The beneficial effects of omega-3 polyunsaturated fatty acids have been widely described in the literature in particular those on cardiovascular system. In the last decade there has been an increased interest in the role of these nutrients in the reduction of articular inflammation as well as in the improvement of clinical symptoms in subjects affected by rheumatic diseases, in particular rheumatoid arthritis (RA).

While the typical diet in the United States has a much greater ratio of omega-6 fatty acids compared with omega-3 fatty acids, research is showing that shifting this ratio-by increased consumption of fatty fish or fish oil supplements-may provide significant health benefits. Reductions in cardiovascular risk, depression, and rheumatoid arthritis symptoms have been correlated with omega-3 fatty acid intake, and there is increased interest in the use of omega-3 fatty acid supplementation for other psychiatric illnesses and prevention of Alzheimer’s disease.

The beneficial properties of fish oil are well known and are related to its fatty acid composition rich in omega-3 polyunsaturated fatty acids. A variety of epidemiological and clinical studies have demonstrated the efficacy of fish oil supplementation in rheumatoid arthritis (RA). The anti-inflammatory effects of fish oil are linked to the production of alternative eicosanoids, to the reduction of proinflammatory cytokines, to the inhibition of the activation of T lymphocytes and of catabolic enzymes. Fish oil supplementation could represent a valuable support to the traditional pharmacological treatment of rheumatoid arthritis.

A study by Berbert AA et al (Nutrition Feb 21 (2): 131-6, 2005) evaluated whether supplementation with olive oil could improve clinical and laboratory parameters of disease activity in patients who had rheumatoid arthritis and were using fish oil supplements.

Forty-three patients were investigated in a parallel randomized design. Patients were assigned to one of three groups. In addition to their usual medication, the first group received placebo (soy oil), the second group received fish oil omega-3 fatty acids (3 g/d), and the third group received fish oil omega-3 fatty acids (3 g/d) and 9.6 mL of olive oil.

Disease activity was measured by clinical and laboratory indicators at the beginning of the study and after 12 and 24 wk. Patients’ satisfaction in activities of daily living was also measured. There was a statistically significant improvement in relation to group 1 with respect to joint pain intensity, right and left handgrip strength after 12 and 24 wk, duration of morning stiffness, onset of fatigue, Ritchie’s articular index for pain joints after 24 wk, ability to bend down to pick up clothing from the floor, and getting in and out of a car after 24 wk. Group 3, but not Group 2, in relation to Group 1 showed additional improvements with respect to duration of morning stiffness after 12 wk, patient global assessment after 12 and 24 wk, ability to turn faucets on and off after 24 wk, and rheumatoid factor after 24 wk. In addition, Group 3 showed a significant improvement in patient global assessment in relation to Group 2 after 12 wk.

Ingestion of fish oil omega-3 fatty acids relieved several clinical parameters used in the present study. However, patients showed a more precocious and accentuated improvement when fish oil supplements were used in combination with olive oil.

More convincing data support the efficacy of omega-3 PUFA in reducing pain, number of tender joints, duration of morning stiffness, use of non-steroidal anti-inflammatory drugs and improving physical performance in RA patients. Kolahi et al (Clin Biochem Dec 23, 2009) from the Biotechnology Research Center in Tabriz University of Medical Sciences conducted a clinical trial to prove that fish oil supplementation decreases serum soluble receptor activator of nuclear factor-kappa B ligand in female patients with RA.

Soluble receptor activator of nuclear factor-kappa B ligand (sRANKL) to osteoprotegerin ratio is designated as a bone metabolism equation in many rheumatologic disorders and would be modified with fish oil (FO) supplementation. Eighty-three females with rheumatoid arthritis were divided randomly to 40 and 43 patients treated with (1 g/day) or without FO for 3 months accompanied with conventional drugs, respectively. Osteoprotegerin, sRANKL, tumor necrosis factor alpha (TNFalpha) serum levels were measured before and after treatment. Serum levels of osteoprotegerin increased, although sRANKL, TNFalpha and sRANKL/osteoprotegerin ratio decreased with FO therapy. A significant positive correlation was observed between sRANKL/osteoprotegerin ratio and TNFalpha levels (r=0.327, p=0.040) in the FO-treated group. CONCLUSIONS: FO could decrease the inflammatory response by lowering of serum TNFalpha levels and sRANKL/osteoprotegerin ratio.

