Assisted living facility ‘tip jar’ raises eyebrows
Q: My nephew, 62, is a stroke victim. He resides in a board and care facility, bedridden and in diapers. There has been some cognitive damage, although he is able to speak coherently. The family pays $4,200 a month out of pocket for his care. There are three other patients at the home, only one of whom is ambulatory.
I am questioning the protocols at the home, which is owned by a registered nurse who is rarely on-site. There are three staffers: a woman who cooks and keeps records of medications and two male aides. One male is always there.
The home keeps a very large “tip jar” on the counter near the front door. I dropped $10 in the jar a while ago and was floored to see several $100 bills in the mix of money. The tips are allegedly used for pizza parties for patients; although when it was my nephew’s birthday, I personally paid for pizza and birthday cake for the house.
I have no experience in this realm of health care. Is a tip jar typical? Is a patient’s family expected to pay “extra” so that the patient gets the attention and treatment we already pay for? One aid told my nephew he would trim his fingernails for $10.
While I don’t need a diagnosis, I would appreciate your point of view. And, if possible, I would like to know the experience of others with loved ones in care.
A: A tip jar is also new to me. In my opinion, medical professionals should perform their jobs without expectation of a tip. What you are describing sounds like there is pressure on visitors to give money, which is uncomfortable and leads to someone reasonably worrying that their loved one isn’t getting good care unless they pay additionally.
On the other hand, I know that many caregivers, such as nursing aides and assistants, do not make a lot of money, and I am sure an extra tip is appreciated.
I’d be happy to hear opinions from readers by email at ToYourGoodHealth @med.cornell.edu or on my Facebook page (facebook.com/ keithroachmd).
Q: I’d like to have your thoughts on what value the NAC supplement may have for reducing cravings for marijuana or nicotine?
I’m 73 and have been smoking marijuana daily since I was 21. Now I’m quitting for health reasons. I’ve been taking 1,000 mg of NAC every morning, as I’ve read it helps with smoking cravings. It also seems to be used for anxiety and other mental health issues, lung and heart problems … the list goes on.
I’m not going to smoke anymore, but I’m just wondering what your take is on this, as I’m thinking of sending it to my 38-year-old son who’s been addicted to vaping/cigarettes since he was a young man. He has ADD, anxiety and problems with breath capacity, and he may have heart problems as well. He’s smoking to relieve the ADD and anxiety. And, of course, he’d like to quit, but it’s so hard to do so.
Can the NAC supplement help me with the urge to smoke? I think it has reduced the cravings, but how would I even know?
A: N-acetyl cysteine, a precursor to the amino acid cysteine, has several roles in medicine, as you say. When inhaled, it breaks up mucous, which helps people cough out thick sputum. When used intravenously, it’s a specific antidote to acetaminophen (Tylenol) overdose. It has been used in these capacities for years and is safe and well-tolerated. But, in addition, there are data that show oral NAC (sold as a dietary supplement) may have a role in helping people overcome addictions to tobacco, with small trials showing a reduction in smoking and the relapse rate in people using NAC compared with placebo. In people who want to reduce their cannabis use, most of the data on NAC has been on younger people (adolescents and young adults), but also show some benefit. More stringent trials are ongoing.
It is very difficult for a single person (patient or physician) to tell whether it’s a “real” effect or a “placebo” effect that is causing the reduction in cravings. Only large-scale, placebo-controlled trials can show with confidence whether the treatment is more effective than a placebo. But since the supplement is inexpensive and highly safe, and since a third-party lab found that the brands of NAC sold at reputable stores are what they say they are, I say it might be helpful.
However, there are many other products that are proven safe and effective to help with quitting smoking, ranging from group tobacco cessation classes, to nicotine replacement therapy, to prescription medications like varenicline and bupropion — all of which have many years of proven clinical efficacy.
Finally, there are a lot of people with attention deficit/ hyperactivity disorder who are not getting appropriate treatment as adults. Getting treatment by an expert in ADD might make quitting smoking easier and may also improve many other areas of functioning for your son.
Q: I have a transparent floater in one eye that stays in the same general area. I went to an optometrist who dilated and took retinal photos of that eye, and they saw nothing. They just told me if I started seeing “curtains, light flashes, changes” to return. Nothing different has occurred yet. My brother swears that eating fresh pineapple daily worked for him. What are your professional thoughts on this “cure”?
A: Floaters are bits of protein in the jelly-like fluid in the back of the eye, called the vitreous humor, which cast a shadow on the retina. Most people know what they are — they are transparent gray specks that seem to float in the visual field. They are most noticeable when looking at something uniform and light in color, like a white wall. Floaters can be normal, but a sudden increase in the number of floaters, especially with any visual change of the type your optometrist mentioned, should cause you to see your eye specialist immediately, as it can indicate a serious eye problem, such as a detached retina.
The body doesn’t have a good way to get rid of these, so they stay in the eye. I think I can guess why your brother thought pineapple might help. Pineapple contains an enzyme that digests protein; unfortunately, the enzyme is broken down in the gut and doesn’t make it into the blood, let alone into the vitreous humor of your eyeballs.
A handful of readers have written me about their experience with getting a vitrectomy, where the vitreous humor is surgically removed, along with the floaters. A person would need to be very bothered indeed to undergo vitrectomy just for the floaters, but some people do see changes in their vision due to a large amount of floaters.
Q: I am a 67-year-old healthy, active woman. Recently, I was in the hospital for a case of transient global amnesia that was diagnosed as a fluke phenomenon. Nonetheless, in an MRI, it was discovered that I have a 3-mm aneurysm on the anterior communicating artery. The neuro team has suggested watching it with scans, starting at six months. I am on baby aspirin, 40 mg of Lipitor and 25 mg of metoprolol. I’m having a very hard time adjusting to this. I think about it constantly. I have lost my appetite and am worried about everything. I’m wondering what I can do. (Hoping not to worry to death.)
A: An arterial aneurysm is a weakening in the wall of an artery, leading the artery to swell like a balloon, which can eventually lead to rupture of the blood vessel. In the brain, this is likely to result in a stroke, sometimes a severe stroke, so I completely understand why you are worried.
However, you don’t need to be so worried. Most aneurysms like these that are discovered incidentally are never destined to rupture. It is likely that even without treatment, this will never bother you, and if they hadn’t done that MRI scan, you would have continued to enjoy good health.
About 3 percent of the population has an aneurysm, but only 0.5 percent of people will die from one. Size is the major risk factor. Below 7 mm, they are very unlikely to rupture. Between 7 and 12 mm, the risk of rupture is about 2.6 percent in five years. As the aneurysm gets bigger, the risk of rupture increases.
I think checking on the size in six months is a good idea. If it hasn’t grown, most experts recommend a yearly test for a few years, and then every two to five years after that.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.