20/100,000 for men ages 15-29 years to 78/100,000 for men aged over 60 years. Of those who died from fall-related injury, 82% were over the age of 60, with more than 70% dying from head injuries.

Schaffarczyk et al. looked at the impact of nonoccupational falls from ladders in men aged over 50 years.⁶ The mean age of the patients in the study was 64 years (range, 50-85), with 27% suffering severe trauma. There was a striking impact on long-term function occurring in over half the study patients. The authors did interviews with patients in follow-up long after the falls and found that most never thought of themselves at risk for a fall, and after the experience of a bad fall, would never consider going on a ladder again. I think it is important for health care professionals to discuss the dangers of ladder use with our older patients, pointing out the higher risk of falling and the potential for the fall to be a life-changing or life-ending event.
 

Let them eat!

Many patients have a reduced appetite as they age. We work hard with our patients to choose a healthy diet throughout their lives, to help ward off obesity, treat hypertension, prevent or control diabetes, or provide heart health. Many patients just stop being interested in food, reduce intake, and may lose weight and muscle mass. When my patients pass the age of 85, I change my focus to encouraging them to eat for calories, socialization, and joy. I think the marginal benefits of more restrictive diets are small, compared with the benefits of helping your patients enjoy eating again. I ask patients what their very favorite foods are and encourage them to have them.

Pearl

Keep your patients eating and moving, except not onto a ladder!

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Holme I, Anderssen SA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med. 2015; 49:743-8.

2. Stewart RAH et al. Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol. 2017 Oct 3;70(14):1689-1700..

3. Saint-Maurice PF et al. Association of daily step count and step intensity with mortality among U.S. adults. JAMA 2020;323:1151-60.

4. Ackland HM et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury. 2016;47:1109-117.

5. Vallmuur K et al. Falls from ladders in Australia: comparing occupational and nonoccupational injuries across age groups. Aust N Z J Public Health. 2016 Dec;40(6):559-63.

6. Schaffarczyk K et al. Nonoccupational falls from ladders in men 50 years and over: Contributing factors and impact. Injury. 2020 Aug;51(8):1798-1804.

I have been in practice for 31 years, so many of my patients are now in their 80s and 90s. Practices age with us, and I have been seeing many of these patients for 25-30 years. I have three rules I try to encourage my elderly patients follow, and I wanted to share them with you.

Absolutely, positively make sure you move!

Our older patients often have many reasons not to move, including pain from arthritis, deconditioning, muscle weakness, fatigue, and depression. “Keeping moving” is probably the most important thing a patient can do for their health.

Holme and Anderssen studied a large cohort of men for cardiovascular risk in 1972 and again in 2000. The surviving men were followed over an additional 12 years.¹ They found that 30 minutes of physical activity 6 days a week was associated with a 40% reduction in mortality. Sedentary men had a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active.

Stewart etal. studied the benefit of physical activity in people with stable coronary disease.² They concluded that, in patients with stable coronary heart disease, more physical activity was associated with lower mortality, and the largest benefit occurred in the sedentary patient groups and the highest cardiac risk groups.

Saint-Maurice et al. studied the effects of total daily step count and step intensity on mortality risk.³ They found that the risk of all-cause mortality decreases as the total number of daily steps increases, but that the speed of those steps did not make a difference. This is very encouraging data for our elderly patients. Moving is the secret, even if it may not be moving at a fast pace!
 

Never, ever get on a ladder!

This one should be part of every geriatric’s assessment and every Medicare wellness exam. I first experienced the horror of what can happen when elderly people climb when a 96-year-old healthy patient of mine fell off his roof and died. I never thought to tell him climbing on the roof was an awful idea.

Akland et al. looked at the epidemiology and outcomes of ladder-related falls that required ICU admission.⁴ Hospital mortality was 26%, and almost all of the mortalities occurred in older males in domestic falls, who died as a result of traumatic brain injury. Fewer than half of the survivors were living independently 1 year after the fall.

Valmuur et al. studied ladder related falls in Australia.⁵ They found that rates of ladder related falls requiring hospitalization rose from about 20/100,000 for men ages 15-29 years to 78/100,000 for men aged over 60 years. Of those who died from fall-related injury, 82% were over the age of 60, with more than 70% dying from head injuries.

Schaffarczyk et al. looked at the impact of nonoccupational falls from ladders in men aged over 50 years.⁶ The mean age of the patients in the study was 64 years (range, 50-85), with 27% suffering severe trauma. There was a striking impact on long-term function occurring in over half the study patients. The authors did interviews with patients in follow-up long after the falls and found that most never thought of themselves at risk for a fall, and after the experience of a bad fall, would never consider going on a ladder again. I think it is important for health care professionals to discuss the dangers of ladder use with our older patients, pointing out the higher risk of falling and the potential for the fall to be a life-changing or life-ending event.
 

Let them eat!

Many patients have a reduced appetite as they age. We work hard with our patients to choose a healthy diet throughout their lives, to help ward off obesity, treat hypertension, prevent or control diabetes, or provide heart health. Many patients just stop being interested in food, reduce intake, and may lose weight and muscle mass. When my patients pass the age of 85, I change my focus to encouraging them to eat for calories, socialization, and joy. I think the marginal benefits of more restrictive diets are small, compared with the benefits of helping your patients enjoy eating again. I ask patients what their very favorite foods are and encourage them to have them.

Pearl

Keep your patients eating and moving, except not onto a ladder!

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Holme I, Anderssen SA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med. 2015; 49:743-8.

2. Stewart RAH et al. Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol. 2017 Oct 3;70(14):1689-1700..

3. Saint-Maurice PF et al. Association of daily step count and step intensity with mortality among U.S. adults. JAMA 2020;323:1151-60.

4. Ackland HM et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury. 2016;47:1109-117.

5. Vallmuur K et al. Falls from ladders in Australia: comparing occupational and nonoccupational injuries across age groups. Aust N Z J Public Health. 2016 Dec;40(6):559-63.

6. Schaffarczyk K et al. Nonoccupational falls from ladders in men 50 years and over: Contributing factors and impact. Injury. 2020 Aug;51(8):1798-1804.