• It's a Two Way Street
• What Questions Should You Ask?
• Your Rights
• Prevention
• The "Easy" Choices
• The "Tougher Choices"

* understand what you can do for yourself,
* and try to have continuity of care.

Continuity of care means having the same clinician (doctor, nurse practitioner, physician assistant) take care of you over a long period of time. Continuity improves patient satisfaction and lowers your cost of care.

* How you feel about the care you receive.
* How much medical care you will need.

Some important concerns patients have about their care include:

* Not being asked their opinion about their health problems;
* Getting explanations of care that were confusing, unclear, too technical or incomplete;
* Not being encouraged to ask questions.

By completing the HowsYourHealth survey, you can help your professional health care worker better serve your needs and avoid these common problems.

* Why is this approach being offered to me? Is the test needed?
* What can I expect if this approach is used? How is it done?
* What is the most likely result one month and 2 years after it is done? In particular, what will be the most likely result if I do nothing?
* What are the other choices?
* What are the benefits and harms of the different choices?
* What will the approaches cost? Will time be needed to recover or adapt to the results of the approach?
* If possible, make a benefit and harm sheet. On one side, list the benefits of the test or treatment; on the other side, the harms. Try to find out if the doctor can tell you " If 100 persons had the same test or treatment I am being offered, how many out of 100 would be benefited and how many harmed?"
* For an important treatment or testing decision, go to www.cochrane.org and look at the abstracts of cochrane reviews. The language is technical so you may need some help. If your topic is covered, this is the most up to date information about certain conditions and treatments. You can also go to http://www.ahrq.gov/questionsaretheanswer to build a list of questions.

And remember, most of the time you do not have to rush to make a decision. If you would like to take more time before you decide what to do, ask your doctor or nurse about the possible harm, or benefit, of waiting.

* your medical record
* privacy of information
* know if your doctor has any conflicts of interest - he or she might benefit financially or otherwise from the choice you make
* refuse or accept any tests or treatments.

This chapter draws your attention to the "easy choices" for improving your health. It also lists some common "tougher choices" you need to think about, and how to make "tough choices".

Patients who quit smoking say that two things really help:1) setting a date to quit; and 2) making a list of what they will do when they want to smoke (chew gum, exercise, etc.). Your doctor can prescribe some medications, like buproprion and nicotine patches, that may help smokers quit. (Patches used for 8 weeks double the quit rate, and don't need to be tapered).

Most murders are not planned. If you have a gun, keep it locked up and unloaded so it can be used only for hunting and target practice.

Suicide can often be prevented if the person thinking about it can have a good talk with someone they trust as soon as possible. Also, telephone crisis help-lines are available to call in many areas. Anyone with suicidal thoughts should seek counseling as soon as possible. Suicide rates are highest for men aged 70 years of age or older.

Seat belts do reduce deaths from car accidents. Helmets reduce head injuries in bicycle and motorcycle accidents but will not protect from fatal neck injuries when speeding.

About half of the deaths from car accidents and homicides involve alcohol or drugs. Many people are now smarter about not drinking and driving. But a lot of people still that a "legal" blood level of alcohol means that they are not impaired. Alcohol impairs at any level. "Legal" drinkers are more likely to have accidents than non-drinkers.

When following a car, do not tailgate. You should be able to count up to two seconds (very slowly) before you pass the road sign that the car ahead of you just passed. Increase your count to four seconds in bad weather.

Smoke detectors do save lives.

In most cases, the tetanus shot includes the diphtheria vaccine. The immunity for both lasts about 10 years. The side effects of the shot are minor and usually involve only local soreness and a slight fever.

Pneumonia and flu shots are recommended for public safety and health workers. Most people on dialysis, and those who have diabetes or diseases of the blood (sickle cell), heart, lung, or liver, should receive these immunizations.

The U. S. Public Health Service strongly encourages older adults to be immunized against influenza, pneumococcal diseases (especially pneumonia), diphtheria, and tetanus. It is helpful to keep a personal immunization record with the types and dates of shots you have received, as well as any side effects or problems that you had.

Hepatitis B causes liver disease. Shots are strongly recommended for most people on dialysis, public safety and health care workers, persons who have injected drugs, and men who engage in homosexual behavior. In areas with high rates of hepatitis B, immunization of all adults and children is now being recommended.

Measles and rubella can be prevented through immunizations. For those at risk the immunization is effective. Women of childbearing age must be immunized against rubella in order to reduce the risk of serious damage to their baby.

