The Impact of Fluctuating Symptoms on People with HIV

One of the problems about neuropathy is that in the beginning, the symptoms can fluctuate. You can have periods with relatively few problems and other times where the neuropathy is clearly a part of your life. The same applies for many people in general with HIV, where neuropathy may only be just one of the health problems they have to live with. Today's post talks about the findings of a survey by the National Aids Trust and comes from aidsmap.com (see link below). The survey found that these fluctuating symptoms can have a significant effect on people's working lives as well as their mental state at any given time. The recommendation is that more studies need to be done.

Fluctuating symptoms have major impact on quality of life and fitness to work, survey finds
Gus Cairns:Published: 07 September 2011

Common but non-specific symptoms of uncertain cause can dominate the day-to-day life of some people with HIV, a survey by the National AIDS Trust has found. In many cases symptoms such as fatigue, insomnia, depression, diarrhoea and neuropathy make it hard to work and perform other daily activities, the report of the survey finds.

The survey also found a significant degree of overlap between symptoms; generally, if people had one symptom, more than two-thirds of them were likely to have at least one other. One other finding was that the majority of respondents found that the symptoms were not only fluctuating, but were also completely unpredictable. This made planned activities, both at work and socially, difficult. About 60% of respondents were employed.

This study is a pilot survey of an independent working group brought together to review the Work Capability Assessment (WCA), the medical procedure under which claimants are assessed for Employment and Support Allowance. The WCA had been criticised, especially in an independent review conducted by occupational health expert Professor Malcolm Harrington, for being inflexible and for not being designed to accommodate illnesses characterised by fluctuating symptoms. See www.aidsmap.com/Whats-happening-to-benefits/page/1793223/ for more on the WCA and the Harrington Report.

Survey results in detail

The NAT study asked people with HIV to complete an online survey about their experience, during the previous six months, of five symptoms commonly associated with HIV: fatigue, anxiety or depression, insomnia, gastro-intestinal problems and neuropathy (nerve pain). There was space to mention other symptoms too.

It is not surprising that in a study inviting people to self-report, the majority of the 265 respondents had at least one of the symptoms on the list. The most common was fatigue, suffered by 57%, followed by depression or anxiety (55%), gastro-intestinal (GI) problems (48%), insomnia (46%) and neuropathy (33%).

More significant was the fact that more people experienced these symptoms as fluctuating rather than constant. Respondents described conditions as ‘constant’ with frequencies ranging from about 38% in insomnia to 24% in the case of GI problems, but as ‘varying over time’ with frequencies ranging from 53% in fatigue to 31% with neuropathy.

Fatigue was mentioned as a particularly common and troubling symptom. Very few respondents could usually predict when fatigue would hit them. One commented that “When I have it I am quite incapacitated and have no choice but to limit, stop or cancel plans to do things.” Another said “it is always there, lurking...if I do anything for more than an hour it begins to kick in.” One respondent managed to hold down a job but always required a nap of one to two hours immediately after coming home. Although 40% of respondents thought a combination of HIV and HIV medications caused their fatigue, 30% said they really had ‘no idea’ what caused it.

Depression and anxiety were nearly as common as fatigue, though respondents did not say they affected work so much. The main feature of these were their frequency: 90% of respondents said they had experienced either or both at some point in the last month. Given that a third of respondents said that bouts of depression or anxiety lasted more than a week at a time, many people must be living with severely disordered mood a lot of the time.

Diarrhoea, nausea and other GI problems were the symptoms most likely to be linked in people’s minds to HIV treatment. Thirty per cent of respondents thought these were the exclusive cause of their problems and 45% thought HIV and HIV treatments were both to blame. The frequency of bouts of diarrhoea varied from once to more than five times a month.

Insomnia and poor sleep, especially chronic, not only impacts on quality of life: it is a cause of significant physical and psychological illness. Although this has been associated with HIV drugs, especially efavirenz, 45% of respondents did not know why their sleep was so poor. Sleeplessness was very unpredictable – people would be fine one night and not the next. Forty-three per cent said having problems sleeping could last for more than a week. When insomnia is this prolonged, memory, mood and cognitive function can be severely affected. One respondent said sleep problems meant “I am unable to focus on my work, feeling like I have jet lag.”

