PsicoGDL

Geriatrics and Gerontology are often used to mean the same thing.  Geriatrics is the branch of medicine that deals with the illness and care of the aged, while Gerontology is the study of factors affecting the normal aging process and the effects of aging on persons of all ages.

Geriatric nursing focuses on the care of the sick elderly.  Gerontologic nursing includes not only the care of the sick elderly, but also health maintenance, illness prevention, and the promotion of quality of life to assist the person to grow to an ideal state of health and well being.

Simply stated, our role as health care providers is to assist our elderly patients to get better, to maintain at their current status – accepting declines – or to ease their dying.

Pharmacotherapy for the elderly can cure or palliate disease as well as enhance health-related quality of life (HRQOL). HRQOL considerations for the elderly include focusing on improvement in physical functioning, psychological functioning, social functioning, and overall health. Despite the benefits of pharmacotherapy, HRQOL can be compromised by drug-related problems. The avoidance of drug related adverse consequences in the elderly requires health care practitioners to become knowledgeable about a number of age-specific issues.

 

GERIATRIC PHARMACOLOGY

In general, everything diminishes with age. Both the pharmacodynamic as well as the pharmacokinetic character changes with time. With aging inherent variability in physiologic differences becomes accentuated. Pharmacodynamic responses are blunted, ability to eliminate drugs is diminished and sensitivity to the toxic effects of drugs is increased. The effects of diseases are often additive and accumulate with time. Disability and capacity for recuperation or compensation are decreased. As a result the incidence of adverse drug events is concentrated in the elderly.

The concern for drug use in the elderly stems from the disproportionate use of drugs in the elderly. Geriatric patients represent 12% of population but receive 30% of all prescriptions. Two thirds use 1 or more drugs daily. Average use is 5 – 12 drugs daily and < 5% use no drugs. One third use 1 or more psychotropic drugs each year.

 

PATHOPHYSIOLOGY OF AGING

 

In the elderly the physiologic underpinnings are altered. There is an altered, usually diminished, receptor sensitivity and responsiveness. The ability to mount a compensatory physiologic response is diminished. Normal homeostatic mechanisms are blunted and sometimes produce inappropriate responses.

The elderly accumulate diseases. Even “healthy” elderly have diminished capacities. Aging is a continuum and the aged are stratified by degree of age. As age progresses so do the exceptional considerations.

ALTERED PHARMACOKINETICS

 

Age related changes are small. Decreased motility and changes in surface area are less significant than disease-specific changes. Effects of age on absorption for delayed and sustained release formulations have not been well-documented. A diminished first-pass effect results in an increased bioavailability.

 

As a consequence of the age-related changes in body composition, polar drugs that are mainly water-soluble tend to have smaller volumes of distribution (V) resulting in higher serum levels in older people. Gentamicin, digoxin, ethanol, theophylline, and cimetidine fall into this category.  Loading doses of digoxin need to be reduced to accommodate these changes. On the other hand, nonpolar compounds tend to be lipid-soluble and so their V increases with age. The main effect of the increased V is a prolongation of half-life. Increased V and t1/2 have been observed for drugs such as diazepam, thiopentone, lignocaine, and chlormethiazole.

 

 

Decrease in Clearance and increase in half- life for renally cleared drugs. The age-related change in renal clearance is the most consistent and predictable change in pharmacokinetics. The dose of most drugs that are renally cleared should be adjusted for renal function. The adjustment method most frequently used is the Cockroft-Gault equation to estimate renal clearance.

 

CLCr (ml/min) =

(140 – age)  (lean weight in kg)

72 (serum creatinine in mg/dL)

ALTERED PHARMACODYNAMICS

There is some evidence in the elderly of altered drug response or “sensitivity.” Four possible mechanisms have been suggested: (1) changes in receptor numbers, (2) changes in receptor affinity, (3) postreceptor alterations, and 4) age-related impairment of homeostatic mechanisms. For example, muscarinic, parathyroid hormone, β-adrenergic, α1-adrenergic, and μ-opioid receptors exhibit reduced density with increasing age. Also, the elderly are more sensitive to the central nervous system effects of benzodiazepines. The elderly also exhibit a greater analgesic responsiveness to opioids when compared with their younger counterparts, even when pharmacokinetic parameters are similar in the two groups. In addition, the elderly demonstrate an enhanced responsiveness to anticoagulants such as warfarin and heparin, as well as thrombolytic therapy. In contrast, the elderly exhibit decreased responsiveness to certain drugs (e.g., β-agonists/antagonists). Also, reflex tachycardia, seen commonly with vasodilator therapy, is often blunted in the elderly. For some drugs (e.g., calcium channel blockers), both enhanced responsiveness (as demonstrated by greater reduction in blood pressure) and decreased responsiveness (as demonstrated by reduced atrioventricular nodal blockade) can occur simultaneously in elders.