If you are planning foreign travel to countries outside of western Europe, you should talk to a doctor or the State Health Department. Some immunizations for travel require several shots, so you should plan to get them several months ahead of your departure.

(www.cdc.gov or www.who.org)

Adults who use alcohol and drugs usually know about some of the risks. If you think that you have a problem, please talk to a health professional about it. Treatments can be very effective once a person has decided to deal with the problem.

Small amounts of alcohol- particularly red wine- are not harmful and may lower heart disease risks. Higher risks for alcohol problems occur in persons over the age 70 or women who have more than a drink every day; for men below the age of 70, a risk is increased if they drink more than 2 drinks a day.

If you answer yes to any of the following questions, you have, or will probably have, a drinking problem.

* Do you need to drink every day?
* Have you tried to cut back on your drinking and not been able to?
* Have you ever blacked out after drinking?
* Do you ever drink secretly?
* Do you get into fights when you are drunk?
* Do you miss work because you are drunk or hung over, or using other drugs?
* Have you ever been in trouble with the law because you were drunk?
* Do you have problems in relationships with friends or family because of your drinking?

Violence or abuse by a family member affects the way we feel about ourselves and the way we look at the world. After an attack most people feel anxious. They are worried that it might happen again, and that they are powerless to stop it. After even one serious episode of violence, many people will have nightmares, anxiety attacks, or withdraw into themselves.

The long term effects of abuse and violence will cause many people to feel nervous or anxious. Some will have headaches or stomach pains. This is a their body's way of showing that they are upset and under a lot of stress. Some become depressed (feel very sad all of the time). Others have panic attacks. They suddenly feel their heart beat fast and they get very shaky. And other people have sudden fears, flashbacks to the events, nightmares, numbing and loss of feeling, reduced interest in usual activities, anger, aggressiveness, and difficulty concentrating.

Many may try alcohol or drugs as a way to escape their feelings and to make themselves feel powerful. But this only seems to work for a very short time. They will take more and more drugs and alcohol, but the false feelings of power will weaken and fade away. Adults who have been abused feel badly about themselves, mistrust others, are aggressive, and have trouble having relationships with others. They are more likely to abuse their children.

Treatment is available to help you recover from this experience. Talk about it to a licensed mental health counselor, minister or priest, school counselor, or your doctor. You can also call your local domestic violence hotline.

* Lowering fat (cholesterol) in the blood by losing weight, avoiding fatty foods, exercising and, when necessary, taking prescription medications.
* Taking a beta blocker pill if you have had a heart attack. Ask your doctor to explain these pills to you if you are not familiar with them.
* Taking a low-dose aspirin a day.
* If you have heart failure, ask your doctor about a "converting enzyme inhibitor" or spironolactone

Pap tests for cervical cancer are generally recommended every three years (after two normal tests, one year apart). Younger women with multiple sex partners or sexual diseases should have a pap test more often and also a test for chlamydia. Women over age 65 need them less frequently and not at all if all previous tests have been normal. Vaccines for the prevention of cervical cancer are now available. They seem to work very well.

Accidents seldom "just happen", and many can be prevented. Because accidental injuries occur more often in later life and result in more serious injuries, attention to safety is especially important for older people.

Protect yourself and your loved ones! Check for harmful things at home, at work and during recreation.

At home are:

• Stairways and halls well lit?
• Loose rugs and extension cords in the way?
• Handrails sturdy and 30 inches higher than stairs?
• Medicines and poisons locked or out of reach?
• Outside steps, ramps, and walkways repaired?
• Water heaters set so that water will not scald skin?
• Smoke detectors in working order?
• Emergency exits planned and quick and easy to unlock?

At work:

• Your protective gear worn? Your masks or safety glasses worn to protect from dust and chemicals?
  
• Your chairs, keyboard, and desk set so that your forearms, wrists and hands are in a straight line?
  
• Lifting is done with your legs by squatting with your back straight, knees bent, and weight held closely to your body?
  
• Hand truck or assistance is used for heavy weights? (More than 40 pounds for women and 80 pounds for men.)

At play:

• Most busy adults do not spend much time worrying about protecting their eyes, ears, or mouth from harm. Take care! Damage is usually permanent and very disabling.
• Sun damage to the skin continues to cause an increase in skin cancers and wrinkles.
• Many people do not wear life vests when boating or protective clothing when around ticks that may carry Lyme Disease.

Falls are the most common cause of fatal injury in older people. If you are an older adult, the following "little things" can make a big difference to prevent falls.

