Preventing falls among senior citizens; preparing for chemotherapy; dealing with burnout and mental exhaustion: Upstate Medical University's HealthLink on Air for Sunday, Nov. 21, 2021

[00:00:00] Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an expert in geriatrics care discusses why it's so important to prevent falls in seniors.

[00:00:10] Andrea Berg, MD: Falls are really one of the most common events, and it's significant because it's an event that threatens the independence of our older adults. So it's a huge issue for us.

[00:00:20] Host Amber Smith: A pharmacist goes over what to expect if you're receiving chemotherapy.

[00:00:25] Timothy Chiang, pharmacist: Remember, there are side effects that can happen, and it's important to try to watch out for those side effects.

[00:00:32] Host Amber Smith: And a doctor who focuses on wellness talks about the root cause of the mental exhaustion so many people are feeling.

[00:00:39] Kaushal Nanavati, MD: In terms of health, wellness, well-being, mental health, there are so many factors, many of which were present before the pandemic, but have been magnified or exacerbated by the pandemic.

[00:00:50] Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news. (music)

[00:00:59] Host Amber Smith: This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a pharmacist gives an overview of chemotherapy, including its accidental discovery.

[00:01:22] Host Amber Smith: Then we'll explore the root cause of the mental exhaustion that seems to be sweeping the nation. But first, an expert in geriatrics talks about why preventing falls in seniors is so important, with some tips for how to do that.

[00:01:40] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Falls can cause serious injuries, especially in people over age 65. The Centers for Disease Control and Prevention says one in four older people falls each year, with fewer than half telling their doctor about their fall.

[00:01:59] Host Amber Smith: I'm talking today with Dr. Andrea Berg. She specializes in geriatric medicine at Upstate. Welcome back to "HealthLink on Air," Dr. Berg, and thank you for your time.

[00:02:08] Andrea Berg, MD: Thank you for having me.

[00:02:10] Host Amber Smith: Now how big of an issue are falls among the patients that your practice sees?

[00:02:16] Andrea Berg, MD: Falls is really one of the most common events, and it's significant because it's an event that threatens the independence of our older adults.

[00:02:23] Andrea Berg, MD: So it's a huge issue for us.

[00:02:27] Host Amber Smith: What types of injuries do you commonly see in someone who falls? Is it true that 95% of hip fractures happen in falls?

[00:02:33] Andrea Berg, MD: That's true. Over 90% of hip fractures are a result of a fall. Almost a third of those who fall may need medical attention relating to that fall. Unfortunately, most of those will all have some restriction on their activity for at least some time.

[00:02:47] Andrea Berg, MD: The injuries vary. Most falls will result in just minor soft-tissue injuries, but 5% to 10% result in a fracture or a more serious soft tissue injury or head injury. But the hip fractures really are a major concern and an issue if they have them.

[00:03:05] Host Amber Smith: Is it always lower-extremity or do you see upper-extremity fractures as well?

[00:03:11] Andrea Berg, MD: Certainly the upper extremity as well, depending upon how all happened, we can have wrist or shoulder injuries. They can have rib fractures as well, depending upon sort of the situation that ended up with the fall. There's some groups that are higher risk, you know, women in nursing home settings. And if they have other medical conditions like dementia, they tend to be highest risk, and we'll see them more often with the hip fractures.

[00:03:37] Host Amber Smith: So let's talk about what recovery is like. If someone over age 65 breaks a bone, what is recovery like for them?

[00:03:46] Andrea Berg, MD: Well, for a fracture, you know, medical management tries to first relieve pain. And ideally to restore bone alignment and allow fractures to heal. If we're in the setting of a hip fracture for a medically stable person with a hip fracture, a surgical repair is recommended and ideally early, within that first 24- to 72-hour period after the fracture, because earlier repair is linked with a lower chance of complications, but then after that there's rehab, and rehab after a hip fracture will continue to include pain management, trying to mobilize people and then again, to prevent complications from happening.

[00:04:24] Host Amber Smith: So to start out with, they may be immobilized for a while before they can get up and do the physical therapy?

[00:04:32] Andrea Berg, MD: Yes. And that opens you up to a whole bunch of other problems, the complications, right, as you quickly can have a loss of strength and you can set yourself up to things like pressure ulcers.

[00:04:45] Andrea Berg, MD: If you're not in an immobilized state, people could get delirious, they can get blood clots, they could get lung issues. So those are the complications that we're really, really trying to avoid.

[00:04:58] Host Amber Smith: So with a fractured hip, because that one seems pretty common, is there casting involved?

[00:05:03] Andrea Berg, MD: Well, yeah, there's a wide variety, depending upon where it is.

[00:05:06] Andrea Berg, MD: If it's a place where they often can just be pinned. So there's a lot of different surgical options where they might have to go in and have a pin, but again, it's not necessarily a cast or brace, but for older folks, rehab isn't necessarily so easy, and working around pain and some of the limitations, that's where restoring function isn't always perfect.

[00:05:28] Andrea Berg, MD: You know, about 75% of hip fracture survivors will return to their prior level of function. But their overall mobility is going to be more limited. Now, half of them will need an assist device, like a cane or a walker and a half of patients will have a need for a stay in a long-term care rehab, but only some of those might not ever return to home.

[00:05:50] Andrea Berg, MD: You know, 25% of those might still be in long-term care a year later. So that's where the functional changes happen in folks that survive these hip fractures. And to note, the hip fractures themselves -- there's a mortality rate. People do die from the fall itself, 5% during that initial hospitalization in some of our frailer folks.