 

Physiologic Changes with Aging

Organ System Manifestation

Body composition

↓ Total body water

↓ Lean body mass

↑ Body fat

↔ or ↓ Serum albumin

↔ or ↑ α1-Acid glycoprotein (↑ by several disease states)

Cardiovascular

↓ Myocardial sensitivity to beta-adrenergic stimulation

↓ Baroreceptor activity

↓ Cardiac output

↑ Total peripheral resistance

Central nervous system

↓ Weight and volume of the brain

Alterations in several aspects of cognition

Endocrine

Thyroid gland atrophies with age

Increase in incidence of diabetes mellitus, thyroid disease

Menopause

Gastrointestinal

↑ Gastric pH

↓ Gastrointestinal blood flow

Delayed gastric emptying

Slowed intestinal transit

Genitourinary

Atrophy of the vagina due to decreased estrogen

Prostatic hypertrophy due to androgenic hormonal changes

Age-related changes may predispose to incontinence

Immune

↓ Cell-mediated immunity

Liver

↓ Liver size

↓ Liver blood flow

Oral

Altered dentition

↓ Ability to taste sweetness, sourness, and bitterness

Pulmonary

↓ Respiratory muscle strength

↓ Chest wall compliance

↓ Total alveolar surface

↓ Vital capacity

↓ Maximal breathing capacity

Renal

↓ Glomerular filtration rate

↓ Renal blood flow

↑ Filtration fraction

↓ Tubular secretory function

↓ Renal mass

Sensory

↓ Accommodation of the lens of the eye, causing farsightedness

Presbycusis (loss of auditory acuity)

↓ Conduction velocity

Skeletal

Loss of skeletal bone mass (osteopenia)

Skin/hair

Skin dryness, wrinkling,

changes in pigmentation, epithelial thinning,

loss of dermal thickness

↓ Number of hair follicles

↓ Number of melanocytes in the hair bulbs

 

COMMON CLINICAL DISORDERS IN GERIATRICS

 

Dementia

Dementia is progressive deterioration in intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living. Diagnosis is by history and physical examination. Potentially reversible causes of cognitive impairment (e.g., drugs, delirium, depression) should be excluded. Treatment is with general measures and usually a cholinesterase inhibitors(donepezil, rivastigmine, galantamine), memantine, or both.

Parkinsonism

It is a relatively common disease of the elderly. Levodopa preparations should be used with caution and bromocriptine and other ergot derivatives should be avoided.

Hypertension

Hypertension is defined as systolic BP >= 140 mm Hg or diastolic BP >= 90 mm Hg. Isolated systolic hypertension, a common form of hypertension in the elderly, is defined as systolic BP >= 140 mm Hg and diastolic BP < 90 mm Hg. For most elderly patients, hypertension does not have a reversible cause and is asymptomatic. Evaluation should include detection of other cardiovascular risk factors and end-organ damage and a search for secondary causes when appropriate. Treatment is with lifestyle modifications and drugs, often starting with a thiazide-type diuretic.

Cardiac failure

Heart failure is common among persons >= 65 years. Its prevalence increases exponentially after age 70. Heart failure is now the most common diagnosis among hospitalized elderly patients. Treatment should be aimed at reducing symptoms, improving quality of life, and preventing acute exacerbations and hospitalization. Diuretics, ACE inhibitors, nitrates and digoxin are important for elderly.

 

Myocardial infarction

Clinically recognized or unrecognized MI occurs in 35% of elderly persons; 60% of hospitalizations due to acute MI occur in persons >= 65yrs. Unless contraindicated, aspirin (or if contraindicated, ticlopidine or clopidogrel) should be given. The role of glycoprotein IIb/IIIa inhibitors (e.g., tirofiban, abciximab) in the treatment of elderly patients with acute MI is under study.

Urinary incontinence

Eight to 34% of community-dwelling elderly persons suffer from urinary incontinence; rates are higher in women than in men, and urinary incontinence affects > 50% of elderly patients in hospitals and in nursing homes. The commonly used drugs for detrusor instability are oxybutynin and tolterodine.

 

Constipation

Constipation is more common in elderly persons–who report more straining and sensation of anal blockage–than in middle-aged persons. It can be treated in most elderly persons with dietary and behavioral changes and judicious use of laxatives and enemas.

Osteoporosis

Fractures resulting from minimal trauma result in significant morbidity and mortality in the elderly. These fragility fractures are related to underlying osteoporosis. Treatment of osteoporosis with bisphosphonate therapy has been shown to be effective in reducing fracture incidence and was largely underutilized in our study.

Arthritis

Osteoarthritis, gout, pseudogout, rheumatoid arthritis and septic arthritis are the important joint diseases in elderly.

DRUG RELATED PROBLEMS IN THE ELDERLY

Although medications used by the elderly can lead to improvement in HRQOL, negative outcomes owing to drug-related problems are considerable. Three important and potentially preventable negative outcomes owing to drug-related problems that can

occur in the elderly are adverse drug withdrawal events (ADWEs), which are clinically significant sets of symptoms or signs caused by the removal of a drug; therapeutic failure (inadequate or inappropriate drug therapy and not related to the natural progression of disease); and adverse drug reactions (ADRs), defined as a reaction that is noxious and unintended and which occurs at dosages normally used in humans for prophylaxis, diagnosis, or therapy.

A number of factors are believed to increase the risk of drug related problems in the elderly, including suboptimal prescribing (e.g., overuse of medications or polypharmacy, inappropriate use, and underuse), medication errors (both dispensing and administration problems), and patient medication nonadherence (both intentional and unintentional).