Neuropathy (nerve pain) was the least-experienced of the conditions but was still suffered by a third of respondents. About equal numbers of people attributed it to HIV itself and to HIV drugs. In some cases the pain of neuropathy was constant – one person said his feet were always sore and this prevented standing or walking for more than 15 minutes. But the majority said that while some symptoms such as numbness were always there others, such as stabbing pains, were unpredictable and often severe.

Most respondents suffered from multiple symptoms: for instance, of those with depression or anxiety, 75% also had fatigue and 57% insomnia; of those with neuropathy, 61% had fatigue and 68% GI problems.

About 40% of respondents were unemployed, with a higher proportion among those reporting GI problems or fluctuating neuropathy. There was a generally positive attitude to work, with one respondent happy to have just started a job after 18 months of unemployment – “I am knackered but happy to be working,” s/he said.

In other cases however it was clear that fluctuating symptoms were significantly affecting people’s ability or willingness to work. One question asked “on how many occasions in the past four weeks have your symptoms significantly affected your ability to work”? A quarter of people with fatigue, 20% with neuropathy, and about 15% of those with depression and GI problems reported that this had happened more than five times in the past four weeks.

One respondent asked: “How do you work round this kind of thing unless you work for yourself or for an extremely understanding employer?”

Conclusions and recommendations

NAT concludes that the responses to their survey reveal that fluctuating symptoms are a cause of real morbidity and distress to people living with HIV and place significant barriers to work. They add that the variation and unpredictability of symptoms was often as much of a problem as the symptoms themselves.

Because the symptoms are fluctuating, ESAs may not capture them if the person is having a ‘good day’, but there are other methods of assessment, such as asking people to keep a symptom diary.

NAT recommends that more research needs to be undertaken into these common, fluctuating symptoms and that HIV organisations should raise awareness amongst employers, and with people with HIV themselves, about the importance of making reasonable adjustments at work to enable people with HIV to continue in employment.

In terms of the ESA itself, NAT recommends that ESAs need to take into account “the full range of barriers fluctuating symptoms present to participation in work and other daily activities,” including their unpredictability and the fact that they come in combination.

“Assessment should consider the impact of fluctuation and the cumulative impact of multiple, lower-level symptoms on people living with HIV,” they comment.

http://aidsmap.com/Fluctuating-symptoms-have-major-impact-on-quality-of-life-and-fitness-to-work-survey-finds/page/2066782/

PEOPLE TRUST TRIVIAL GRAPHS AND FORMULAS

Beware of trivial graphs and formulas, warns new research from Cornell University.

Published this week in Public Understanding of Science, the Cornell Food and Brand Lab study found trivial graphs or formulas accompanying medical information can lead consumers to believe products are more effective.

"Your faith in science may actually make you more likely to trust information that appears scientific but really doesn't tell you much," said lead author Aner Tal, post-doctoral researcher at the Cornell Food and Brand Lab. "Anything that looks scientific can make information you read a lot more convincing."

The study showed that when a graph -- with no new information -- was added to the description of a medication, 96.6 percent of people believed that the medicines were effective in reducing illness verses 67.7 percent of people who were shown the product information without the graph.

"Even those with professed faith in science were more likely to be swayed by trivial scientific looking product information," said Tal. "In fact, the more people believed in science, the more they were convinced by the graphs. What this means is that when you read claims about new products, whether it's a medication or a new technology, you should ask yourself, 'where does this information come from?', 'what's the basis for the claims being made?' Don't let things that look scientific but don't really tell you much fool you. Sometimes a graph is just a graph!"

Vitamins B12 And D3 For People Living With Neuropathy And HIV

Today's post from nybc.wordpress.com (see link below) looks at Vitamins B12 and D3; two of the key vitamins people should ensure remain at healthy levels, when living with the side effects of HIV including neuropathy. Of course, the New York Buyers Club is a very well known supplier of supplements and vitamins and this blog makes a point of not advertising for commercial sites but this article does give some very good medical information based on the findings of the Canadian, Catie HIV organisation and reliably informs you of the reason why you might need supplementation - after that the decision is yours as to where you buy what you need. Personally, I would always check with your doctor first - a simple blood test will tell you if you're deficient in any vitamin or mineral areas and it's possible you can get any supplements free on prescription after that - if not, perfectly good supplements can be bought cheaply almost everywhere these days. There are also various other articles about B and D vitamins to be found in the list to the right of this blog and they may help further with your decision making.

