May 27, 2014

Step Lively

Riddle: What test is easy, fast, reproducible, cheap, can be done in any physician’s office and is a good predictor of mortality?

Answer: Gait speed. 
As the authors of a short essay in JAMA argue, measuring how quickly a person walks 4 meters at his or her usual walking speed is just such a test. Since decisions from whether to screen for breast cancer to how tightly to control diabetes depend on prognosis, a simple way to estimate life-expectancy is very useful. 

Detecting low gait speed should alert the clinician to think about possible causes: undiagnosed Parkinson’s disease, unrecognized heart failure, or other potentially treatable conditions. And monitoring gait speed may prove to be a good way to objectively assess the response to treatment.

But here's what's so surprising. Nobody measures gait speed. Open the medical record of any 85 year old patient and you won’t find gait speed recorded anywhere, though 52% of women over 85 have a gait speed less than the 0.6 meters/second cutoff that defines “dysmotility” as do 31% of men over 85.

There’s been a lot of interest recently in defining “low value medical care,” tests and treatments for which the ratio between cost and benefit is high. Here’s a high value test, one where the cost is measured in pennies and the benefit is at least moderately great. While it seems prudent for doctors to perform less low value care, maybe it would also be wise to provide more high value care.

May 19, 2014

The Comic Side

When I was growing up, my mother taught me that comic books were junk; they were not “real” books; they were worse than worthless. So I didn’t read any comic books, and as an adult, I never read any graphic novels.

Then I received a copy of Roz Chast’s memoir about the final years of her parents’ lives: Can’t we talk about something more pleasant? This book, written by a cartoonist for the New Yorker is astonishing. It manages to show the poignancy, the pain, and the supreme importance of just about all the challenges of life in the end zone. It’s impossible to capture the essence of this tour de force with just the words—the pictures do not merely illustrate the words, they complement them, enrich them, amplify them. But here are a few snippets, to whet your appetite:

On the tight bond between a man and woman who have lived together for over 60 years:
Narrator—“They were a tight little unit”
Mother—“Co-dependent? Of course we’re co-dependent!”
Father—“Thank God!”

Dealing with increasing impairment:
Daughter—“Mom! Listen to me. You can’t drive with one eye. You have no depth perception.”
Mother—“Not a problem. Daddy guided me.”

On advance care planning:
Daughter--“My mother’s line had always been: ‘I don’t want to be a pulsating piece of protoplasm.”

Early dementia:
Narrator—“One of the worst parts of [dementia] must be that you have to get terrible news over and over again. On the other hand, maybe in between the times of knowing the bad news, you forget it and live as if everything was hunky-dory.”
Picture--Dad singing “oh what a beautiful morning” and practically skipping

Cleaning out her parents’ apartment when they move into an assisted living facility:
Daughter—“I was sick of the ransacking, the picking over and deciding, the dust, and not particularly interesting trips down memory lane.”
Picture: All the old stuff on an ice floe, going out to sea, with the daughter waving goodbye from the shore.

The social scene at assisted living:
Narrator—“You didn’t want to get stuck sitting with a Drooler [at dinner] or a soon-to-be Alzheimer’s person, who was holding onto her assisted living status by her last fingertip.”

Worrying about finances as the expenses mount up:
Daughter—“I felt like a disgusting person, worrying about the money. But it was hard not to, especially when I thought about what this ‘extra care’ might cost…”

The forms denial takes—when dad was dying:
Mother—“We have to get him some soup.”

The platitudes and terminology of end of life care:
Picture—Woman standing next to a big sign/blackboard with a pointer, drawing attention to the phrases “OK to let go; the work of dying; palliative care.”

The last phase of life:
Daughter—“My mother was existing in a state of suspended animation. She was not living and not dying. She didn’t watch TV, read, go outside, play the piano, socialize, or even get out of bed. She slept, drank Ensures, got cleaned by [an] aide, and went back to sleep.”

May 12, 2014

Down for the Count

The US Census Bureau released a new report this week about our aging population. Actually, it came out with 4 separate estimates, each based on slightly different underlying assumptions about developments in the next 40 years. The age structure of the population depends on 3 factors: fertility, mortality, and immigration. It turns out we can be fairly confident about the first two; the last one is far more uncertain. What was fascinating about the report is what most news media didn’t say about it.