Overuse

Polypharmacy can be defined as either the concomitant use of multiple drugs or the administration of more medications than are indicated clinically. Multiple medication use has been strongly associated with ADRs. Polypharmacy is also problematic for elderly

patients because it may increase the risk of geriatric syndromes (e.g., falls, cognitive impairment), diminished functional status, and health care costs.

 

Inappropriate prescribing

Inappropriate prescribing can be defined as prescribing of medications outside the bounds of accepted medical standards.

Underuse

An important and increasingly recognized problem in elders is underuse, defined as the omission of drug therapy that is indicated forthe treatment or prevention of a disease or condition. Underuse may have an important relationship with negative health outcomes in the elderly, including functional disability, death, and health services use.

Medication Nonadherence

Medication nonadherence is a common problem in the elderly. Nonadherence is associated with increased health services use and adverse drug reactions.

 

Approach to medication prescribing

 

At the point of initial prescribing, it is important to avoid using medications that are potentially inappropriate in the elderly. When starting a new medication, the lowest

possible dose should be used and titrated slowly. A rule of thumb to help prevent potentially harmful iatrogenic illness is to initiate a medication at one-third to one-half of the manufacturer’s recommended dosage. Whenever possible, once-a-day dosing is preferred since complex dosing makes it difficult for patients to adhere to medications. Each medication should be matched  with its diagnosis, and those without a clear indication should be eliminated. A medication should not be added to combat the side effects of another one. When multiple medications are used for one diagnosis, maximizing doses should be considered  the number of medications.  A time-limited prescription should be written  and a team approach, involving the family, caregiver and pharmacist should be followed.

 

 

GERIATRIC CARE

 

Generally, elderly have a different perception of life and death. They tend to be more anxious about disabilities, as it may lead to loss of independence and a precursor of death. They do not want to be a burden to themselves or to the family or society. The central theme of geriatric care is “Care rather than Cure”. Geriatric care aims at achieving:

 

Best forms of health care

 

 

Geriatric care principles

 

 

Differences between general and geriatric principles

General Principles

Geriatric Principles

Aim: to cure the disease

 

Aim: to cure if possible /take care always

 

Investigation & diagnosis is important

 

Investigations as per the wishes and

convenience of elders

 

Curative / extensive surgery

 

Curative/ palliative surgery

 

Preserve life at any cost

 

Preserve functional capacity

 

 

 

Geriatric Assessment

 

A comprehensive multidimensional geriatric assessment is the first step in treating the geriatric patients. It is important to examine physiological, mental and emotional functions as well as socioeconomic and environmental factors. A systematic evaluation of the patient’s ability to perform the tasks associated with independent living should be done and recorded for problem detection and treatment.

History taking in elders

 

 

Physical examination

 

Provide a comfortable environment for the elderly and carry out complete clinical examination under good lighting. Sometimes it is necessary to postpone the examination according to the patient’s wishes. Examine the following and record the findings.

 

Diagnosis

 

Treatment

among them.

-plained, if and when the surgery is contemplated.

the disease, complications and prognosis.

 

 

STRATEGIES OF HEALTHY PRESCRIBING IN OLDER PATIENTS

The vision is that older people should  participate to their fullest ability in decisions about their health and wellbeing and in family  and community life. They are supported in this by co-ordinated and responsive health and disability support programmes.

The following eight objectives identify areas where change is essential if the vision is to be achieved.

1. Older people and their families are able to make well-informed choices about options for healthy living, health care and/or disability support needs.

2. Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.

3. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family and carers.

4. The health and disability support needs of older will be met by appropriate, integrated health care and disability support services.

5. Population-based health initiatives and programmes will promote health and wellbeing in older age.

6. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

7. Admission to general hospital services will be integrated with any community-based care and support that an older person requires.

8. Older people with high and complex health and disability support needs will have access to flexible, timely and co-ordinated services and living options that take account of family and carer needs.

 

ROLE OF PHARMACIST IN GERIATRIC CARE

 

Pharmacists are committed to optimizing pharmaceutical therapies for each patient to improve outcomes and reduce costs. They are making significant contributions to the profession through specialized pharmaceutical care. Pharmacists, aided by a comprehensive system employing information technology and clinical “best practices ” work with physicians to identify patients at risk for a given disease state and ensure that optimal drug therapy is received and unnecessary healthcare expenditures are eliminated. Medications are probably the single most important healthcare technology in preventing illness, disability and health in the geriatric population. New products provide pharmacists with valuable tools for promoting quality of life but also confer upon them the more difficult task as well as the greater responsibility of balancing clinical effects to provide the highest possible quality of life for their patients.

