January 24, 2006

Does Exercise Prevent Dementia?

We would all like to believe that if only we eat well and exercise regularly, we will remain vigorous well into our eighties and perhaps our nineties. But is it true? A new study published this week argues that exercise can help fend off dementia, one of the major plagues of old age.

Writing in the Annals of Internal Medicine, a leading medical journal, Dr. Eric Larson and his colleagues in Seattle, Washington, describe a study in which they monitored a group of 1740 people over age 65 for an average of 6 years to see whether they developed dementia. To be part of the study, you had to be free of any evidence of dementia. You were asked questions about your medical conditions, whether you smoked, whether you used alcohol, and whether you rated your health as excellent, very good, fair, or poor. You were also asked one question about exercise: over the past year, how many times per week did you spend at least 15 minutes on an activity such as walking, hiking, bicycling, aerobics, or swimming. All the people who agreed to be in the study were then tested for dementia twice a year. By the end of 6 years, 1185 of them were still free of dementia, 158 had been diagnosed with dementia, and another 397 either died or withdrew from the study. The authors then compared the risk of developing dementia among those who had said they exercised at least 3 times a week with the risk of developing dementia among those who said they exercised less than 3 times a week. What they found was that when they made adjustments to account for factors such as age and gender, the exercise group was 32% less likely than the low-exercise group to be diagnosed with dementia. (See Eric Larson, Li Wang, James Brown et al, “Exercise is Associated with Reduced Risk for Incident Dementia among Persons 65 Years of Age and Older,” Annals of Internal Medicine 2006; 144: 73-81).

Physical activity in both middle age and old age is a good idea for a variety of reasons. In addition to its well-known effects on preventing heart disease, the leading cause of death in older adults, exercise can prevent or at least delay the onset of frailty, a syndrome in which people typically have multiple medical problems which together cause impairments in their ability to function in their daily lives (see my book, Lifelines: Living Longer, Growing Frail, Taking Heart, NY: Norton, 2001.) Exercise can help prevent obesity, which is currently epidemic in the U.S. But it’s important to remember that while exercise can decrease the risk of a variety of conditions that afflict older people, it does not prevent them. In the study of exercise and dementia, for instance, fully two-thirds of the people who developed dementia had exercised at least 3 times a week. Among those who did not get dementia, there were more regular exercisers (77% instead of 67%), but it was hardly the case that the couch potatoes got dementia and the exercisers did not. In fact, in this study of relatively young, educated, middle class people, dementia didn’t develop very often either in exercisers (10.38%) or non-exercisers (16.4%). Among the general population over age 85, by contrast, nearly 50% have dementia.

It’s also important to realize that the new study doesn’t definitively show a causal connection between lack of exercise and dementia. Because it is an observational study and not a randomized trial—the people in the study were watched and tested rather than being assigned to either an exercise group or a sedentary group—we don’t know for sure whether it was exercise that was responsible for the difference in outcomes. The authors did their best to make statistical corrections to account for factors such as age, cigarette smoking, and alcohol use that might affect the likelihood of getting dementia. But it’s possible that people who exercised (or more precisely who said they exercised) were also more socially active or intellectually engaged and it was those behaviors that helped protect them from dementia. It’s even possible that the people who didn’t exercise were already in the early stages of dementia—so early they still did well on the tests of cognitive function they were given—and that it was the dementia that prevented them from exercising rather than the other way around.

The answer to whether you should exercise, whether you are 60, 70, or 80, is a resounding yes. But will exercise save you from dementia? Maybe, but don’t count on it.

January 18, 2006

The Supreme Court and Physician-Assisted Suicide

The good news is that the Supreme Court just ruled 6-3 that the U.S. Attorney General has no business trying to prevent Oregon from implementing its physician-assisted suicide law (Linda Greenhouse, “Justices Reject U.S. Bid to Block Assisted Suicide,” NY Times, 1/18/062006;). Regardless of what you think about the appropriateness of physician-assisted suicide—and I think there are better ways to address end-of-life suffering—you should be glad that the Court has upheld Oregon’s law. The Supreme Court already concluded 8 years ago that there is no constitutional right to physician-assisted suicide, but neither is there any constitutional prohibition of the practice. States were held to be free to pass legislation legalizing physician-assisted suicide if they wished.