[00:06:13] Andrea Berg, MD: But a year out, 25% can die just because of complications from the fracture. So that's why we take these falls really seriously, because they can have real impacts on people's survival.

[00:06:25] Host Amber Smith: It sounds like recovery can be very challenging.

[00:06:30] Andrea Berg, MD: Yeah, that's why we try to prevent them, if possible.

[00:06:33] Host Amber Smith: You mentioned this can threaten someone's independence. So even if someone, if all they break is a wrist or an ankle, can an older person live alone and have a healthy recovery without assistance for an injury like that?

[00:06:48] Andrea Berg, MD: It's hard to make broad blankets (statements), but even those that don't experience physical injury, you know, falls definitely are associated with declines in their functional status and that they have an increased likelihood that they're going to need more supports either in their home or, God forbid, having to leave their home and transition into a skilled nursing placement.

[00:07:08] Andrea Berg, MD: In general, people are going to have an increased need for medical services. And the bigger concern too, is that they might develop a fear of falling, which unto itself sets them up for a negative impact on their quality of life and a higher risk of falling again.

[00:07:24] Host Amber Smith: You're listening to Upstate's "HealthLink on Air. "This is your host, Amber Smith, talking with geriatric specialist Dr. Andrea Berg. Let's talk about some of the typical reasons that someone who is older might fall. What do you typically see?

[00:07:38] Andrea Berg, MD: The falls, like many things in geriatrics, are rarely one thing. It's often an accumulation of a lot of little things that can add up, but there are some age-related changes that could set people up for a fall -- you know, changes in strength, balance, our nervous system.

[00:07:54] Andrea Berg, MD: Those are normal age changes that might increase people's risk of falling. But then there's medical causes too, that you layer on to those changes and they could really increase people's risk, and that's really varied, and changes in vision, changes in cognition, dementia, Parkinson's or stroke or blood pressure, almost anything you can see how arthritis, these common conditions that happen as we get older, can cumulatively increase somebody's risk of falling.

[00:08:23] Andrea Berg, MD: So it's really important that on working with your medical providers, you try to optimize your medical therapy monitoring for disease progression, so that we're always avoiding things like that, that we choose our medications appropriately, we could maybe avoid people being at an increased risk of falls.

[00:08:41] Host Amber Smith: You mentioned medications. I mean, there's some of them that leave a person feeling a bit dizzy. I can imagine that might make someone more prone to falling. Right?

[00:08:52] Andrea Berg, MD: Absolutely. There's a bunch of high-risk meds. A lot of them have to do with sleeping. A lot of our hypnotics that people take a lot of, medications for sleeping, trying to make them feel a little sedated is their goal.

[00:09:04] Andrea Berg, MD: But unfortunately that could cloud people's thinking, it could impair their balance. And that group is really high risk for setting up people for falls. Some of the mood medications as well, and that's for anxiety or depression and like benzodiazepines in particular, we really try to avoid as people get older because they have been shown to significantly increase people's risk of falling, but even blood pressure medicines, if they're medicines like diuretics that could lower people's blood pressure, perhaps too much, or set them up for being a little dehydrated, that could increase people's risk for falling.

[00:09:38] Andrea Berg, MD: So in general, we try real hard to just limit the medications to those that we really need, you know, less is more. And that's something that we frequently will be doing in our offices and looking through and saying, are there safer options? Can we use the lowest effective dose possible and the fewest meds?

[00:09:57] Host Amber Smith: I'm assuming in Central New York, fall hazards increase during the winter months. Do you see more patients who've slipped on the ice?

[00:10:04] Andrea Berg, MD: Yeah, absolutely. But you know, the summer months have their own challenges as well, when it comes to high temperatures and hydration, but definitely slipping on the ice or just uneven and slippery surfaces come with their risks.

[00:10:17] Host Amber Smith: Now I've heard that a person who falls once has a really good chance of falling again, but I don't understand the reasons for that.

[00:10:27] Andrea Berg, MD: That's absolutely true. And that's a screen that we do in the office. If somebody's coming in with an initial fall, then we'll look into it. But a history of falls puts them in a different category, where we have to think a little bit more holistically on how can we prevent them in a broader approach.

[00:10:43] Andrea Berg, MD: I think fear of falling plays into that repeated fall, though. A fear of falling can lead people to kind of play it safe too much, and they might restrict what they're doing, and then that's negative for their quality of life. They're not interacting as much. They're less social, but also it could lead to poor balance.

[00:11:01] Andrea Berg, MD: They might change the way they are walking, even as the fear limits their natural stride. And that becomes a risk factor for future falls.

[00:11:09] Host Amber Smith: What do you say to a patient who has survived a bad fall and now is petrified of falling again?

[00:11:14] Andrea Berg, MD: You know, there's actually a whole group of therapy, cognitive behavioral therapy, that has been shown to be very helpful and in this, they aim to change how the person thinks, that's the cognitive part, and then how they act, that's the behavioral part.

[00:11:29] Andrea Berg, MD: And looking to kind of overcome that fear of falling they're shifting their focus away from more pessimistic thoughts and things that they could do, like exercise to promote their balance and their safety.

[00:11:41] Host Amber Smith: Well, let's talk about some of the ways that family members can help reduce the chance of their older loved ones falling.

[00:11:47] Host Amber Smith: What do you recommend?

[00:11:48] Andrea Berg, MD: One of the first things we look at is the home environment. And that's sort of hard sometimes for us in an office to get a sense of what's the reality of people day-to-day, so they're real basic things, like making sure the lighting is adequate, particularly at night. Removing things around the house, on the floor, that might be a hazard.