 

Pain management is one area of medicine which has seen several technological advancements across the globe. Spurred by this global happening, chronic pain management clinics in developing countries have also begun using novel techniques in the areas of pain imaging, pain assessment, and intervention for chronic pain management.   Chronic pain can refer to any type of pain that endures even after an injury has been healed, pain connected to any degenerative or relentless disease, long-standing pain for which the cause cannot be identified, or cancer pain. In general, pain that continues even after six months is chronic and requires treatment. The diagnosis and treatment of a particular patient at a chronic pain management clinic usually requires the involvement of several specialists including anesthesiologists, psychiatrists, physiatrists, neurologists, and nurses. Several therapies are combined in order to at least make the patient feel more comfortable if the pain cannot be stopped, to help him/her return to work, to do away with his/her depression, and to improve his/her physical functioning. Thus, these therapies are medication, surgery, psychological counselling, therapies to stimulate the nerves, lifestyle changes, anesthesiological therapies, and rehabilitation. Medication recommended for patients in chronic pain management clinics can vary from NSAIDS for pain that is not too bad to narcotic drugs for more severe pain. Physical therapy is one common therapeutic technique used in the management of chronic pain in such clinics. It involves training the patient to enhance his flexibility, endurance, and strength; to move in a way that is structurally correct and safe; and most importantly to handle pain. Therapeutic exercise is an important feature of physical therapy. Another important technique used in chronic pain management clinics is Transcutaneous Electrical Nerve Stimulation (TENS). This technique provides relief for patients suffering from conditions such as arthritic pain or pain in the lower back, by the use of low-voltage electric current. To sum up, once pain has become chronic, complete freedom from the pain is difficult. However, chronic pain management clinics, through the use of multiple techniques used in conjunction with one another, can help sufferers of chronic pain enjoy a happier and more active life.

Many students declare psychology as their major in college with the hopes of becoming a therapist, helping clients through their problems while they lie on the couch, and even opening their own private practice. For some, it is quite a rude awakening to discover that one of the required courses is statistics. Well, why in the world would a psychologist need to learn and master statistics?

What most students do not realize is that psychology is much more than simply talking clients through psychological or adjustment issues. This reflects just one aspect of psychology – the practice-oriented side. There are many psychologists and dozens of specializations that design research studies and use statistics in order to help others in a different way. Even practice-oriented psychologists in Clinical and Counseling Psychology may make use of statistics. How so?

Lets say that after a few years of treating clients who are coming in for marital counseling you develop a program to help build more effective communication and conflict resolution skills. After a few months of treatment, you’ve noticed a dramatic increase in your clients’ satisfaction with their marriages. You want to develop this program to help more clients than you can reach through your one office, but first you need to demonstrate with hard-core numbers that the program is effective. Now you find it necessary to design a study and use statistics to provide evidence that the program does indeed work. As a matter of fact, you may have former clients take a survey one year after treatment to estimate the long-term effect of your program. Can you see now how statistics would be necessary? Rather than paying thousands of dollars to complete this project, you have received all of the training you need in college to conduct the study yourself.

Even outside of the practice-oriented specializations of psychology, there are a number of psychologists who work at academic institutions, research organizations, and government agencies using statistics every single day. Statistics can be used to determine if the media indeed does cause children to exhibit violent behavior, whether a community service project causes people to develop stronger empathy skills, or even whether a new training program increases productivity within the workplace.

No matter what your interests or specialization in psychology, if you are planning on growing your career, you will need to learn and understand statistics. Believe it or not, those classes are far from useless. Statistics are essential to earn your diploma in psychology and perform as an effective psychologist.

Managing Clinical Investigator Compensation report ( http://www.bharatbook.com/Market-Research-Reports/Managing-Clinical-Investigator-Compensation.html ) presents an essential source in establishing transparent and defensible compensation processes for clinical investigators not only saves money – it is absolutely essential in today’s restrictive pharma landscape. Regulatory groups, legislative bodies and consumer advocacy groups are applying relentless pressure on commercial relationships with physicians, altering and often limiting industry practices. Now the ripple effect is hitting clinical operations. Some investigations in the area have garnered public attention, with more bound to follow. We projects that within five years the same regulatory scrutiny currently on the commercial side will expand to the clinical side. Companies that do not recognize this inevitable reality and formalize their FMV processes today put themselves at great risk for compromised trial results, an audit, financial damage and regulatory scrutiny. Diligence and constant monitoring will go a long way to preventing careless errors and courting potentially dangerous consequences. Managing Clinical Investigator Compensation gives your company what it needs to be proactive and prepare for change while avoiding common pitfalls.

Use the data benchmarks to: Control costs Establish current, market based payments to investigators Develop regulation-proof calculation and documentation methods Stay current on the latest FMV regulation concerns and trends Therapeutic Areas Included in Report:Autoimmune Cardiology and Thrombosis CNS/Psychology Dermatology Endocrinology Gastroenterology Hematology Infectious Diseases Medical Devices Musculoskeletal Oncology Respiratory Women’s Health Metrics Included in Report:Managing Clinical Investigator Compensation’s three chapters include compensation data collected from clinical investigators as well as pharmaceutical, biotechnology and medical device companies. Data include breakdowns by phase, therapeutic area and experience. 