State legislatures haven’t exactly jumped at the opportunity to pass such legislation. To date, only Oregon has a “death with dignity” law. And very few individuals have taken the steps outlined by the law to obtain prescriptions for medication they could use to end their lives (only 326 people between 1997 and 2004). Even fewer actually took the medication (only 208)—most died of their underlying disease and just wanted the medication as an insurance policy. There are even some suggestions that the availability of physician assisted suicide in Oregon led to improved palliative care and more referrals to hospice as physicians developed a heightened awareness of the inadequacies of end-of-life care. Instead of choosing to end their lives as a response to their physical or psychic distress, patients have enhanced access to programs that ameliorate symptoms and provide support to both patients and families.

Former Attorney General Ashcroft did not approve of physician assisted suicide and tried various strategies to declare Oregon’s law unconstitutional. The most recent was the argument that physicians who prescribed medication that could enable a patient to end his life violated the Controlled Substances Act of 1970. These physicians, he believed, should have their federal prescribing privileges revoked and be prosecuted. Such measures would potentially have dire effects on physician prescribing sufficient pain medication for dying patients (see T. Quill and D. Meier, “The Big Chill: Inserting the DEA into End-of-Life care,” New England Journal of Medicine 2006;354: 1-3;). The Controlled Substances Act was intended to prevent the use of addictive medication as recreational drugs. Invoking it to prevent dying patients from exercising control over their deaths is sheer trickery, attempted sleight-of-hand to interfere with a medical practice of which the Administration disapproved. Fortunately, the trick failed and physicians can continue to prescribe opioids (which, parenthetically, are not typically the medications prescribed to aid in suicide) and other controlled substances to treat pain, shortness of breath, and additional symptoms near the end of life without fear they will be punished.

The bad news is that Chief Justice Roberts joined the predictable duo of Scalia and Thomas in dissenting from the majority opinion. We can anticipate that Judge Alito, when he is confirmed as the next member of the Supreme Court, which appears almost certain, will join with his ideologically motivated colleagues in interpreting the law so as to support his moral and political views. That still leaves a majority of justices, some of whom are considered liberal and others of whom are considered conservative, without these unfortunate biases. But it’s a tenuous majority, composed of Justice John Paul Stevens (age 85), Ruth Bader Ginsburg (age 72), Anthony Kennedy (age 69), David Souter (66) and Stephen Breyer (67). On the other hand, we have Justice Antonin Scalia (69), Clarence Thomas (57), John Roberts (50), and probably soon will have Samuel Alito (55). My geriatric word of the day is the fervent hope that Justice Stevens remains healthy for at least the next 2 years.

Congress Slashes Geriatric Education Funding

Within a 2-week period, we witnessed 3 seminal events in the development of U.S. policy toward older people. First, in mid-December, the White House held a Conference on Aging. This is an event that takes place every 10 years and is attended by delegates from all over the country who pass resolutions designed to give guidance to Congress on how best to improve the quality of life of older Americans. This year’s theme was “The Booming Dynamics of Aging.” The top 10 resolutions passed included 2 that focused on educating health care providers: “Support geriatric education for all health care professionals” was one. The other was “Attain adequate numbers of healthcare personnel in all professions who are skilled, culturally competent, and specialized in geriatrics.” Interestingly, President Bush did not set foot in the meeting, the only sitting president to miss the event in 50 years, according to Ruth Garrett, writing in the Tennessean.com (“Frist gives care for the elderly a congressional kick in the gut,” December 29, 2005.)

The second milestone was the trashing of 3 major government programs that have been funding geriatric education for years. Reportedly, Senate Majority Leader Bill Frist knew that the senators wanted to deal with the budget and did not want to have to come back after the holidays, so he rushed through a voice vote on the measure. The vote was tied 50-50, with Vice President Cheney casting the tie-breaking vote. The 3 programs that were consigned to the dustbin collectively cost $31.5 million in 2005. The total estimated federal spending over the next 5 years will be $14.3 trillion.