Why Vitamins B12 and D3 Are Especially Important to People with HIV 
Posted by jarebe December 8, 2013 New York Buyers’ Club – The Blog
A nonprofit source for dietary supplements
 
Our friends at the Canadian AIDS Treatment Information Exchange (CATIE), a Canadian government-supported education and prevention organization, recently published an excellent guide to managing HIV medication side effects. This online guide covers the territory from body shape changes, to gastrointestinal disorders, to neurological effects, to emotional wellness, to fatigue, to sexual difficulties.

The Appendix to this guide focuses on two vitamins, both of which have been highlighted as especially important for people with HIV: B12 and D3. Deficiency of these two vitamins appears to be common among people with HIV, and supplementing to correct the deficiency can bring about major improvements in health. So it’s definitely worthwhile to check your B12 and D3 status, and, if you’re deficient, find a good supplementation strategy. Note that NYBC stocks both of these inexpensive vitamins: the methylcobalamin form of Vitamin B12 recommended below; and several strengths of Vitamin D3, including the commonly recommended D3 – 2500IU format.

Below are the CATIE recommendations:

Vitamin B12

A number of studies have shown that vitamin B12 is deficient in a large percentage of people with HIV, and the deficiency can begin early in the disease. Vitamin B12 deficiency can result in neurologic symptoms — for example, numbness, tingling and loss of dexterity — and the deterioration of mental function, which causes symptoms such as foggy thinking, memory loss, confusion, disorientation, depression, irrational anger and paranoia. Deficiency can also cause anemia. (See the section on Fatigue for more discussion of anemia.) It has also been linked to lower production of the hormone melatonin, which can affect the wake-sleep cycle.

If you have developed any of the emotional or mental symptoms mentioned above, especially combined with chronic fatigue, vitamin B12 deficiency could be contributing. This is especially true if you also have other symptoms that this deficiency can cause, including neuropathy, weakness and difficulty with balance or walking. On the other hand, these symptoms can also be associated with HIV itself, with hypothyroidism or advanced cases of syphilis called neurosyphilis. A thorough workup for all potential diagnoses is key to determining the cause.

Research at Yale University has shown that the standard blood test for vitamin B12 deficiency is not always reliable. Some people who appear to have “normal” blood levels are actually deficient, and could potentially benefit from supplementation.

The dose of vitamin B12 required varies from individual to individual and working with a doctor or naturopathic doctor to determine the correct dose is recommended. Vitamin B12 can be taken orally, by nasal gel or by injection. The best way to take it depends on the underlying cause of the deficiency, so it’s important to be properly assessed before starting supplements. For oral therapy, a typical recommendation is 1,000 to 2,000 mcg daily.

One way to know if supplementation can help you is to do a trial run of vitamin B12 supplementation for at least six to eight weeks. If you are using pills or sublingual lozenges, the most useful form of vitamin B12 is methylcobalamin. Talk to your doctor before starting any new supplement to make sure it is safe for you.

Some people will see improvements after a few days of taking vitamin B12 and may do well taking it in a tablet or lozenge that goes under the tongue. Others will need several months to see results and may need nasal gel or injections for the best improvements. For many people, supplementation has been a very important part of an approach to resolving mental and emotional problems.

Vitamin D

Some studies show that vitamin D deficiency, and often quite severe deficiency, is a common problem in people with HIV. Vitamin D is intimately linked with calcium levels, and deficiency has been linked to a number of health problems, including bone problems, depression, sleep problems, peripheral neuropathy, joint and muscle pain and muscle weakness. It is worth noting that in many of these cases there is a link between vitamin D and the health condition, but it is not certain that a lack of vitamin D causes the health problem.

A blood test can determine whether or not you are deficient in vitamin D. If you are taking vitamin D, the test will show whether you are taking a proper dose for health, while avoiding any risk of taking an amount that could be toxic (although research has shown that toxicity is highly unlikely, even in doses up to 10,000 IU daily when done under medical supervision). The cost of the test may not be covered by all provincial or territorial healthcare plans or may be covered only in certain situations. Check with your doctor for availability in your region.

The best test for vitamin D is the 25-hydroxyvitamin D blood test. There is some debate about the best levels of vitamin D, but most experts believe that the minimum value for health is between 50 and 75 nmol/l. Many people use supplements to boost their levels to more than 100 nmol/l.