Investigator Compensation: Industry DataPercentage of time that companies monitor negotiations between CROs and investigators Percentage of companies that hire CROs to recruit investigators Percentage of companies that hire CROs to contract investigators Percentage of time that CROs handle investigator payments Percentage of companies with a formal process in place for determining investigator compensation Percentage of companies that allow primary investigators to concurrently lead clinical trials for other companies Average years of experience required for primary investigators, by phase Average years of experience required for primary investigators, by company type and by phase Investigator Compensation: Investigator DataPercentage of investigators involved in each type of clinical trial Number of trials that an average investigator is currently leading, by category Average number of companies that investigators have run trials for, by years Years of experience by investigator type (i.e., primary or secondary)

 

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Researchers at University of Oxford said that such kids are more likely to have psychiatric or behavioural disorders. They also said that boys in particular could be affected if their father had depression or was an alcoholic. Te peak age for men to be affected by psychiatric disorders is the same as the peak age for becoming a father – between 18 and 35. Paternal depression during the postnatal period, measured at eight weeks after birth, has been linked to increasing the chance of the child subsequently developing behavioural and emotional problems from 10 percent to 20 percent. During the study, researchers found that teenage offspring of depressed fathers also have an increased risk of various psychological problems, including depression and suicidal behaviour. Researchers said that around 2 percent of men are affected by generalised anxiety disorder, and children whose parents have anxiety disorders have a two-fold increased risk of developing such disorders themselves, Paternal alcoholism is also linked to an increased risk of mood disorders, depressive symptoms, poor performance at school, low self-esteem and problems forming relationships. The research team, led by psychiatrist Professor Paul Ramchandani, said more studies were needed on how fathers” psychiatric disorders affect their children’s development. “Men’s roles in bringing up children have changed significantly over the last century, with many dads now taking on an active ”nurturing role” so it’s important that there is more research into the relationship between fathers” mental health problems and how these may affect their children,” the BBC quoted Emily Wooster, policy and campaign manager for the mental health charity Mind, as saying.

Trent Consultants Psychology Clinic. Dedicated to the study, diagnosis, and treatment of mental, emotional and behavioral disorders. Trent Consultants has a variety of programs for parents who want to give their children a headstart in life. Trent Consultants website www.trentconsultants.org Email: childcare@trentconsultants.org

If you are looking for a psychology scholarship, the American Psychological Association should be one of the first places you look. The American Psychological Association, which is more commonly known by its abbreviation APA, is a professional organization that represents psychologists in the United States.  After one look at the American Psychological Assoc Scholarship details on their website, it is easy to see that there are many scholarships, grants and financial aid opportunities available through the association.

The American Psychological Association has approximately 150,000 members and an annual budget of around $70 million.  Their writing format is also known to be the most universally accepted writing style in the United States for social and behavioral sciences.  It is a well known and respected organization.  The American Psychological Association should not be confused with the American Psychiatric Association, however, when looking for scholarships or any other information associated with the APA.

If you are looking for American Psychological Assoc Scholarship details, look no further than the APA’s Scholarships and Awards page on the web.  This online resource provides students the opportunity to search the APA’s database of psychology scholarships, grants and awards.  Many of the scholarships listed within this resource site are sponsored by the American Psychological Association.  There are achievement awards, fellowships, scholarships, grants, prizes, non-clinical internships and lectures sponsored by APA Divisions, federal agencies, private organizations, the APA, the APF, honor societies, APAGS, the APA Practice Organization and individual states.

If you are looking specifically for a psychology scholarship that is sponsored by the APA, there are many different options out there to choose from.  The American Psychological Association and its affiliate organizations provide a wide range of grants, scholarships and awards.  Their goal is to advance the science and practice of psychology in an effort to understand behavior and promote health, education and human welfare.  With such a wide range of scholarships and other types of financial aid either sponsored by or recommended by the American Psychological Association, any high achieving student in the psychology field should be able to find a prize or award that they may qualify for.

IVF or in vitro fertilisation is slowly emerging as one of the preferred answers to issues like infertility and cases of miscarriage and failure in conceiving. IVF clinics are mushrooming in most cities of the world claiming to provide top class treatment and sure shot result. However, it is absolutely imperative to understand the various features that are integral to good IVF clinics.IVF clinics must have the following facilities. There must be a Reproductive Endocrinologist or Reproduction surgeon. The Endocrinologist must essentially supervise at least twenty follicular recruitment cycles in a year to certify for the job. The surgeon should have specializations in areas of obstruction, uterine abnormalities and other reproductive organ disorders as they require treatment via surgery or microsurgery. Services of a Reproductive Immunologist should also be available at IVF clinics in order to treat patients with immunological barriers against pregnancy. The clinic should also be able to contact special labs which have testing capabilities of such immunological obstruction. The clinic should enjoy the services of an Embryologist who should at least have a doctorate in chemical, biological or physical science. The person should have earlier performed at least 100 IVF procedures in a year. At least one person in the department must have expertise in fields like andrology, pre-implantation, pre and post fertilisation and embryology.The IVF clinics also need the services of a Reproductive Urologist or Reproductive surgeon. The urologist must be adept at handling male factor related problems like urinary tract disorders. The surgeon should have at least two years of training as a surgeon and must be certified to perform microsurgeries. The clinic also requires Andrologists or laboratory specialists with degrees in treatment cycle, biochemistry, physiology or endocrinology. These people generally look at sperm quality and hormonal issues and prepare the sperm for fertilisation along with the embryologist. They can also serve the purpose of urologists. The IVF clinic should also offer genetic counselling and have on board a geneticist. The geneticists look for genetic disorders in parents prior to the procedure and also offer guidance and remedies. Cryopreservation or the facility of freeing and storing embryos for further use or sale should also be available. Moreover, the clinic should also offer round-the-clock monitoring facilities and ample availability of staff at all times. Apart from this the clinic must house a laboratory that has been certified by an appropriate governing body.Other services of IVF clinics include psychological counselling and also a rigorous process of screening when donors are involved. Other factors that determine the choice a particular IVF clinic include factors like distance from home, the cost, the kind of counselling that is offered, the recommendations made by a certified doctor, the presence of a patient support group, the areas of specialisation of the clinic, the rate of success achieved by the clinic, the kind of advertising that the clinic indulges in and reports and reviews by earlier patients or of friends and relatives who might know of the clinic.

