October 27, 2013

Turning Back the Clock

A fascinating article in this month’s health policy journal Health Affairs concludes that by focusing on diseases one at a time—trying to prevent heart disease or cancer or dementia—we are shooting ourselves in the foot. Instead, we should devote greater effort to delaying the aging process altogether. If we could slow aging, we could in principle delay the onset and progression of all fatal and disabling diseases at once. Instead of surviving your heart attack and then going on to suffer from dementia or cancer, you would remain healthy longer, perhaps dying suddenly, as centenarians have been reported to do. But will delaying aging improve the quality of life? And how likely are we to actually postpone aging any time soon?

Using a complicated model known as the Future Elderly Model (FEM), the authors predict what will happen to health care spending, functional status, and life expectancy under various scenarios. What they find is that decreasing the incidence of heart disease by 25% between 2010 and 2030 wouldn’t do very much for disability rates or overall mortality. Ditto for decreasing the incidence of cancer the same amount during the same period. In fact, mortality and disability would be much the same as what we can expect if the incidence of cancer and heart disease stayed the same and all that changed is that the number of older people increased, as we can expect when the baby boomers reach old age. Delaying aging, by contrast, would have a dramatic effect on both length and quality of life. These benefits would come at a considerable cost—by 2060, costs would be $295 billion greater in the delayed aging scenario than in the status quo scenario because all those people who live longer would typically qualify for Medicare and Social Security. The good financial news, however, is that changing the age of eligibility for Medicare from 65 to 68 and raising the age of eligibility for Social Security from 67 to 68 would offset the increased costs.

All very compelling. But just what are these potential advances that will allow us to delay aging? The Health Affairs authors cite two scientific papers, one in the Journal of Clinical Investigation and one in a journal called Experimental Gerontology, both published this year. The papers are very intriguing.

The two papers focus on the fact that aging cells secrete a variety of nasty substances that cause chronic inflammation, at least in mice. These chemicals are collectively referred to as SASP (senescence-associated secretory phenotype). SASP or the cells that make them are potential targets for drugs to delay the aging process. So far so good. But as one of the authors points out, it’s not known if SASP causes chronic age-related disease in people. Moreover, it’s entirely possible that disrupting the processes that cause aging and death will turn on the processes that promote cancer. Finally, as another of the authors argued, actually carrying out clinical research in humans, testing whether a drug (if we had one) has a beneficial effect, will take an estimated 17 years. This would bring us to 2030, the exact date in the Health Affairs article by which all the good effects of delaying aging are assumed to have already happened, according to their model. If we aren’t likely to have any aging-delaying drug available for clinical use before 2030, we can’t plausibly expect any beneficial effect until well after that time.

So by all means, let’s go ahead and invest in the basic science of aging. Let’s encourage more clinically trained geriatricians to go into this kind of research (reportedly of 7000 board certified geriatricians, only 12 have research grants from the biological division of the National Institute on Aging). But in the mean time, let’s figure out how best to care for the many frail elders who will be with us for years to come.

October 20, 2013

Are Hospitals Bad for Your Health?

When I was a medical resident, I noticed that bad things kept happening to my older patients: many got confused and some fell and maybe even broke a hip. I wondered whether the problems they developed were related to the acute medical illness for which they were admitted or to the hospitalization itself. 

So I did a study in which I compared the experience of older patients to that of people under 70. By looking through patients’ hospital charts and sitting in on the nurses’ rounds every day, the time when they reported to the next shift what was really going on with their patients, I was able to determine who was confused, who fell, who stopped eating, and who was incontinent. Then I analyzed whether there was any conceivable relationship between their medical problems and the symptom they developed. For example, a person admitted with a stroke or meningitis (an infection of the lining of the brain) could be expected to be confused but not a patient with a stomach ulcer. 

What I found was that 40% of the older patients, compared to 9% of the younger ones, had one or more of these symptoms that couldn’t be explained by their admitting diagnosis. Moreover, as soon as patients had one of these problems, doctors intervened in some way—they ordered restraints for the patients who had fallen or a urinary catheter for those who were incontinent—and all those interventions in turn predisposed to new problems. In subsequent years, several other investigators documented the perils of hospitalization for older people and geriatricians introduced ACE (acute care for the elderly) units to minimize the risk of hospital-induced problems. These units have made a difference, but even in specialized units, older people are at risk of hospital-related complications.