While sunlight and fortified foods are two possible sources of vitamin D, the surest way to get adequate levels of this vitamin is by taking a supplement. The best dose to take depends on the person. A daily dose of 1,000 to 2,000 IU is common, but your doctor may recommend a lower or higher dose for you, depending on the level of vitamin D in your blood and any health conditions you might have. People should not take more than 4,000 IU per day without letting their doctor know. Look for the D3 form of the vitamin rather than the D2 form. Vitamin D3 is the active form of the vitamin and there is some evidence that people with HIV have difficulty converting vitamin D2 to vitamin D3. Historically, vitamin D3 supplements are less commonly associated with reports of toxicity than the D2 form.

It is best to do a baseline test so you know your initial level of vitamin D. Then, have regular follow-up tests to see if supplementation has gotten you to an optimal level and that you are not taking too much. Regular testing is the only way to be sure you attain — and then maintain — the optimal level for health.

With proper supplementation, problems caused by vitamin D deficiency can usually be efficiently reversed.

http://nybc.wordpress.com/2013/12/08/why-vitamins-b12-and-d3-are-especially-important-to-people-with-hiv/

OPTIMISTIC PEOPLE HAVE HEALTHIER HEARTS

People who have upbeat outlooks on life have significantly better cardiovascular health, suggests a new study that examined associations between optimism and heart health in more than 5,100 adults.

"Individuals with the highest levels of optimism have twice the odds of being in ideal cardiovascular health compared to their more pessimistic counterparts," said lead author Rosalba Hernandez, a professor of social work at the University of Illinois. "This association remains significant, even after adjusting for socio-demographic characteristics and poor mental health."

Participants' cardiovascular health was assessed using seven metrics: blood pressure, body mass index, fasting plasma glucose and serum cholesterol levels, dietary intake, physical activity and tobacco use -- the same metrics used by the American Heart Association to define heart health and being targeted by the AHA in its Life's Simple 7 public awareness campaign.

In accordance with AHA's heart-health criteria, the researchers allocated 0, 1 or 2 points -- representing poor, intermediate and ideal scores, respectively -- to participants on each of the seven health metrics, which were then summed to arrive at a total cardiovascular health score. Participants' total health scores ranged from 0 to 14, with a higher total score indicative of better health.

The participants, who ranged in age from 45-84, also completed surveys that assessed their mental health, levels of optimism, and physical health, based upon self-reported extant medical diagnoses of arthritis, liver and kidney disease.

Individuals' total health scores increased in tandem with their levels of optimism. People who were the most optimistic were 50 and 76 percent more likely to have total health scores in the intermediate or ideal ranges, respectively.

The association between optimism and cardiovascular health was even stronger when socio-demographic characteristics such as age, race and ethnicity, income and education status were factored in. People who were the most optimistic were twice as likely to have ideal cardiovascular health, and 55 percent more likely to have a total health score in the intermediate range, the researchers found.

Optimists had significantly better blood sugar and total cholesterol levels than their counterparts. They also were more physically active, had healthier body mass indexes and were less likely to smoke, according to a paper on the research that appears in the January/February 2015 issue of Health Behavior and Policy Review.

The findings may be of clinical significance, given that a 2013 study indicated that a one-point increase in an individual's total-health score on the LS7 was associated with an 8 percent reduction in their risk of stroke, Hernandez said.

"At the population level, even this moderate difference in cardiovascular health translates into a significant reduction in death rates," Hernandez said. "This evidence, which is hypothesized to occur through a biobehavioral mechanism, suggests that prevention strategies that target modification of psychological well-being -- e.g., optimism -- may be a potential avenue for AHA to reach its goal of improving Americans' cardiovascular health by 20 percent before 2020."

Believed to be the first study to examine the association of optimism and cardiovascular health in a large, ethnically and racially diverse population, the sample for the current study was 38 percent white, 28 percent African-American, 22 percent Hispanic/Latino and 12 percent Chinese.

Data for the study were derived from the Multi-Ethnic Study of Atherosclerosis, an ongoing examination of subclinical cardiovascular disease that includes 6,000 people from six U.S. regions, including Baltimore, Chicago, Forsyth County in North Carolina, and Los Angeles County.

Begun in July 2000, MESA followed participants for 11 years, collecting data every 18 months to two years. Hernandez, who is an affiliated investigator on MESA, is leading a team in conducting prospective analyses on the associations found between optimism and heart health.

"We now have available data to examine optimism at baseline and cardiovascular health a decade later," said Hernandez, who expects to have an abstract completed in 2015.