There is no doubt that IVF technology represents one of modern medicine’s success stories. IVF can help infertile couples to start their own family. Increase in infertility among young people has led to mushrooming of IVF clinics all over the world claiming high class facilities and sure shot results. But many among these might be fake opportunistic clinics which take advantage of patients’ insecurities and vulnerability arising from desperation to conceive. Such clinics will only leave the patients mentally, physically and economically drained. The worst is that the patients loose confidence in IVF technology thus depriving themselves of their only chance to parenthood. It is therefore crucial to choose the right IVF clinic. Choosing a fertility clinic can be quite a daunting task. One must understand the various features which are essential for a good IVF clinic.A good IVF clinic must provide high class medical treatment, staff facilities, and proper hygiene. Typical treatments which should be available in IVF clinics all over the world include: •    In Vitro Fertilisation (IVF) •    Intra-cytoplasmic Sperm Insemination (ICSI) •    Embryo freezing •    Donor Insemination (DI) •    Egg donation •    Egg sharing •    SurrogacyThe clinic must provide standard storage facilities for freezing eggs or embryos and must have access to donor sperm, eggs and embryos. The IVF clinic must also have an inbuilt laboratory with qualified technicians available round the clock so that all needed tests could be performed and results be provided the same day. The clinic might also have a tie up with an outside laboratory.The most important characteristic to look for while choosing a good IVF clinic is its staff. Along with gynaecologists and obstetricians, there must be a Reproduction surgeon to rectify conditions like obstruction in fallopian tubes, uterine abnormalities and other reproductive organ abnormalities which might require surgery. An Endocrinologist is needed to monitor the hormonal levels particularly during the stage of ovarian stimulation. Reproductive immunologist is required to counter immunological problems which might arise during implantation and course of pregnancy. An embryologist and an andrologist are other indispensable members of the IVF doctors’ team.  They treat eggs and sperms before fertilization and then handle storage and transfer of viable embryos. Reproductive urologist is yet another important IVF doctor who specialises in treating urinary tract disorders in males particularly. Clinic must also provide services of a geneticist who helps in assessing congenital abnormalities the foetus might be subjected to. A psychological counsellor should also be available to help patients during the mentally exhaustive IVF cycle. Cost of the treatment and size of the clinic should not be the determining factors for the quality of service available. Larger clinics may have shorter waiting lists, but a more personal approach with a smaller clinic might be more preferable where one gets to know everyone on the team. Other important factors that need to be considered while choosing the right IVF clinic are its location, success rate, reputation and kind of counselling and support available to the patients.

Substance Abuse Counselors help people who have substance abuse problems, people who fear that they may develop substance abuse problems and the friends and family members of addicts who are suffering from or have suffered from substance abuse problems.

As a Substance Abuse Counselor you will help people who are addicted to drugs, alcohol or both. You will also help addicts with practical aspects of life and dealing with real life issues such as finding a job. As a Substance Abuse Counselor you won’t prescribe medicines or provide medical or psychological therapy. You would usually be employed by Doctors, Psychologists or Social Workers.

As a Substance Abuse Counselor you can find employment opportunities with halfway houses, outpatient clinics, hospitals, treatment centers, or social services agencies. You will also conduct counseling sessions for an addict or a group of addicts where they help addicts to talk about and cope with their addiction problems. At halfway houses, you will be helping addicts who live there while they are under treatment. At the outpatient clinics you would be helping the addicts who regularly come there for their treatment.

As a Substance Abuse Counselor, you won’t be just working with drug addicts or alcoholics. You will also be working with people who want to quit habits such as smoking or those who want to quit their dependancy on pain killer medicines.

In order to work as a Substance Abuse Counselor, you can start by getting training on the job. This training can last from six months and can go for as long as two years. You can also get an Associates Degree or a Bachelors Degree in Substance Abuse Psychology. You will study a number of concepts, theories, studies, methods of research, trends and values that apply to human behavior related to substance abuse. You will also learn how to apply scientific methods to evaluate behavior and mental processes relating to personal, social and organizational issues in connection with substance abuse.

You can also work your way towards a Masters Degree in Mental Health Counseling. As a Substance Abuse Counselor, you can earn an average annual salary of above $30,000 per year.

Thus, as a Substance Abuse Counselor you will be a part of the country’s network of personnel who are preventing the crime of drug use and abuse from affecting the young and old alike – helping people live better lives and finding their way to a healthier, happier future.