Today, there is a renewed interest in learning about the perils of hospitalization. One prominent researcher introduced the concept of “post-hospitalization syndrome,” arguing that older patients are at heightened risk of problems after discharge, problems related not only to the acute illness for which they were hospitalized, but also to the debilitating effects of having been in the hospital. Patients are often sleep-deprived, poorly nourished, and de-conditioned after a hospital stay, and it is these factors that may predispose to difficulties in the 30 days after discharge. According to this analysis, physicians and nurses need to pay more attention to making the hospital a better and safer place for patients.

Now a new study picks up on the theme of the post-hospitalization syndrome, measuring the risk of adverse drug reactions during this period of heightened vulnerability. Pharmacists reviewed the records of 850 older people who collectively experienced 1000 hospitalizations and they identified 330 possible adverse drug events (injury from a drug and not the underlying disease) during the 45 days after discharge. Physicians looked through the list and agreed that 242 cases were truly adverse drug events, of which 2.5% were life threatening and another 21% were serious. They deemed just about one-third of these events preventable. Most of the drugs causing these problems were cardiovascular drugs or diuretics (fluid pills that are typically also used to treat heart disease); the next major class of offenders was narcotics. The authors conclude that doctors need to do a better job in the hospital (deciding on what medications a patient should be discharged) and afterwards (monitoring for side-effects). 

It seems that patients still get into trouble after hospitalization, particularly frail elders, just as they did 30 years ago when I published my study of iatrogenesis. Adverse drug reactions are yet another form of trouble. But what are the implications of these observations? We should try harder to make the hospital a safer place for frail old patients. We should watch assiduously every time an older patient starts a new drug, and people who are discharged from the hospital often go home with several new medications or new doses of old medications. 

Maybe we should also think about whether the patient should really have been admitted to the hospital in the first place. Perhaps his illness could have been prevented. More plausibly, perhaps we could treat the illness in a way that didn’t necessitate admission to a large, alien institution like a hospital. An older person cared for at home when he develops pneumonia or a worsening of his chronic heart failure won’t suffer from confusion induced by unfamiliar surroundings. He won’t have his sleep disrupted by monitors going off in the adjacent bed or nurses and doctors talking loudly in the hall. Of course he won’t have all the benefits of acute hospital care either, the sophisticated technology, the 24-hour nursing care. But maybe the risks aren’t always worth the benefits. Maybe we should design alternatives to hospital care that feature some of the benefits of the hospital but all the benefits of home.

October 13, 2013

Talking the Talk

A new survey asking people about their wishes for end-of-life care has been getting quite a bit of publicity lately. Commissioned by “The Conversation Project,” a laudable grassroots effort to encourage families to talk to each other about the kind of medical care they would want in their final days, the poll reports some interesting observations—and raises some important questions.

Like other earlier studies, this one finds that most adults (94%) think it is important to talk about end-of-life care. An extensive California study, for example, found that 83% of the adults surveyed thought it was important to make their end-of-life wishes known, A poll of adults in Massachusetts found that 84% of adults were comfortable talking about dying. 

And like earlier studies, this one finds that though people think that talking about dying is important, many of them don’t actually talk about it (in the new study, only 27% did). In California, only 36% of adults actually had something in writing about their wishes; in Massachusetts, 51% had had a conversation with family members.

But if we look at people who are very sick or very old or both and ask whether they talked to their families about their wishes, the picture that emerges is a bit different. The Pew Research Center conducted a national poll in 2005 (with 1500 subjects) and another one in 2009 (with 2969 subjects) and found that while only 11% of people aged 18-29 had any kind of written documentation of their end of life wishes, 51% of those over 65 had such a document. Moreover, 63% of older Americans had talked to their adult children about their wishes for medical care in the event of incapacity—and among older women, 71% had had such conversations. So when the new study from the Conversation Project reports that only 27% of those polled had talked to family members about their personal wishes, is this too low? 