[00:12:12] Andrea Berg, MD: If there are things like door jambs, accounting for them, looking for loose carpeting or throw rugs, looking at the furniture, maybe replacing some of the existing furniture with safer, more stable and more appropriate height options. Support structures: Sometimes we, even for folks that are repeated fallers, partner with our physical therapy colleagues, and they do home safety assessments, and they'll look at high-risk areas like the bathrooms and make some suggestions on where some grab bars should be installed or elevated toilet seats, so very basic functional things to set people up to succeed. Non-slip bathmats or a bedside commode to avoid people having to use the restroom a lot in the evening.

[00:12:53] Andrea Berg, MD: So those are some things that families can do if we're worried to avoid falls, or if somebody has fallen, to avoid future falls. But then also very basic things like footwear, and making sure that the shoes that people are wearing are not only fashionable, but functional as well, that they are a good fit, that they're non-slip, that they're not high heels and that they have a really good surface area contact ratio.

[00:13:21] Andrea Berg, MD: So those are some things that family members I think can be helpful with, to prevent falls.

[00:13:28] Host Amber Smith: I noticed you said footwear. You're not talking about just wearing socks in the house because socks are slippery, right?

[00:13:35] Andrea Berg, MD: Absolutely, yeah.

[00:13:36] Host Amber Smith: Is it a good idea to go barefoot?

[00:13:39] Andrea Berg, MD: You know, in your own house, I think that for people, if they're at a higher risk of falls, I think it's better to have supportive footwear that have a little bit more of a tread, and that'll give more balance and stability for folks. There's a lot of reasons, like you said before, that people have medical conditions that might impair their ability to feel on the bottom of their feet. And so you want to set them up for success, that they're not in an unsafe place that they could trip.

[00:14:05] Andrea Berg, MD: So if they're a high-risk faller, I would wear supportive footwear instead of certainly not socks and bare feet.

[00:14:12] Host Amber Smith: Now does vitamin D play a role in preventing falls?

[00:14:16] Andrea Berg, MD: Yeah, that's interesting. So if people are deficient, if they're low in vitamin D, there's certainly a role in falls, but it hasn't been shown. For awhile, there was thoughts of we'll give D to everybody, but it hasn't been shown that just giving vitamin D to people that don't have low vitamin D levels improves fall risk. But certainly it's something we check for. And if somebody is low in vitamin D and by that, it's usually agreed upon that like a total D level of less than 30 (nanograms per milliliter, abbreviated ng/mL), we should supplement them appropriately with pills with daily supplements, because that has been shown to improve muscle strength as well as bone health.

[00:14:54] Host Amber Smith: How do geriatricians like yourself evaluate an individual's risk for falling? If you have a new patient coming in, what sorts of questions would you ask them?

[00:15:06] Andrea Berg, MD: Well, we have to ask explicitly if they've fallen, because often people don't necessarily report falls on their own. So asking about if they have a history of falls or if they've fallen recently, and a little bit about the setting around the falls, if they come in with a fall, it's really important, but other things as well, just asking about any difficulty people are having with walking or with balance, if they're having trouble getting up from a chair, they're having a false start where they have to do a couple of tries to get up before they're able to stand, they're having dizziness when they stand or problems with their eyes, any weakness or sort of numbness. Those are all red flags that would make me concerned about safety involved.

[00:15:51] Andrea Berg, MD: And those are definitely screening questions that we ask.

[00:15:54] Host Amber Smith: If you identify someone who has a fall risk, does that person still needs some sort of activity or exercise? And if so, what sorts of things do you recommend if the fall risk for someone is relatively high?

[00:16:10] Andrea Berg, MD: I recommend activity for everybody. I think that shouldn't be something that we reserve for just those at risk of falling. I'd like to take a more proactive, preventative approach. So exercise programs, there are some that are better than others. For fall reduction, exercise programs that have more than one type of exercise have been shown to be the best.

[00:16:29] Andrea Berg, MD: And by that, I mean a combination of exercises that improve gait, balance, strength and coordination. So things with resistance stands, we often use for some of the strength training, like those big, elastic, rubber bands. But also things that focus on functional fitness, like squats. that will strengthen areas of our body that we need to stand and to sit appropriately, even our upper arms as well, or our core.

[00:16:58] Andrea Berg, MD: Those are things that will prevent people from day to day as they're transferring and going about their days, keep them fit enough to not set them up for a fall.

[00:17:08] Host Amber Smith: Thank you, Dr. Berg. I really appreciate you making time to talk to us about how falls can affect the older generation. My guest has been Dr. Andrea Berg. She's an assistant professor in geriatric medicine at Upstate I'm Amber Smith for Upstate's "HealthLink on Air."

[00:17:30] Host Amber Smith: What to expect if you're receiving chemotherapy: next on Upstate's "HealthLink on Air."

[00:17:52] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." You may have heard about chemotherapy as a treatment for cancer. Today, we'll delve deeper into what it is and how it works with Timothy Chang. He's a pharmacist at the Upstate Cancer Center. Thank you for being here, Mr. Chiang.

[00:18:11] Timothy Chiang, pharmacist: Thank you for having me today.

[00:18:13] Host Amber Smith: What is chemotherapy? Is there a standard definition?

[00:18:18] Timothy Chiang, pharmacist: So if we look at the definition of chemotherapy, it's any medications that are used to treat fast-growing cells in the body, and typically this is referring to cancer cells.

[00:18:30] Host Amber Smith: So by fast-growing, if there's other cells that are fast-growing, they might be affected as well.

[00:18:38] Timothy Chiang, pharmacist: Yes, they can be, which leads to some of the side effects that can happen with chemotherapy.