In another study, Adam et al ( Rheumatol Intl Jan;(1):27-36) investigated the effects of both dietary measures, alone and in combination, on inflammation, fatty acid composition of erythrocyte lipids, eicosanoids, and cytokine biosynthesis in patients with RA.

Sixty-eight patients with definitive RA were matched into two groups of 34 subjects each. One group was observed for 8 months on a normal western diet (WD) and the other on an anti-inflammatory diet (AID) providing an arachidonic acid intake of less than 90 mg/day. Patients in both groups were allocated to receive placebo or fish oil capsules (30 mg/kg body weight) for 3 months in a double-blind crossover study with a 2-month washout period between treatments.

Clinical examination and routine laboratory findings were evaluated every month, and erythrocyte fatty acids, eicosanoids, and cytokines were evaluated before and after each 3-month experimental period. Sixty patients completed the study. In AID patients, but not in WD patients, the numbers of tender and swollen joints decreased by 14% during placebo treatment. In AID patients, as compared to WD patients, fish oil led to a significant reduction in the numbers of tender (28% vs 11%) and swollen (34% vs 22%) joints Compared to baseline levels, higher enrichment of eicosapentaenoic acid in erythrocyte lipids (244% vs 217%) and lower formation of leukotriene B(4) , 11-dehydro-thromboxane B(2) (15% vs 10%, P less than 0.05), and prostaglandin metabolites (21% vs 16%, P less than 0.003) were found in AID patients, especially when fish oil was given during months 6-8 of the experiment.

A diet low in arachidonic acid ameliorates clinical signs of inflammation in patients with RA and augments the beneficial effect of fish oil supplementation.

Dr. Jack Haddad, MD, MBA is the founder and owner of King of Home Care, an independently owned non-medical In-home care agency. In addition to his compassion and dedication to the home care industry, Dr. Haddad’s expertise and knowledge with hospice care is evident by the clinical research trials that he has conducted over the years.

Many elders and their families are considering home care as a viable option, as the costs for nursing care facilities rises to astronomical figures. Many elders enjoy the independence of living in their homes, while receiving the required medical care that cannot be furnished from their relatives or friends.

At some point we may need to make decisions for ourselves or our loved ones when living at home alone is no longer possible and more care is needed. But can we afford the elder care costs? How much do the options really cost?

The preponderance of evidence from studies of cost-effectiveness suggests that home health care is less expensive than extended hospitalization from the standpoint of third-party payers, especially when specific patient groups are studied, such as those with incurable cancer requiring parenteral nutrition or individuals requiring intravenous antibiotics.

A prospective clinical assessment by Kramer et al, which was published in the Journal of Health Services Research, reported the following:

Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states.

Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients.

Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients.

From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.

Moreover, home care appears to be a more viable option in the case of patients who are not severely disabled and who do not have profound functional problems such as mental status impairment or incontinence.

As discussed previously, prospective payment under Medicare is likely to increase the number of elderly patients discharged from the hospital with “subacute” care needs. That said, home health care should be encouraged by public policy as an alternative
for many of these individuals by creating incentives for treating patients with skilled care needs in the home.

Furthermore, there is considerable interest in expanding the scope of home health services to provide a substitute for patients generally treated in nursing homes and covered by Medicaid. Medicaid Waiver Programs (Section 2176) and other demonstration
programs approach this by providing additional services (such as homemakers and adult day care), which assist in compensating for functional disabilities and poor social supports.

In view of the changing demographics of the population, it seems advisable to pursue alternatives to nursing home care for patients in need of long-term care. Onemajor advantage of home health agencies is that they require considerably
less capital to initiate than is required for nursing home construction. On the other hand, it is extremely difficult to provide a range of functional services in the home or community at a cost comparable to nursing home care for patients with heavy care needs in this area. The
cost-effectiveness of the home care option seems to depend in part on the ability to select patients who would otherwise utilize nursing home care but who can be treated in the home at comparable or lower cost.

Jack Haddad, MD, MBA
Portfolio Manager
MD Capital Management

Affiliated Hospitals
Sutter-Roseville Medical Center, Roseville, CA
San Francisco General Hospital, San Francisco, CA
San Jose Orthopedic Medical Group, San Jose, CA
Highland Hospital, Oakland, CA

Dr. Jack Haddad, MD, MBA is the founder and owner of King of Home Care, an independently owned non-medical In-home care agency. In addition to his compassion and dedication to the home care industry, Dr. Haddad’s expertise and knowledge with Home Care is evident by the clinical research trials that he has conducted over the years.