While I agree that it’s a good idea for everyone to designate a health care proxy—to state who will make medical decisions on their behalf if they are unable to do so themselves—I don’t think it makes sense for everyone to have “the conversation” about end-of-life care. The overwhelming majority of Americans will die in old age: people over 64 account for 12% of the population but 70% of the deaths;  I estimate that asking everyone who is between 18 and 64 to talk about their wishes for medical care at the end of life means that about 280 people will have such a conversation for every person who ends up actually dying in the next year.  It’s far more reasonable to target advance care planning to those people who are likely to get very sick in the relatively near future, which means those who are elderly or who already have a life-limiting illness such as advanced heart failure or metastatic cancer. Moreover, if 20- or 30-year-olds actually did have “the conversation,” they would likely express preferences that will change by the time they are old and dying. How much suffering you are willing to endure in exchange for a small chance of living longer or how much debility you find tolerable may be very different, depending on whether you are already 80 and have outlived most of your birth cohort and on your underlying health status at the time you develop a terminal illness. 

If pitching discussions about dying to everyone is excessive, talking only about dying isn’t enough. Once it becomes clear that a person is truly dying—and many people who are at that stage have difficulty accepting that the end is imminent, a situation made worse by doctors who have difficulty telling them where they stand—the vast majority of people don’t want more tests and treatments. The default approach to people who will surely die within a few months no matter what is done should be a focus on comfort. Conversations are needed principally to communicate that the end is near and to identify the small minority who do want trials of treatment that have only a very, very small chance of benefit. 

What we need desperately to talk about is the final phase of life, whether that is measured in months or in years, a time demarcated by a marked decline in the ability to function independently. The 85-year old with heart failure, diabetes, arthritis, and kidney problems may not be dying in any conventional sense of the term, but she is likely to develop some kind of acute illness in the near future, whether pneumonia or dehydration or an exacerbation of her heart condition, and thinking in advance about the approach to medical care that is right for her is critically important. She has real choices to make: does she want maximal medical therapy? Comfort-oriented treatment? Or something in between? As Katy Butler makes so poignantly clear in her recent book, Knocking on Heaven’s Door, this final phase can last a long time—it was 7 years between the time when her father got his pacemaker and death—but decisions made along the way dramatically shape the experience of those years.

So I’m not at all surprised that 94% of the 1067 people surveyed for The Conversation Project said that it is important to talk to your loved ones about your end-of-life care wishes but only 27% have had a discussion about “what they do and don’t want in their final days.” I applaud the Conversation Project for encouraging people to open the door to discussing difficult topics. But let’s be selective about whom we invite in and what we talk about.

October 06, 2013

Where in the World is the USA?

The widespread belief in American exceptionalism means that we tend to think we are unique. Often, being unique slips into being the best. But for a long time, I’ve had a sneaking suspicion that we might be able to learn something about how to improve life for older people by looking at other countries. A new study based on data from the UN, the World Health Organization, and the World Bank, suggests we could.

The report was released on October 1, the International Day of Older Persons, a day that will be celebrated at the UN this week but that I confess I wasn’t even aware existed. The authors created a “global age watch index,” made up of 4 domains: economics, employment and education, the environment, and health. Based on these measures, the best place to live if you’re over 65 is Sweden, which was in the top 10 in all 4 domains. The US placed 8th in the overall ranking (a geometric mean of the 4 domains). But if we look at the health status component, we find a bleaker picture.
Health status was measured based on life expectancy at age 60 (WHO data), healthy life expectancy at age 60 (data from the Global Burden of Disease Study, Institute of Health Metrics and Evaluation, Seattle), and psychological wellbeing (based on the Gallup WorldView, a subjective assessment of whether one’s life has an important purpose or meaning). Based on these indicators, the US ranking is an embarrassing 24. 

Actually, the US didn’t do so well in the economic or environmental domains either—its overall score is respectable mainly because of relatively high employment and high educational attainment among American elders. In terms of income security, the ranking is #36, reflecting a marked income inequality. And on the “enabling environment” dimension, which measures things like social connections and access to public transportation, the US came in at 16.

So who are the role models? Three countries stand out as having high rankings across the board: Sweden, Norway, and Germany. The second tier is comprised of the Netherlands, Canada, Switzerland, and New Zealand. Maybe it’s time we explore what these other countries are doing right and have the humility to learn from their example.