[00:18:43] Host Amber Smith: I see. Well, so it's not a particular medication or even a combination of medications.

[00:18:50] Timothy Chiang, pharmacist: No, it's referring to a just a group of medications that can do this particular thing of killing those fast-growing cells.

[00:18:58] Timothy Chiang, pharmacist: So it's just a general term.

[00:19:01] Host Amber Smith: How many different chemotherapy drugs are there?

[00:19:05] Timothy Chiang, pharmacist: Probably close to a couple of hundred medications available right now, and as time goes on this number keeps growing and growing.

[00:19:14] Host Amber Smith: So are, are some of the same drugs used for a variety of different cancers, or does every cancer have its own, you know, unique kind of chemotherapy?

[00:19:26] Timothy Chiang, pharmacist: Depending on the medication, there is some overlap with medication between the different types of cancers. It depends: A lot of this depends on the sensitivity of the tumor to these different types of chemotherapy and if they are sensitive, there is a potential for using these chemotherapies in those medications.

[00:19:45] Host Amber Smith: Well, can you tell us about the first chemotherapy drug? I mean, how many years ago was this developed?

[00:19:53] Timothy Chiang, pharmacist: So the first chemotherapy drug was available back in the 1940s, and development of it was actually fairly interesting. It was derived from mustard gas that was used in World War I by the Germans, and what ended up happening was, a doctor was looking at some of the autopsy results on, in some of the soldiers from the First World War, and they noticed that the bone marrow in those patients was significantly altered by the mustard gas. And then they looked at this and realized that they might be able to use this type of medication for cancer. And so, they did some modification to the mustard gas and made it into an injectable product at that point. So it was called nitrogen mustard, and now it's commonly known as a drug called mechlorethamine.

[00:20:46] Timothy Chiang, pharmacist: And they used it to treat the first lymphoma patient in the 1940s, and that patient had great results with it and ended up in remission at that time.

[00:20:55] Host Amber Smith: So sort of discovered by accident?

[00:20:58] Timothy Chiang, pharmacist: Yes.

[00:20:59] Host Amber Smith: Wow. So the patient in the '40s had lymphoma. What kind of cancer is that?

[00:21:05] Timothy Chiang, pharmacist: It's a blood type of cancer. A cell type in the lymph node starts growing uncontrollably.

[00:21:10] Timothy Chiang, pharmacist: And there are some more underlying things that can cause this, but that's the general definition.

[00:21:17] Host Amber Smith: Interesting. Well, can you walk us through how chemotherapy has evolved since then?

[00:21:24] Timothy Chiang, pharmacist: In the broadest terms, chemotherapy can affect all types of cells. As time's gone on, scientists are now looking at using more targeted approaches to try to minimize some of the toxicities to patients.

[00:21:36] Timothy Chiang, pharmacist: So as you look as time has gone on, the chemotherapy has become more and more targeted towards specific targets on the cancer cells. So a lot of the new oral medications that are out there, they're called molecular targets on the outside of the tumors, and they stop cell signaling, so a lot of the newer drugs are targeting this and some of the newer IV (intravenous) medications are looking at the same thing. They're targeting a specific module on the outside of that tumor and trying to minimize toxicity to our patients.

[00:22:04] Host Amber Smith: That's what I was going to wonder. So, I mean, because if this started with mustard, gas, toxic, it's become, the drugs have become less toxic over time.

[00:22:13] Timothy Chiang, pharmacist: So we hope they've become less toxic. Unfortunately, there are still a lot of side effects with some of these newer medications, they're just trying to focus it more, unfortunately by inhibiting a specific target, though. Sometimes those targets still affect some normal cell function as well. And that's what leads to some of these side effects.

[00:22:35] Host Amber Smith: So is the goal of chemotherapy always to kill the cancer cells?

[00:22:41] Timothy Chiang, pharmacist: It's either to kill the cancer cells or to slow down the growth of the cancer cells as well.

[00:22:48] Host Amber Smith: And then you use the term cell signaling that does that have to do with cell growth?

[00:22:53] Timothy Chiang, pharmacist: Yes. It can deal with cell growth. Yeah.

[00:22:57] Host Amber Smith: What about, are there other diseases other than cancer, for which chemotherapy may be prescribed?

[00:23:05] Timothy Chiang, pharmacist: Yes. There's some autoimmune type diseases that it can be used for. So things like rheumatoid arthritis, multiple sclerosis is starting to utilize some chemotherapy medications to try to slow down the course of the disease by stopping the immune system.

[00:23:21] Host Amber Smith: Interesting. You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with pharmacist Timothy Chang from the Upstate Cancer Center, and our subject today is chemotherapy. Why are some chemotherapy medications oral and some intravenous, through a needle?

[00:23:41] Timothy Chiang, pharmacist: So it depends on how the medication can be absorbed. Some medications can be absorbed orally and then if when they go through the gut, they need to be converted by the liver, and some medications just aren't able to be absorbed that way, we can utilize the gut. Sometimes that is the best option. And also has to do with some of the toxicities available in the medications as well

[00:24:05] Host Amber Smith: Which works quicker, oral or intravenous?

[00:24:10] Timothy Chiang, pharmacist: Typically, IV has a faster onset of action, just because it's going straight into the bloodstream. The oral medications still work fairly quickly though, and so, I wouldn't say one's faster than the other necessarily.

[00:24:24] Host Amber Smith: And with other types of medications, I hear the term "time release," because they're meant to, you know, work over a course of hours or days, I guess.

[00:24:34] Host Amber Smith: Does that apply to chemotherapy drugs as well?