• Have vision tested regularly and properly corrected.
• Make sure that medicines are labeled with large print. Both illness and the side effects of medicines increase the risk of falls. Use egg cartons or special containers to lay out pills correctly.
• Limit your intake of alcohol. Even a little alcohol can disturb already impaired balance and reflexes.
• Use a cane, walking stick, or walker to help maintain balance on uneven or unfamiliar ground or if you sometimes feel dizzy. Use special caution when walking outdoors on wet and icy pavement. Have a grab bar installed in your bathroom if you are the least bit unsteady.
• Wear high-collared shoes that have rubber soles and low heels. Avoid wearing only socks or smooth - soled slippers on stairs and waxed floors. They make it very easy to slip.
• Approximately 5% of adults have a lot of problems feeling dizzy. If you feel dizzy, use caution in getting up too quickly after eating, or lying down or resting. Low blood pressure may cause dizziness at these times.
• Make sure that the nighttime temperature in your home is no lower than 60°F. Prolonged exposure to cold temperatures may cause body temperatures to drop, leading to falls. Most older people cannot tolerate cold as well as younger people.
• Maintain a regular program of exercise. Regular physical activity improves strength and muscle tone. This will help you move more easily and keep your joints, tendons, and ligaments more flexible. Many older people enjoy walking and swimming. Mild weight bearing activities may even reduce the loss of bone due to osteoporosis.

Doctors' guesses (predictions) about what might happen to you when you have a disease or are given a treatment are pretty good in many cases. But sometimes the predictions can be wrong. Your doctor should try to tell you when information is good and also when it is not very good.

A decision is easiest for you when the problem is serious, and the treatment is safe and works well. Your choice for treatment is usually easy when you are offered medicine for an obvious infection, very high blood pressure, very high blood sugar (diabetes), heart pains, and heart failure.

Sometimes, the effect of treatment on your future health can be unclear. In these cases, consider whether the treatment will cause more harm than good.

Sometimes testing is proven to save some lives. You and your doctor should discuss testing that effectively detects early stages of disease. Especially if treatment is available and reduces further complications or death. A good example, testing for bowel cancer.

Although there is some disagreement among experts about testing for high cholesterol, many feel that beginning testing in men aged 35-40 and women aged 45-50 is a good idea. (If there is a strong family history of hardening of the arteries or high cholesterol in family members below the age 65, testing would begin age 20). The challenge is for the person who is found to have a high cholesterol - and many Americans will have a somewhat high number (over 200). They will worry about it and may successfully reduce the number with exercise and diet. On balance, this is usually a benefit. Their insurance companies may ask about the number and changes rates based on it. This is not a benefit. If they do not reduce it by diet, they may then be asked to consider pills.

If you are a 40 year old woman with a slight cholesterol increase (230) and you do not smoke, have diabetes or have high blood pressure, your chances of having fatal or non fatal heart disease in the next five years is less than 3 in 100; successful treatment with diet and exercise or drugs for five years may reduce this chance to 2 in 100 - a difference of 1 in one hundred. A 60 year old man or 70 year old woman might reduce their risks from 13 to 9 in 100 - a difference of 4 in 100. If medications are chosen, they would cost at least $5000 over the five years.

In other situations, testing makes sense but is not yet proven to save lives. A good example is the test for prostate cancer. A (PSA) blood test that can discover cancer in some men earlier than the "old" method of testing. (The old test is performed by feeling the prostate with a gloved finger). Finding prostate cancer early is appealing because it offers a hope for cancer cure. Men who don't want a PSA blood test for cancer are betting that they won't have prostate cancer, that the treatment is not that helpful, or that risks of treatment now are not worth a possible improvement in the number of years to be gained.

The PSA test, like the test for blood in the stool for bowel cancer, may indicate that a man has cancer when he does not. Additional tests then have to be done. Some men just don't want to go through all of this.

Another example of testing that is not proven to save lives is cholesterol testing in young women.

Health choices are always hard. You have to figure out which of the benefits and harms of treatment matter most to you.

Many women worry about breast cancer and some organizations believe that mammograms in young women will save lives. Other organizations disagree. About 3 of 1000 women who are 40 will die of breast cancer in ten years and 18 will die from something else. Estimates are that mammograms beginning at age 40 might save one cancer death in 1000 women but increase the risk of biopsy of the breast to about 5 for every 100 women tested. This is because there will be many falsely abnormal mammograms (30 for every one hundred women after ten years).