Co-authors of the current study were Kiarri N. Kershaw of Northwestern University; Juned Siddique, Honghan Ning and Donald M. Lloyd-Jones, all of Northwestern University; Julia K. Boehm of Chapman University; Laura D. Kubzansky of Harvard University; and Ana Diez-Roux of Drexel University.

The National Heart, Lung and Blood Institute and the National Center for Research Resources funded the research.

Tips For Care Givers of People In Chronic Pain

Today's post from psychologytoday.com (see link below) follows on from yesterday's post in that it offers tips for people involved with people living with chronic pain. This time, it's a warning list for carers and supporters of chronic pain patients. Caring for people with illness is often a strenuous, thankless and stressful business and can often lead to the carer him- or herself becoming ill. It's very important then that the carer takes care of himself otherwise both people suffer from the consequences and that defeats the object. It's easy to forget that becoming a carer means giving up a part of your own independence and these 'not-to-do' hints are well-worth reading. If you're the person who is living with chronic pain it's worth reminding yourself that it's often family and friends who are being forced into the position of carer and unconsciously taking advantage of their good natures is an easy mistake to make.
 

A Not-To-Do List For Caregivers of the Chronically Ill
Published on January 23, 2014 by Toni Bernhard, J.D. in Turning Straw Into Gold
Six items that belong on a Not-To-Do List for an oft-forgotten group: caregivers

In August 2013, I posted “A Not-To-Do List for the Chronically Ill.” It led me to turn my attention to those who take care of us. In a study published in the Journal of the Royal Society of Medicine, “Quality of life: impact of chronic illness on the partner,” JRSM, v. 94 (11) Nov. 2001, the authors stated:

…the most striking research finding is a tendency for the partner’s quality of life to be worse than that of the patient.

The people who are least likely to be surprised by this finding are not just caregivers, but those who are in their care. The study focused on partners and spouses, but I'm certain that the finding would be the same when the relationship of caregiver and “cared-for” is parent/child, child/parent, sibling/sibling… or a host of other relationships.

From my own personal experience, as well as from feedback from others, I’ve learned a lot about the life of a caregiver (called “carers” in most countries other than the U.S.). If you’re a caregiver, here is my Not-To-Do list for you.

1. DO NOT shy away from sharing with others that you’ve become a caregiver.

The reluctance to tell others about this life-changing, high stress event is particularly prevalent among men. They’re likely to hide it at work. They often hide it from their friends. It’s a sad commentary on our culture that we still haven’t found a way to make men feel comfortable sharing with others that, when they’re at home, they’re taking care of a partner, a sibling, a parent, or a grown child. They’re doing the cooking and the cleaning; they’re running all the errands; they may even be providing nursing-type assistance.

The consequence of caregivers hiding their role is that people who’d be willing to help don’t even know that help is needed. Not only can this lead to caregiver burn-out, it also helps account for why caregivers have a high incidence of clinical depression. The National Family Caregiving Association found that over 60% of caregivers who provide at least 20 hours of caregiving a week suffer from depression.

If you’re a caregiver, I hope you’ll talk to others about your life. If you’re the one being cared for, encourage your caregiver to share with others the difficulties he or she is facing. No one benefits from a caregiver “going it alone.” It may take only one friend to make a significant difference in a caregiver’s life: one friend whom he or she can confide in and talk to about how stressful and difficult life has become; one friend whom he or she can ask for help and support. “Troubles shared are troubles halved” is one of those good clichés.

2. DO NOT pretend that everything is like it used to be; you need time to grieve the loss of your old life.

Many people (including myself) have written about the need for the chronically ill—including those in chronic pain—to go through the same type of grieving process that’s triggered by other life-disrupting events, such as the break-up of a relationship or the death of a loved one.
If you're a caregiver, you need time to grieve too.

The drastic change in your life can be a shock. One day you were free to go out whenever you wanted and hang out with whomever you wanted. The next day, you were tied to the house and expected to understand how to take care of someone who may need help with the most intimate of life functions. Our culture does a poor job of preparing people for this very real possibility. (An estimated 45 million people in the U.S. alone are caregivers for elderly relatives or the chronically ill.)

In addition to grieving the loss of freedom, you may be mourning the loss of the relationship you once had with the person you're caring for. In my life, except when we were at our respective jobs, my husband (also named Tony) and I used to do almost everything together. Now when he goes out, he almost always goes out alone.