One of the victims is the Geriatric Training Program for Physicians, Dentists, and Mental Health Professionals which offered 1- or 2-year programs to train geriatric academicians. I was Director of the Harvard Geriatrics Fellowship Program for years and we relied heavily on government support to provide stipends to young doctors and dentists who wanted to specialize in geriatrics. We were able to offer our fellows a broad exposure to hospital care, outpatient care, rehabilitative care, and nursing home care, as well as a year to begin developing expertise in research. Our fellows went on to become prominent researchers, teachers, and practitioners. The government funded 13 such programs in 2005 and will fund 0 in 2006.

The second program that was axed is the Geriatric Academic Career Award initiative, which provided stipends to junior faculty members who were committed to teaching geriatrics. There are very few opportunities for physicians to develop expertise and experience in teaching. This was one way to be launched on a teaching career. In 2005, awards were given to 102 promising young professionals. In 2006, there will be none.

Finally, funding for the nation’s Geriatric Educational Centers was eliminated. These Centers offered educational programs to health care professionals to train them in issues of importance to the health of older individuals. Since the Centers were introduced 20 years ago, they have touched the lives of over 425,000 professionals in 27 disciplines, according to the National Association of Geriatric Education Centers. All 50 states had such Centers. They will all disappear. (See the article in the Boston Globe on January 13, 2006 by Sue Levkoff, “Assault on the Elderly.”)

The third landmark is that on January 1, 2006, the first of the 76 million baby boomers turned age 60. There was a fair amount of hoopla about this in the media. Congress and the President do not seem to have noticed.

January 13, 2006

On Medicare Part D

As of January 1, 2006, if you are elderly, disabled, or both you are eligible to receive a prescription drug benefit through Medicare. If you are one of the millions of Americans who had no coverage for prescription drugs, this is welcome news. If you are one of the millions of other Americans who already had coverage for prescription drugs through a private plan, this means confusion as you try to decide whether to switch to a new plan, and if so, to which one. If you are one of the approximately 7 million people who are enrolled in both Medicare and in Medicaid, the new law means an obligatory change to the Medicare prescription drug plan, which in turn may result in some degree of confusion during the transition period.

Medicare is providing information on the web to help you decide what to do (go to www.medicare.gov); many local pharmacies are offering advice; and the Medicare Advantage programs (which used to be known as Medicare plus Choice or Medicare Part C) have their own hotlines. While the decisions you make should depend on your individual circumstances and your own preferences, a few general observations may help:

To Enroll or Not to Enroll

  1. Medicare enrollees who are taking many medications and who previously had no health insurance coverage for drugs will almost undoubtedly benefit by enrolling in Medicare Part D. The part D plans will not pay for everything: in addition to a monthly premium charge, there is a $250 deductible for most plans, patients typically have to pay 25% of the next $2000 of drug costs, and generally you will have to pay the entire cost of the next $2850. Only after you have purchased $5100 worth of medicines will most plans start paying at a rate of approximately 95%. Nonetheless, for patients with high expenditures, such a plan is far superior to no plan at all.
  2. Medicare enrollees who are taking few medications and previously had no health insurance coverage for drugs will not benefit from enrolling in Medicare Part D over the short run. However, you should recognize that there is a penalty for enrolling after May 15, 2006: the rates will be higher for people who join after this date. Moreover, the majority of older people eventually will take quite a few medications. Thus, you may find it advantageous to enroll in Medicare Part D now. If you are willing to gamble that you will remain very healthy, if you have ample savings, or if you are already extremely elderly (perhaps over age 90), you may prefer to take your chances and not enroll in Medicare part D.
  3. Medicare enrollees who are already enrolled in a plan that covers prescription medicines will probably find that it makes sense to switch to a Medicare plan because the Medicare plans are typically more comprehensive. Doing so sooner rather than later (ie by May 15, 2006), allows you to get the best rate. However, some plans in which older people are currently enrolled may offer better coverage than the Medicare part D plans. It’s crucial to compare plans carefully. Also keep in mind that the companies that currently provide health care plans for retirees may decide to drop the coverage in the future—this has been happening with great regularity.
  4. The “dually eligible,” those who are on both Medicaid and Medicare, were automatically switched to a Medicare Part D plan as of January 1, 2006. You can opt for a different Medicare plan from the one you were assigned to, but you cannot continue coverage under Medicaid. Your new plan is likely to be different from your old plan in a number of ways: there may be copays for medications of $5, whereas previously you may have paid only $1-2 or nothing at all. Certain medications are explicitly excluded from coverage under Medicare Part D that were covered under Medicaid, such as benzodiazepines and drugs for weight loss or weight gain, although provisions may be made to remedy this problem.