Canadian experts recommend that young women make their own choice about mammograms; American experts more actively encourage women below aged 50 to have mammograms.

The simple rules are:

* Always go for the obvious---smoking (no real cost to quit), diet (no real cost to change), and blood pressure control ( if diet does not work there are lots of inexpensive, very effective treatments).

* Unless you have (sugar) diabetes or hardening of the arteries, you will get most benefit by getting total cholesterol as close as you can to 200 - 220 and LDL cholesterol near 115

* Only in diabetics or those with heart disease is there likely to be much benefit by pushing LDL cholesterol lower.

The treatment choices are:

* diet - expect a 10% (25 point) reduction; remember its weight and saturated fats, not only cholesterol that hurt you.

* garlic - 5% (10 point)

* fat lowering pills - much more reduction; if possible the lowest cost medicines should be considered (niacin) to reduce the lifetime cost of treatment.

* aspirin once a day; perhaps helpful to reduce risk for hardening of arteries.

Low dose estrogen hormone replacement is effective and seems quite safe when taken for 5 years or fewer years to reduce hot flashes. Longer-term use will reduce the risk for weak bones but it will slightly increase the risk for uterus (womb) cancer. Adding progesterone to reduce the uterus cancer risk adds other risks such as a higher risk for blood clots, breast cancer, and heart disease. More information on this topic is found in Women's Health.

This choice is very difficult because there are so many different choices for hormone replacement prevention of weak bones, and hardening of the arteries.

More information on this topic is found in Women's Health.

What about herbs and plant supplements? Most are not regulated and they may contain impurities that might harm you. The table lists common herbal supplements. Most are not proved to work and those with an * are known to cause problems in some doses.

aloe vera - psoriasis, constipation
black cohash - hot flashes in women
chamomile - stomach and bowel
chaste tree - premenstrual pain
echinacea** - colds and flu
ephedra* - weight loss
feverfew - migraine headaches
garlic - hardening of arteries, high cholesterol
ginger - motion sickness, weight loss
ginko** - hardening of the arteries, depression, memory
ginseng - tiredness
guarana - tiredness, weight loss
green tea - bowel cancer
hawthorne - heart trouble
horse chestnut* - vein problems
kava - anxiety
milk thistle - liver disease
mistletoe* - cancer
peppermint - stomach and bowel
primrose oil - premenstrual pain, skin problems**
saw palmetto - urinary difficulty in men
soy proteins - how flashes in women**
St. John's Wort* - mild depression
Valerian - anxiety, trouble sleeping

* known to cause problems with other medications or alone

** recent scientific studies show little effect

The non-plant supplement glucosamine that has some effect in arthritis. The benefit are unclear for these other non-plan supplements: zinc, DHEA, coenzyme q10, and chromium.

Older persons face many risks from diseases and "problems of aging". Older persons also have more problems with complications from treatments than younger persons. A high risk of other health problems, combined with complications, make the overall benefits of many treatments lower in the elderly.

Here is an example. A women who is 85 has a swelling in the large blood vessel (aorta) in her belly. The chance that it might break in five years is about 10% (1 in 10) or 9 chances in 10 that it won't break. During these five years, she has about 5 chances in 10 of dying from a disease other than the swollen aorta. Fixing her blood vessel with surgery will only take care of that risk of death. But the surgery can result in death for up to 8% in women her age.

Compare her to a younger woman. For a 65 year old women, only 1 in 10 will die of other cause in five years and the risk of surgery is about half as large (3%). The table shows you what happens five years in the future to "average" older persons.

For the same reasons, mammograms and bowel cancer tests are 10 times less likely to result in benefit for persons who are over the age of 80 in comparison to persons aged 70-80.

Typical rates of serious problems following surgery are shown for the following age groups. If you are going to have surgery, you need to discuss the risk and benefits with the doctor using these types of numbers as a starting point. These numbers are for ALL surgeries and all persons. Your health and the type of surgery will greatly affect the number you are told. But you should ask for a number and think about it carefully.

Age at Surgery Chance of Serious Problems:

This type of information may be important for you to keep in mind when you talk to your doctor or nurse. Make sure you are satisfied that you know the answers to the questions listed at the beginning of this section.

What would an insurance company tell an older person about the future?

We have tried to make the How's Your Health error-free. However, those involved in its preparation can not warrant that all of the information is accurate and complete. When you use How's Your Health as a guide for your health and medical care, be sure to discuss any questions about it with your doctor, nurse, or other health care worker.