Introduction

Policy and procedural recommendations shall be given on any failure to meet the intended outcomes. (Grimshaw et al, 2001)

Definition of clinical guidelines and a brief description of the sources

Clinical guidelines may be defined as systematically developed statements that enable patients and practitioners to make decisions about their clinical circumstances and health care circumstances. Clinical guidelines are important in setting out the specific treatment and diagnostic modalities when dealing with patients. Additionally, these guidelines are important in setting out recommendations that have been drawn from published literature and systematic review. (Kanfer, F. & Saslow, 1999)

Usually, guidelines are important in doing the following;

It should be noted that these guidelines are not fixed protocols as such, they are mere recommendations and responsible clinical management is what can ensure that patients receive the care that they deserve. In fact, each clinician ought to have his or her own kind of treatment plan that should be tailored to the needs of every patient and the specific circumstances under which these treatment plans are being carried out. (NICE, 2003a)

It should be noted that there are specific users that were targeted by this guidelines. The first category in this priority list is composed of clinicians. The latter term covers nurses, physicians, and health care professionals. Additionally, some non-clinicians such as managed care organisations or groups that deal with patients or health care resources as well are affected by these guidelines. It can therefore be said that the clinical guidelines supersede the clinical environment and reach other arenas that revolve around healthcare management. (Field & Lohr, 1992)

Clinical guidelines are usually written through expert panels. These panels may belong to different branches of medicine and are usually unpaid for their services. The latter committees are chaired by experts appointed by the health regulatory body on the basis of their expertise in clinical and scientific fields. After this expert panel has written down its draft, it is then reviewed by other external members who are also regarded as experts since they possess the same qualifications that the members of the committee do. The following features are usually examined after creation of these guidelines

After the external review has been done, then the expert panel looks into the comments given by the reviewers and makes changes on the draft that they have created. Thereafter, another draft is written down and posted on the NHS website so that the public can review it too. Usually, members are allowed to view their comments about it or they can attend a public forum convened by the expert panel that allows them to make comments about this second draft. (Eddy, 1990)

Given the common differences between these two groups, then there are certain circumstances in which a conflict of interest might arise between them. Normally, the review groups and members of the actual writing committee might have to manage conflicts of interests. In the event that such an issue occurs, then the members of the expert panel and the review team are expected to make a written statement about this to a review panel that operates internally. Matters surrounding their nomination and acceptance will be discussed in that particular statement.

While the most important factor in selection of members is both clinical and scientific expertise, the potential of conflict of interests is usually taken into consideration. Also, during a general meeting, members are supposed to reveal cases of conflict of interest through direct verbal disclosure. A methodologist may be hired to deal with writing groups to provide some sort of objectivity in the process of ranking evidence. Also this methodologist is given the responsibility is making evidence tables and facilitating consensus. Opportunities for public review are given the second time and a final decision is made. (Ley, 1988)

It should be noted that within the United Kingdom, there are close to 2000 guidelines that have been developed for auditing processes. In fact some clinicians have asserted that there may be too many tidal guidelines affecting their respective lives.

Expected impact of clinical guidelines in health care

One of the general expectations of clinical guidelines writers is improvement of health care quality. The latter are designed to provide recommendations that would assist in the care and treatment of patients by health care practitioners. The guidelines are supposed to be utilised both in the training and education of health professionals. This can go a long way in assisting patients to make the right kind of decisions. Additionally, communication between health professionals and patients should also be improved through these guidelines.

It is expected that these clinical guidelines will promote scientific quality during clinical practices. Additionally, they are intended on adding ethical dimensions in practise. This is largely because the guidelines seek to protect the rights of patients with regard to their clinical experience. (Kazdin, 2001)

Clinical guidelines are designed in order to assist in identification of major decisions to be made around patients. In this regard, care needs to be given to the potential repercussions of these choices. It should be noted that the process of dealing with patients is a very intricate one. Consequently, some sorts of guidelines can be very important in clarifying some of these issues. It should be noted that guidelines are important in determining some of the potential effects that clinical decisions can have on a patient. Most of the time, there are certain roadblocks that one may encounter when making decisions yet relatively little is know about the decision making process itself. (Baum Et al, 1997)

Some of the key decisions that doctors and other clinicians have to make include

Usually, one can be able to map out a diagram in order to understand key decisions that clinicians are confronted with and some of the effects of those decisions may have upon the patient (s) under consideration. (Eccles et al, 1996)

Clinical guidelines have also been created with the intention of putting together all the necessary and valid evidence that clinicians require in order to make informed decisions. It is assumed that the necessary research evidence is available in different fields of medicine. Additionally, emphasis is given to the key areas of decision making. Most of the time, there are certain kinds of problems that need solutions that are evidence based. A number of groups operating in these specific areas of research have acknowledged the fact that there should be adoption of comprehensive and systematic overviews of evidence by clinicians. (NICE, 2003b)

Evidence based practice is largely based on the existence of particular evidence related to specific patients. In this scenario, it is assumed that clinical guidelines will go a long way in assisting clinicians to make decisions about certain conditions because of the existence of evidence about a specific condition.