Many major news outlets didn’t mention the report at all. I suppose it’s not exactly newsworthy, in that it’s just an updated version of earlier projections, based on the latest available statistics. The NY Times focused on 2 pieces of data: the absolute size of the elderly population: 43.1 million in 2012 and nearly double that, or 83.7 million, in 2050; and the fact that while this may seem dramatic, the numbers are far more dramatic in other parts of the developed world. People over 65 will make up just over 20% of the US population in 2030 (the peak year of the elder explosion, when all the baby boomers will have turned 65),  but in Japan they will make up 33% of the population and in Germany 28%.  Reuters, as reported by Business Insideralso points to the absolute and relative size of the aging population in the US. In addition, it comments on the male/female ratio among old people: right now, 66.6% of Americans over 85 are women, but in 2050 the gap between the sexes will have narrowed, and 61.9% will be women. Finally, Business Insider notes that our society in general and old people in particular will be more racially and ethnically diverse in another 40 years.

What I didn’t see commented on was the changing old age dependency ratio (the population age 65 and over divided by the population from 18-64, multiplied by 100). Right now in the US this ratio is about 21, which means there are roughly 5 working age people to support each old person. In 2030, the ratio will be 35, or only about 3 working people per oldster. That means that every person will have to devote a larger fraction of his or her effort to providing for their elders. But these projections are for the “middle series,” the average of the various predictions. Immigration will play a critical role in determining the actually age structure of the US population over the next 40 years. It will dramatically impact the size of the working age population, the people who will be responsible for most of the economic output of the country—and for supporting the older generation. By 2050, the “High Series” projects 10 million more people age 18-64 than does the “Middle Series." This is because we’re likely to see only modest changes in either fertility or mortality rates in the coming years. The one area where we do have a choice—because it reflects political, not scientific factors—is immigration. So if we want to have a maximally productive economy, and parenthetically if we want to have a way to care for all those old people, we need to increase immigration. And we better start now.

May 05, 2014

About Time

Just over a year ago, physician-researcher Harlan Krumholz created a stir by describing the “post-hospital syndrome.” Some patients, he argued, were so traumatized by hospitalization that they went home in some ways sicker than when they entered the hospital. They were confused (delirious) or they had a new “hospital-acquired infection” (so common that it has its own acronym, HAI) or they suffered a side-effect from a new medication, perhaps one that was no better (and evidently in some ways considerably worse) than the medicine they had taken previously. Readmissions to the hospital, the number one bugaboo of Medicare these days, result from the illnesses induced by a previous hospitalization, Krumholz argued. Now, writing together with health economist and policy maven Allan Detsky, Krumholz recommends a few practical steps that might alleviate the problem. 

The authors suggest 7 commonsense, seemingly simple changes that could make the hospital a less toxic environment for older people (particularly frail older people although they don’t specifically identify this subgroup as especially prone to developing problems in the hospital). Hospitals should personalize their care to make patients feel like individuals (for example, allowing them to wear their own clothes); they should ensure that patients get enough rest and nourishment (abandoning the practice of waking the patient up to check vital signs every few hours and of supplying unappetizing meals adhering to draconian dietary restrictions); hospitals should reduce stress by providing privacy and decreasing uncertainty (giving patients a schedule of their daily activities and a list of the names of those taking care of them); they should eliminate unnecessary tests and procedures (that unwarranted urine test that shows bacteria may lead to unwarranted antibiotics that in turn result in diarrhea—along with promoting the development of resistant bacteria); hospitals should avoid abrupt changes in medication regimens (introducing new medicines in the middle of the night, for example, in response to a transient increase in blood pressure or heart rate, medications that are then continued, only to produce dangerously low blood pressure or heart rate); they should encourage physical activity to avoid the rapid deconditioning that occurs with even a few days of bed-rest; and hospitals should provide a post-discharge “safety net” by scheduling follow-up appointments.

Harlan and Detsky are absolutely right: we should do everything they advise. The only problem is that most of these solutions were proposed 30 years ago as a way to avoid adverse consequences of hospitalization. Many of them were instituted, at least on a limited scale, through the introduction of Acute Care for the Elderly (ACE) units. ACE units have spread through many US hospitals and they have been studied extensively. They do seem to help—a little. But a recent review article and meta-analysis found that the risk of falls, delirium, pressure ulcers, and decline in independence remain stubbornly high. While the focus of this analysis was on problems that arise during the hospitalization, it is equally applicable to what happens after discharge since these “new” problems are in fact generated by events occurring during the hospital stay.

So yes, we should redouble our efforts to make the principles of the ACE unit a reality in all American hospitals. And we should update the list of ACE unit practices to include those that recent work suggests are important along with those clearly identified in the early 1980s as important (for example, attention to diet and supplying patients with the names of their hospital clinicians). But these measures alone will not fix the problem of frequent readmissions to the hospital, any more than better “transitional care” (doing a better job of passing the baton from hospital staff to outpatient primary care clinicians) has solved the problem. It is a step and an important step. The next step will be to keep frail, older patients—the ones most likely to develop adverse consequences of hospitalization or “post-hospitalization syndrome”—out of the hospital in the first place.