Caring for a family member inflicted with symptoms of Alzheimer’s disease is both debilitating and a challenging task. Each day brings new demands as the caregiver copes with the rapid progression of the new patterns of behavior of the Alzheimer’s patient.

In preparing and setting up an effective home care for an Alzheimer’s patient, a compassionate caregiver must make the following changes in a new home environment:

1. As the disease progresses, adjusting your communication style to the patient’s changing needs.

2. Scheduling visitors to avoid surprises and have something to look forward to. Even if the elder with dementia does not recognize those who visit, the contact is nonetheless valuable for them.

3. Establishing routines in activities of daily living. Be accepting of the increasingly limited capabilities of the person with dementia and implement care strategies accordingly. Do your best to be patient, kind, flexible, supportive, and calm. This disease is no one’s fault, although it is very aggravating and disappointing.

By the same token, don’t take problem behaviors (like aggressiveness or wandering) personally. Accept the symptoms of the disease and proceed from there. Remember that the person is not behaving this way on purpose.

Plan activities that the patient is interested in, such as art, cooking, walking, swimming, or gardening. Focus on enjoyment, not achievement. If the person is lucid enough, involve them in making music, doing puzzles or crosswords, or playing memory games, card or board games. Or, the patient may passively enjoy hearing music, contact with pets, or sitting outside in the garden.

Go for walks in the neighborhood, go for a drive, or spend time at a park. Walking is often therapeutic, although the pace may not be as vigorous as you might like. Develop a style of paying more attention to the beauty and novelty of your surroundings as you walk.

4. Maintaining social contacts and fun. During the early stage of the disease, caregivers can promote the patient’s sense of well being by providing emotional support and by helping to maintain familiar activities and social contacts.

Even when Alzheimer’s patients no longer have the cognitive ability to understand your humor, they can still appreciate it. They may still smile or laugh and sharing that laughter can be a relief to both you and your charge. Use the same modes of humor as you always have: teasing, nonsense, clowning. Be even more silly than usual!

To counteract isolation and loneliness, encourage family and friends to stay involved. Take the patient to family gatherings if it’s comfortable to do so. Schedule visitors, to avoid surprises and have something to look forward to. Even if the elder with dementia does not recognize those who visit, the contact is nonetheless valuable for them.

Sometimes the caregiver will want to join the patient in family gatherings or stay in the home when visitors are present. Caregivers can start feeling isolated and lonely themselves as more and more of their time is built around the elder’s needs. If the patient feels safe with the visitors, the caregiver can use the visiting time as an opportunity for relief and respite. Adult day care has similar benefits: social stimulation for the patient and free time for the caregiver.

5. Promote comfort and safety. As problems with memory and judgment increase, the patient becomes more vulnerable to accidents and injuries. There will be times when you’ll want to remind the person that they have Alzheimer’s. At other times it might be better to refer to a “memory problem.” Even if you repeatedly tell the elder that they have Alzheimer’s disease, they may not remember that you told them. Be prepared to patiently repeat the information at times when you’re trying to help the person understand why they can’t do something or why you are taking over a task the person used to do.

Carefully screened and compassionate caregivers regard their responsibility as a way of being involved with their loved one. Their caring is based on unconditional love, and they do not consider it a burden. Dementia patients are able to read body language and to respond to the positive attitudes of the caregiver. Where patient and caregiver have had problems in their past relationship, it can be especially challenging to empathize and be kind, so a support system for the caregiver is most important.

6. Communicate with an Alzheimer’s patient. A good home care service trains caregivers to acknowledge requests and respond to these patients. Don’t argue or try to change the person’s mind, even if you believe the request is irrational. Be affectionate with the patient, if this feels natural. Try not to set up a cycle of paying attention only when the person displays problem behaviors. Break this negative cycle by being supportive of positive behavior.

Jack Haddad, MD, MBA
Portfolio Manager
MD Capital Management
Affiliated Hospitals
Sutter-Roseville Medical Center, Roseville, CA
San Francisco General Hospital, San Francisco, CA
San Jose Orthopedic Medical Group, San Jose, CA
Highland Hospital, Oakland, CA

Dr. Jack Haddad, MD, MBA is the founder and owner of King of Home Care, an independently owned non-medical In-home care agency. In addition to his compassion and dedication to the home care industry, Dr. Haddad’s expertise and knowledge with In-Home Care is evident by the clinical research trials that he has conducted over the years.