[00:24:36] Timothy Chiang, pharmacist: Certain chemotherapy medications, and sometimes that has to do with where in the GI (gastrointestinal) tract it needs to be absorbed from, so sometimes they'll say it's a time-release medication,though, so it has some protection for the medication. So it needs to get to a certain part of the gut in order for it to absorb properly.

[00:24:56] Host Amber Smith: Now if someone needs an infusion and needs the intravenous chemotherapy type through an infusion, what determines if that person is going to be hospitalized for that, or if they come, you know, and go home after the infusion?

[00:25:12] Timothy Chiang, pharmacist: So that's a great question. Sometimes it has to do with some certain risk factors for the patients.

[00:25:17] Timothy Chiang, pharmacist: So if they are at risk for having some type of reaction, they maybe could end up in the hospital. Depending on when they're diagnosed, too, unfortunately, some patients are then diagnosed right in the hospital, so they need to get treated right away. Also depending on the cancer type as well, so certain acute leukemias need to be treated in the hospital just because of the severity of his disease.

[00:25:40] Timothy Chiang, pharmacist: If it's not as severe, they can be treated on an outpatient basis if the medication allows for it to be like that, and also, depending, some patients need something called a continuous infusion, where they need to be hooked up to a pump. If we're able to, we'll send them home with something.

[00:25:54] Timothy Chiang, pharmacist: If not, they need to be admitted to the hospital just because of the time it takes for the infusion to go in.

[00:26:01] Host Amber Smith: In general, how would you tell a person to prepare for chemotherapy?

[00:26:08] Timothy Chiang, pharmacist: So the best thing to tell a patient is to get plenty of rest and keep up their nutrition. That is really the key factor to preparing themselves for this.

[00:26:20] Host Amber Smith: So be well rested, well hydrated, you know, good nutrition. Are there a set of side effects that are common with all chemotherapies, or is it very individualized to the drug?

[00:26:33] Timothy Chiang, pharmacist: It's individualized to the drug. Yeah, it's very individualized to the drug and to the patients, too. Some patients will not have any side effects from the medications and some patients will have some reactions to the medication.

[00:26:49] Host Amber Smith: I've heard about people losing their hair during treatment because of chemotherapy, is that as common today, as it used to be?

[00:26:58] Timothy Chiang, pharmacist: Again, it depends on the medication. So as we were talking about before, with some of the side effects, we had said that chemotherapy works on the fast-growing cells in the body, and one of the fastest growing cells in the body are the cells that produce the hair. And so, like I said, if the chemotherapy is targeting those rapidly growing cells, that's one of the first things that unfortunately can go, is the hair loss

[00:27:26] Host Amber Smith: Well, other than rest and nutrition, is there anything people can do, maybe during an infusion, even, that will help their body receive the medication?

[00:27:36] Timothy Chiang, pharmacist: Hydration and nutrition are probably the best things that they can do. And just making sure they have a good support system as well, to make sure those people around them that are able to help them during this tough time.

[00:27:48] Host Amber Smith: Are there medications or strategies that can be useful to offset any negative side effects, such as nausea or fatigue?

[00:27:57] Timothy Chiang, pharmacist: Yes. So as far as the nausea and vomiting go, and that is also one of the major side effects with a lot of these medications. And depending on the medication that's being given, there's a wide range of anti-nausea medications that would be given. One example is a medication called Zofran or ondansetron that seems to be the most commonly used one. And then depending on the combination of chemotherapy medications that are being given, certain combinations have a higher potential for patients to have nausea and vomiting. And in those groups of patients, we'll give a combination of anti-nausea medications to try to help calm that down.

[00:28:35] Timothy Chiang, pharmacist: And it's always important for the patients to remember, too, what we're going to give them, the most common anti-nausea medications, if they have nausea and vomiting still through that, though, it's important for the patients always let either the pharmacy or the nurse or the oncologist know, and then they can always find something a little bit stronger to help these patients through this tough time.

[00:28:58] Timothy Chiang, pharmacist: You don't want a patient to go home with that nausea and vomiting, have these poor outcomes because of that.

[00:29:05] Host Amber Smith: Do you have any advice for family members or loved ones for how they can help someone who's undergoing chemotherapy?

[00:29:12] Timothy Chiang, pharmacist: So the best thing to do is be an advocate for the patient. Do your research on the chemotherapy medication that the patient is going to be getting, be present for that education part of it and just keep an eye out for the patient.

[00:29:25] Timothy Chiang, pharmacist: Sometimes patients are too weak to say anything or too scared to mention anything. But if you can be an advocate for them, that really is the best thing. And the other thing to remember too, is, with some of these newer oral medications, it seems that if it's an oral medication, there won't be any side effects with these medications, but it's important to stay on schedule with those medications.

[00:29:45] Timothy Chiang, pharmacist: And also remember there are side effects that can happen and it's important to try to watch out for those side effects. And then if we can keep those under control, the patients can stay on those therapies for a longer period of time and hopefully have a better outcome and keep the disease in check.

[00:29:59] Host Amber Smith: Thank you to pharmacist Timothy Chang from the Upstate Cancer Center. I'm Amber Smith for Upstate's podcast and radio talk show, "HealthLink on Air."

[00:30:13] Host Amber Smith: Next on Upstate's "HealthLink on Air": Are you feeling mentally exhausted?

[00:30:37] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." As we approach the end of the second year of the pandemic, if you're feeling mentally exhausted, you're definitely not alone. Here with me to talk about what's happening is Dr. Kaushal Nanavati. He's Upstate's assistant dean of wellness and the medical director of integrative medicine and survivorship, and also an assistant professor of family medicine.