Research on the actual impact of clinical guidelines

Research shows that some of these intended outcomes are yet to be achieved. The first aspect that is with regard to making evidence based decisions. While the potential for existence of this kind of practice is high, much is yet to be done in terms of the practicality of these guidelines. Evidence based clinical guidelines are available in a format that may not be valuable to clinicians. For instance, one may find that the evidence in these clinical guidelines is presented in terms of relative rewards or relative risks. This means that in order for the latter guidelines to work, then clinicians need to be given information in absolute terms such as the number of health event that occurred in a certain year or the number of patients who require treatment in order to hinder occurrence of a certain event among other things. Since this kind of issue is missing for health practitioners, then it may be relatively difficult trying to come up with certain kinds of changes in this regard. (Eccles, 2001)

If clinical guidelines were presented in a manner that was directly useful to practitioners, then it would have been safe to say that the intended outcomes have been achieved. However, since this is not the case, then one can assert that the expected impacts of these programs have not yet been achieved. Perhaps, the likelihood of this occurrence can be heightened by updating clinical guidelines as more publications on evidence based practices have been unleashed. Explicit statements about the risks and rewards of certain patient treatments or issues can be weighed and the best decisions made. In fact, because of the lack of availability of evidence based publications, most guidelines are general in nature and hence lack the explicitness necessary for implementation of these outcomes.

Lastly, the intended impact of these clinical guidelines has been minimised by the kind of format that the guidelines are presented in. In order to ensure success of the guidelines, clinicians should be able to retrieve, access and understand information in these guidelines easily. Clinicians have moved with the times and because of the computer era, most of them have found that it is relatively easier to access their information through the World Wide Web. (Gollwitzer, 1999)

While the latter intervention may seem quite well intentioned, their implementations are yet to come to pass in this kind of arrangement. Most of the time, clinicians ted o look for guidelines that allow identification of key decisions and their consequences easily, a review of the relevant evidence required to review this information and lastly, there is a need to have information available in a simple but yet easily accessible format. (Grady et al, 1997)

However, there is a wide variation in health care practice that shows that practitioners are utilising different information to make their decisions. Such evidence is particularly embarrassing to the health care profession since clinical guidelines are supposed to be the common language that allows all health care stakeholders (such as scientists, purchasers, practitioners and patients) to share this information between one another. However, since this is not the case, then it can be said that there are still a number of things that need to be changed in this regard as health care variations are an embarrassment in the field. (Stern & Brennan, 1994)

Evidence based model

A number of researches have been done in evidence based models and their level of implantation. One such study was proven by Rashidian, A. And Russell I. In their study known as “Clinical guidelines in primary care – the complexities of changing prescribing behaviour in the NHS for the International Society of Technology Assessment in Health care in the year 2002. The main aim of this research was to assess the attitudes of general practitioners towards the major facilitators or barriers in implementation. The research was a qualitative study and utilised both semi structured and structured interviews.

The latter research used the some them sot identify what the overall issues were in terms of clinical guidelines and attitudes towards them. They were as follows

It was found that most clinicians had very little consensus on their respective guidelines. Additionally, it was also found that there was very little agreement on the kind of guidelines that were effective for certain conditions. On top of the latter, it was acknowledged that if the government backed up certain initiatives, then chances of success were much higher. Also, clinicians claimed that there was a positive influence of the guidelines on nurses but the same could not be said about computerisation of the guidelines and the use of primary care organisation in the implementation of these guidelines. (Cone,1997)

Diffusion of innovation, organisational theory and knowledge management

Application to policy or practise examples

It should also be noted that policies and practices can be utilised to change the overall impact of clinical guidelines as they are today. Usually, most policies have involved a series of complicated procedures such as educational outreach, reminders and feedback. However, evidence shows that certain simple policy procedures may go a long way in improving this kind of approach. (NICE, 2003 c)

One such route is the use of appropriate wording. Research shows that instead of placing too much emphasis on getting doctors to follow guidelines, perhaps policy procedures need to be changed so as to offer concise and clear recommendations. The first thing that could be done so as to ascertain that the statements used in these guidelines are concrete and statements made are easily understood.

If there are specific pan sin how behavioural changes can be made, then this can go a long way in ensuring that clinical guidelines affect changes. There are a wide series of evidence based practise incorporated in most clinical guidelines; however, much is yet to be done in terms of the explicitness of the instruction. A survey done among national clinicians nationwide revealed that sixty seven percent of the individuals who participated in this kind of review were able to implement the guideline because they were clear and precise. Conversely, only the thirty six percent of clinicians were able to change their behaviour when the policies and procedures were not clearly written down. (Eccles et al, 2001)

In this regard, it my be necessary for the clinical guidelines to specify the what, when, why and how of these issues critically. An example of how this needs to be done is through the use of National institute for clinical guidelines that were received by a wide number of NHS practitioners. The latter guideline was very rich in evidence based practice. However, there was an inadequacy in terms of behaviour specific issues. The guideline was very long and its recommendations were slightly over twenty pages. On the other hand, it is important to note that such specifications would have been highly effective if there are no other kinds of imperatives that these issues bring out. Also, the style in which this recommendation was made had a high effect on the kind of issues facing these particular issues. (Grol, 1997)

The process of specifying behaviour serves two major functions. The first is that it heightens the implementation process. As it has been asserted earlier, clear guidelines are more likely to increase clinician’s confidence of what needs to be done. Additionally, it can go a long way in ensuring that the antecedents and consequences of any clinical decisions are clearly understood thus improving behavioural outcomes. (NICE, 2002)

Conclusion

In order to change clinical behaviour, there are a series of complex issues that have to be covered. Clinical guidelines can contribute towards changing this behaviour but there is a disparity between the creation of these guidelines and their implementation. The most effective is to ensure that the guidelines are evidence based and that they reflect positively on this matter.

References

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