Which Plan to Choose

  1. Choosing based on price: the cheaper plans offer less comprehensive coverage, although all plans provide at least 2 drugs within each “class,” for example 2 drugs to lower blood sugar. Each plan’s formulary, or list of covered medicines, includes “all or substantially all” antidepressant medications, antipsychotic medications, cancer medicines, and anti-seizure medicines. There are plans with no deductible, plans that cover the “gap” or “doughnut hole” (between $2250 and $5100 where the basic plan offers no coverage), and plans that charge different co-payments depending on the brand (ie $5 for a generic medication, $10 for a relatively inexpensive brand name medication, and $25 for a more expensive brand name medication). Plans that provide broader coverage will have higher premiums.
  2. Choosing based on specific medicines: if you are taking several medications currently and if it is important to continue taking exactly the same version of those medications, you should look for a plan that includes those medicines. In general, substituting one medicine of a particular class for another one in the same class may be confusing initially but it rarely makes a difference in terms of your health. Sometimes patients respond better to one drug rather than another, or have side-effects from one drug and not another similar drug. If you know that you are best off with precisely the medicines you are taking, because you have already been on other versions and have had problems, then you should seek a plan that covers your current medicines.
  3. Choosing based on convenience: you should check which plans your local pharmacy accepts. You should also consider whether a given plan offers a mail order service. If you take medications on a regular basis and are on a fairly stable regimen, it may be very useful to be able to send away for your medications. You will then get a 90-day supply in the mail.

For more details on what Medicare Part D means for the dually eligible, see RA Elliott, SR Majumdar, MR Gillick and SB Soumerai, “Medicare Drug Benefit: Benefits and Consequences for the Poor and the Disabled,” New England Journal of Medicine 2005; 353: 2739-41.

January 12, 2006

An Introduction

The “Perspectives on Aging” website has been set up to communicate with the general public about controversial issues affecting older people through commentaries on topics of timely interest. I am a physician specializing in the care of the elderly, with particular interests in making decisions about medical treatment and in ethical issues that arise near the end of life. While I will address on this site that are of potential concern to all older individuals and their families, I am particularly interested in providing information and guidance to the sickest, frailest, and oldest of the old.

My background is in internal medicine, with specialty certification in both geriatrics (medical care of older patients) and palliative medicine (care of people facing life-threatening illness). I have practiced medicine in a neighborhood health center, a community hospital, in a number of nursing homes, and in several tertiary care teaching hospitals. Throughout my career, I have been affiliated with Harvard Medical School, where I am an Associate Professor. Stimulated by my clinical experiences, I have written extensively about issues in geriatric care. While much of my work has been published in medical journals including the New England Journal of Medicine, the Annals of Internal Medicine, and the Journal of the American Geriatric Society, I have also written for a general audience. In particular, I have published 3 books, one on dementia (Tangled Minds: Understanding Alzheimer’s Disease and Other Dementias), one on frailty (Lifelines: Living Longer, Getting Frail, Taking Heart), and one on medical decision-making in old age (Choosing Medical Care in Old Age: What Kind, How Much, When to Stop). My newest book will be published in March of 2006 and will be called The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies.

It takes years to write a book and have it published and much is happening all the time that affects older people: Medicare has just rolled out a new prescription drug benefit; the Centers for Medicare and Medicaid Services (which runs the Medicare program) has agreed to pay for eligible patients to receive sophisticated technological interventions such as an implantable defibrillator (like what Vice President Cheney has); new initiatives have been introduced that have the potential to radically transform nursing homes. I want to be able to talk to older patients and their children about these issues as they arise; to that end, this website has been created.