[00:31:01] Host Amber Smith: Thank you for making time for this talk, Dr. Nanavati.

[00:31:04] Kaushal Nanavati, MD: Amber, I'm glad to be back.

[00:31:07] Host Amber Smith: Well, a record number of Americans are quitting their jobs. There's a labor shortage that seems to be impacting all industries. So I want to ask you about the root cause of this turmoil. Do you think this mass exodus is because of the pandemic?

[00:31:23] Kaushal Nanavati, MD: You know, honestly, it's a multifactorial thing. So this question that you're posing: a little different than some of the past conversations we've had. You know, there are economic theories and political theories and all that, the specialists of those talk about that. But in terms of, you know, health, wellness, well-being, mental health, there are so many factors that, many of which were present before the pandemic, but have been magnified or exacerbated by the pandemic.

[00:31:47] Kaushal Nanavati, MD: So what we've noticed with surveys that have been done by multiple organizations that do these things, there's increased anxiety. There's decreased enthusiasm for work, lack of motivation or decreased motivation, rather, a reduced focus at work, increased sense of depression, people feeling more isolation and kind of less of a network of support.

[00:32:10] Kaushal Nanavati, MD: Even insomnia, lack of sleep and sleep disturbance. And a lot of this is fueled by what's happened during this time frame, which, you know, employees have felt economic uncertainty, right? People that have to deal with family members at home who might be recovering. I give the example of teachers often, who are possibly parents, so they've got kids at home are trying to do homeschooling while the teacher may have to be at school, and what a difficult task, right? And then the administrators that have to try to support them. And at the same time, manage and continue the education, the care. So it's almost become like a no-win situation.

[00:32:50] Kaushal Nanavati, MD: And so that makes it difficult at multiple levels. Both the employee, the employer have their own unique stressors that they're both dealing with.

[00:32:59] Host Amber Smith: Well, some economists and social scientists are suggesting something more existential. They're saying that this rise of remote work may have permanently altered the way we think about our lives and the world.

[00:33:11] Host Amber Smith: What are you hearing from your patients or your colleagues or the medical students you teach?

[00:33:16] Kaushal Nanavati, MD: So I think it's been a multifactorial. I would say that, you know, there are some who have thrived with the flexibility that they've been able to have working from home has worked out for some people, learning online has worked out for some people, but not everybody is comfortable with.

[00:33:34] Kaushal Nanavati, MD: And there are people who by nature thrive in social situations, being around people and for them to be suddenly in front of a computer, one screen or two screens or three screens, and having no physical engagement, no social engagement with other people, that's led to increased anxiety, depression.

[00:33:54] Kaushal Nanavati, MD: And frankly speaking, when you suddenly tell people, you can work from home companies, start to sell builings or divest in physical space. That can be very scary because that actually sometimes creates economic uncertainty for people. You know, am I going to have a job? Is my job really that necessary? If it's not there, are they going to hire out or outsource what I'm doing?

[00:34:17] Kaushal Nanavati, MD: For students, when you think about college students, even high school students and medical students, when you have classes that require hands-on that are now being done online, right? The classic example is anatomy, right?

[00:34:29] Kaushal Nanavati, MD: Learning things that supposed to be hands-on, lab science classes, right? Classes that require a group engagement. Being on a screen isn't the same as connecting in person, right? I'm a person who loves to take a board and start writing stuff and mapping things out people. And it's harder to do on a screen.

[00:34:48] Kaushal Nanavati, MD: There are technologies that are evolving as a result, and I think that's some of the gain that we will get is the technological evolution that this has kind of forced upon us in some ways and actually engendered, will shift things for the long term for sure. You think about telemedicine and telehealth, remote patient monitoring in health care.

[00:35:09] Kaushal Nanavati, MD: And some of these things are advances that should allow us to manage population health better in the future. But once we get better at utilizing them and figure out models that actually make them viable, you know, both economically and from the health perspective.

[00:35:24] Host Amber Smith: With all of what's been happening. Some people are leaving their jobs or retiring early because they're just mentally exhausted or they're burned out.

[00:35:32] Host Amber Smith: And I think healthcare workers are among those with the highest reported cases of burnout. So can we talk about some of the reasons for that? Is it all the fault of the pandemic or is there something more?

[00:35:45] Kaushal Nanavati, MD: So one, actually two, out of 10 Americans, we're about 20% or one in five Americans. However you want to say the numbers had, you know, anxiety, depression/mental illness even before the pandemic. Now with the pandemic that's been magnified and what many people have realized is that, you know what? The stress just isn't worth it for my health. And so people and I just read an article about, you know, a couple who basically retired but had enough in their savings where they didn't necessarily jump onto collecting Social Security.

[00:36:17] Kaushal Nanavati, MD: They're going to use up some of their retirement and wait to collect Social Security until they're older, because then they get a higher absolute amount in their Social Security. So people are getting creative in what they're doing. For employers, it's a very difficult thing. And health care, it's a big problem because to replace an experienced employee who has a skill set is not only very expensive, it's time consuming. And in that time frame, when you don't have someone to fill the gap, at the end of the day, that can impact patient care, right? Community care, and the health of an entire population. Plus the people that are left behind now have a greater burden to manage and to take care of. So, it's a huge stressor. In fact, for employers, one of the things that they've talked about is, you know, for them the mental and emotional health of employees and the physical health of employees is actually a much higher factor for them than some other things that people might think of naturally, simply because when employees are anxious or depressed, their functional ability goes down.