This past Christmas, Tony went to a holiday party—by himself. He rarely goes to these events anymore, but the couple who were hosting it issued a special invitation to him, so he went. He saw people from our smallish town whom he hadn’t seen for years. This is the type of event that would have been fun for us to “compare notes” about afterward. Instead, when he got home, he told me who was there and how they’d all asked how I was doing (a question that, once answered, tends to be a conversation killer, even though people ask with the best of intentions).

Pretending that everything is like it used to be doesn’t work: caregivers need time to mourn the loss of their old life and to adjust to their new one.

3. DO NOT attempt to be Super Caregiver.

Let yourself have “bad” days when, even though you’re doing what needs to be done for the person you care for, your heart isn’t in it and you wish you were free of the obligation and the burden. Don’t feel guilty if resentment arises now and then. Like everyone else in this life, you’re going to have good days and bad days.

On the flip side, don’t feel guilty when you have a good time. Be on the alert for that Super Caregiver mentality that has you thinking you’re not an adequate caregiver unless you’re giving the person in your care 100% of your attention and unless you’re sure never to have more fun than he or she is having.

Speaking personally, I want Tony to have a good time. It makes me feel less bad about the drastic change in his life and about the responsibilities he’s had to take on. As an added bonus, it makes me happy to know he’s having fun. Buddhists call this mudita—feeling joy for other people who are happy. It’s a practice to cultivate, and a wonderful side-effect of mudita is that feeling happy for Tony often boomerangs, meaning it comes back at me so that I begin to feel happy myself, as if I’m having a good time through him.

A few weeks ago, he took our granddaughter, Cam, to see the Harlem Globetrotters. When I was growing up, my dad took me to see the Globetrotters whenever they came to town, so it would have been a treat for me to take Cam. But I couldn’t, so Tony did. My choice was to be envious and resentful—or to be happy for Tony. I chose the latter. And so, throughout the afternoon, I imagined the two of them in their seats—Tony pointing out a dribbling sleight-of-hand that Cam might have missed, both of them laughing at the Globetrotters' antics just as I had. The result was that I felt joy myself, especially knowing that my caregiver was having a good time.

4. DO NOT be reluctant to share your challenges and difficulties with the person in your care.

Of course, every relationship is different, but sharing your struggles with the person you’re caring for can make the two of you closer, despite the many changes in your lives together.

Many caregivers are reluctant to share their difficulties for fear of making the person in their care feel worse. But sharing your struggles and even your sorrows can make the “cared for” person feel as if he or she is giving you emotional support. As a result, not only will you get that support, but the person you’re caring for will feel as if he or she is contributing to the well-being of the relationship. In addition, there may be important issues, such as financial constraints, that badly need to be talked about in order to avoid harder times down the road.

5. DO NOT become isolated yourself even if the person you care for is housebound.

Caregivers are often as isolated as the person they’re taking care of. If this is the case for you, consider asking someone to step in for part of a day so you can do something for yourself. Many communities have programs that provide this kind of support. In my town, there’s an organization called Citizens Who Care. They have a program called Time Off for Caregivers. Volunteers visit people’s houses for the specific purpose of allowing a caregiver to go out for a while.

There are also online support groups for caregivers that can go a long way toward easing isolation. Here are two organizations that can help: Family Caregiver Alliance, http://www.caregiver.org/caregiver/jsp/home.jsp, and Empowering Caregivers, http://www.care-givers.com/. Connecting with others in this way benefits both you and the person you’re caring for, because it puts you in touch with others who understand the challenges you’re facing. Not only can this uplift your spirits and renew your commitment, it can also provide valuable information that will make it easier for you to carry out your responsibilities.

6. DO NOT neglect your own health.

You can’t be an effective a caregiver if you don’t care for yourself physically and emotionally. Ignoring your own physical and mental health can negatively impact both you and the person you’re caring for.

Caring for yourself is part of being a good caregiver for another.

© 2014 Toni Bernhard www.tonibernhard.com

Thank you for reading my work. My most recent book is titled How to Wake Up: A Buddhist-Inspired Guide to Navigating Joy and Sorrow.

I'm also the author of the award-winning How to Be Sick: A Buddhist-Inspired Guide for the Chronically Ill and their Caregivers.

http://www.psychologytoday.com/blog/turning-straw-gold/201401/not-do-list-caregivers-the-chronically-ill