[00:37:23] Kaushal Nanavati, MD: We know that things like lighting affect it, we've talked about that before, with Dr. (Usha) Satish on a show before. But at the same time you think about the mood, the tone, you know, the attitude, and one person who is burnt out or depressed or anxious at work can impact the entire team, especially in health care, where we're so intimately connected in the work that we do in caring for the lives that we're privileged to care for.

[00:37:48] Host Amber Smith: You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith talking with Dr. Kaushal Nanavati about the collective level of mental exhaustion in America as we're wrapping up the second year of the pandemic. Dr. Nanavati is Upstate's assistant dean of wellness, so he's focused on what can be done to improve the situation, especially among health care workers. Now, Dr. Nanavati, you and I have talked before about ways that individuals can cope during stressful times, but this feels like more than that. Because even some of the most well adjusted, mentally balanced people are leaving careers because of working conditions.

[00:38:25] Host Amber Smith: So how do we as a nation fix this?

[00:38:28] Kaushal Nanavati, MD: So I think this is a big, big point. And it's not just a nation, it's a global issue, in terms of what we've come to focus on in society. When we talk about efficiency, we talk about things like resilience, we talk about performance measures and all of those things.

[00:38:43] Kaushal Nanavati, MD: And recently I had a chance to speak in front of a group of finance folks and even in their industry, stress, anxiety, burnout, those were really high. And so when we think about it, think about wellness as what a system offers, right, for its employees or for the people in its charge, so that they can actually have greater sense of well-being and well-being is what people do for themselves, right? So we think about well-being, and we've talked about this and we'll continue to talk about this. Talk about the core four: nutrition, physical exercise, stress management, spiritual wellness, and there are eight domains of wellness that incorporate everything from finance, social, emotional, occupational environmental factors, nutrition and physical factors, etc.

[00:39:29] Kaushal Nanavati, MD: But the reality is, as systems, we really have to think about what is it that we're offering for the people that work for us, that we care for. And some of the most important things when we think about it, are flexibility, right? So that we meet people where they are. Life is a dynamic, it's not a static. And a lot of companies have, you know, fixed benefits packages and kind of fixed plans in place, but people's lives change, right? And during this pandemic, it really became evident that not everybody has the same needs. And not everybody has the same stressors. Some people needed time to take care of loved ones and home, right? Other people had the flexibility to actually offer more time at work, right? And so they could benefit from that extra time.

[00:40:13] Kaushal Nanavati, MD: Others started to just not take care of their mental, emotional, nutritional, physical health. And for them, a robust employee assistance program, uh, is something that could not only be, everyone thinks of EAP or employee assistance says, oh, if I have a mental health problem, I can call them. The reality is an employee assistance program should be able to help with setting up things like child care, right?

[00:40:36] Kaushal Nanavati, MD: Finding resources, whether it's mental health or financial health or physical health and offering those things that become a comprehensive. And that can flex, right, with what a person needs so that people can adjust and adapt to their life. And the company adjusts with them, that's embracing the relationship with the employee vs. dictating or directing the relationship,

[00:40:58] Kaushal Nanavati, MD: ? And as we start to do that, we start to realize that employers and employees can actually be, it's a relationship, right? And a relationship is stronger, it's like a ladder. . The two posts are held together by the rungs: communication, trust, honesty, flexibility, right? Compassion, love, all of those things and more are qualities that bring that relationship together.

[00:41:20] Kaushal Nanavati, MD: It has to be done from both sides. And so employees have to recognize the stressors that employers are facing right now, just to keep the doors open and that employers have to recognize that employees coming in every day are bringing in a greater burden than that's been the past. And when the pandemic ends, these problems were here before.

[00:41:39] Kaushal Nanavati, MD: If we have the wisdom to learn from this, what will happen is we will adapt to a new world with new rules of engagement, right? Which are different than what they were before the pandemic. And when we do that, I think we'll be able to come out of it in a healthier way. Hopefully that's the goal. Uh, and not every industry will come out the same, not every organization will come out the same. Not every person will come out the same, but what we can do, and especially representing an institution, is be open, meet people where they are, learn their life story first, because then we get context and perspective for each employee.

[00:42:19] Kaushal Nanavati, MD: And that's how an institutions can support them.

[00:42:22] Host Amber Smith: And what you're talking about, I think, can apply to every company or business. But I'm feeling like the in health care, I mean, we have to heal the healers first, right? Because they're the ones we turn to, to take care of us. Are there specific fixes being talked about in health care?

[00:42:41] Kaushal Nanavati, MD: So I think, as I mentioned earlier, if you look at health care, it's a broad spectrum, right? Nurses, health care providers, front desk staff, complementary providers, and all those in health care, administrators, teachers, faculty students, right? And patients. All have a different perspective on this and different needs.

[00:43:02] Kaushal Nanavati, MD: And the most important thing I think that any health care organization can do is continue to gauge their employees. I think managers during times of stress and distress should create a more regular and consistent connection with their employees to actually connect ,right, to learn where they are. Because if we make assumptions, you know, employers underestimate the degree of distress that employees feel and have felt during this pandemic. Surveys have showed that again and again.

[00:43:32] Kaushal Nanavati, MD: And so employers are missing the mark when employers start to give messages out of positivity without acknowledging the stress and distress that their employees are feeling. I think the first place is to meet people where they are to acknowledge what the reality is and the fact that the administrators and bosses are feeling it too, vs. the boss comes in and says, hey, listen, you guys are doing great. Keep going. You know, it's a matter of saying, look, I'm stressed too. This is an unpredictable public health crisis. I don't say unprecedented because different eras have had different things, but definitely unpredictable. And in that sense, we're all in this boat, and I don't have an answer, but together we can come up with one, is a more realistic perspective than to say, you know what? Keep going, right?

[00:44:16] Kaushal Nanavati, MD: Because that can be overwhelming when somebody who doesn't feel like they're seen and acknowledged, and that can be very stressful for people.

[00:44:24] Host Amber Smith: It's been stressful. It's been traumatic. It's been a long two years. I understand that trauma can impact people long term, and the pandemic has certainly been traumatic for many people.

[00:44:34] Host Amber Smith: How do you think this is likely to affect us in the decades ahead?

[00:44:38] Kaushal Nanavati, MD: I think it reinforces the message that is time tested, which is to focus on the fundamentals, right? For each individual and as systems coming back and focusing on the fundamentals, so for any company and any health system, right? Its greatest asset are the people that make it, right?

[00:44:56] Kaushal Nanavati, MD: And so they really have to think about that. And then the customer base is just as strong an asset. So they have to think about communication there, and being real, and for individuals focusing on the fundamentals is recognizing that you have to take care of your own health. You know, I had a lady recently came to me with a lot of stress and she talked about the fact that, you know what, I'm just completely burnt out and drained of energy because I'm caring for so many things and juggling so many balls.

[00:45:23] Kaushal Nanavati, MD: And I say, you know, it's interesting. The human heart is a giver. It gives all day long, keeps on giving, but it's figured something out. It's got these coronary arteries, so every time it pumps, it feeds itself first, so it can keep going. And so for people to recognize that we have to do what is necessary to take care of our own health.

[00:45:42] Kaushal Nanavati, MD: And for each of us is different, right? For some people in nutrition, some people exercise, some people, stress management, mindfulness, some people, getting better sleep, you know, refocusing on what they value and prioritize. I think this pandemic has really helped a lot of people recognize that the things that were priorities before aren't necessarily the things that are the immutables right, and the fundamentals. And so hopefully through this pandemic, people focus on the fundamentals that mattered the most and recognize that, you know, the meaningful relationships in their life are the things that oftentimes, provide for sustain happiness, more so than, other factors that they may have valued before.

[00:46:22] Host Amber Smith: Well, I appreciate you making time to talk with us about this. My guest has been Dr. Kaushal Nanavati. He's the assistant dean of wellness at Upstate and also the medical director of integrative medicine and survivorship. And an assistant professor of family medicine. I'm Amber Smith for Upstate's "HealthLink on Air."

[00:46:56] Host Amber Smith: And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

[00:47:05] Deirdre Neilen, PhD: Alice Haynes is a family physician in Lewiston, Maine, where she cares for refugees, asylum seekers and the dispossessed. Her poem "Prognosis" captures a moment of helplessness on the physician's part, realizing no medicine can fix this.

[00:47:21] Deirdre Neilen, PhD: "Prognosis"

[00:47:23] Deirdre Neilen, PhD: One foot is lost, both kidneys abandoned,

[00:47:27] Deirdre Neilen, PhD: He feeds his heart through a straw of tin.

[00:47:30] Deirdre Neilen, PhD: Life oozes out; a rusty pot

[00:47:33] Deirdre Neilen, PhD: that nut and screw cannot repair.

[00:47:36] Deirdre Neilen, PhD: Depleted, the physician sighs,

[00:47:39] Deirdre Neilen, PhD: contemplates her empty hands.

[00:47:41] Deirdre Neilen, PhD: Thin as a mantis, she stumbles,

[00:47:44] Deirdre Neilen, PhD: tears the hem of understanding.

[00:47:47] Deirdre Neilen, PhD: The patient bargains for reprieve,

[00:47:49] Deirdre Neilen, PhD: disturbed by dreams of roots and damp.

[00:47:53] Deirdre Neilen, PhD: The doctor busies books and screens,

[00:47:56] Deirdre Neilen, PhD: then marks the chart with arcane words.

[00:48:00] Deirdre Neilen, PhD: Another kind of sadness is movingly displayed in Tennessee poet Renee Emerson's poem. "Doctors' Tears." Emerson's most recent book is "Threshing Floor."

[00:48:11] Deirdre Neilen, PhD: "Doctor's Tears"

[00:48:13] Deirdre Neilen, PhD: The class they don't speak of is the one where doctors

[00:48:16] Deirdre Neilen, PhD: learn to see tears the way they see breasts: just flesh,

[00:48:21] Deirdre Neilen, PhD: body, as separate from lost as a leaf from the air.

[00:48:26] Deirdre Neilen, PhD: ECMO tears, burned arm tears, the tears of mothers

[00:48:30] Deirdre Neilen, PhD: holding dead children -- they learn to ignore them

[00:48:34] Deirdre Neilen, PhD: as friendly people ignore a bad voice, singing loudly in the crowd.

[00:48:39] Deirdre Neilen, PhD: So when her doctors touched her hair and cried,

[00:48:43] Deirdre Neilen, PhD: I knew my infant child had mastered that class,

[00:48:46] Deirdre Neilen, PhD: and it felt good to see all the whitecoats break

[00:48:50] Deirdre Neilen, PhD: like a plate thrown in anger,

[00:48:52] Deirdre Neilen, PhD: the little slivers of porcelain

[00:48:54] Deirdre Neilen, PhD: working their way into bare feet.

[00:49:16] Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": how the gamma tile is used to treat brain tumors. If you missed any of today's show or for more consumer health podcasts, visit our website at healthlinkonair.org.

[00:49:36] Host Amber Smith: Or do a podcast search for the phrase "HealthLink on Air." Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.