Happy Birthday, Medicare!

It's Medicare's 50th birthday! See more on my blog next Sunday.

How Much Good Could the WHCOA Do if the WHCOA Could Do Good?

A few weeks ago, I blogged about the upcoming White House Conference on Aging. This once-a-decade event took place last week. What, if anything, did it accomplish?

It was a modest affair, attended by a mere 200 invited delegates (though observed on line by 600 “watch parties”) that was more of a highly scripted performance than a platform for hashing out policy recommendations. This was no surprise, as Congress never allocated funds to support the event, so that it took place at all is something of a miracle. For all its limitations, it did accomplish something.  It was of symbolic significance, a way for the White House to affirm that the health and well-being of the older population are a concern for the entire society. It was also a forum for presenting recommendations for what people outside the federal government can do to address important public policy issues—given that Congress refuses to do so.

The Conference was of symbolic significance: it was hosted by the White House and the President actually made an appearance, addressing the attendees. And it turned to groups other than Congress to implement policy. In particular, it turned to state government, to the nursing home industry, and to the corporate world. State governments were exhorted to adopt 401K type savings plans for older people—a corresponding initiative, incidentally, failed in Congress. The nursing home industry will be charged with implementing a lengthy set of new rules proposed by the Centers for Medicare and Medicaid Services designed to improve quality of care in nursing homes. This means the nursing homes will have to pay for the enhanced training for nurses and nurses aides that the regulations would mandate as well as infection control committees to monitor antibiotic use and a host of other mandates. And corporations were given shining examples of creative technological approaches to the problems of aging: the ride-sharing service, Uber, detailed a new program that will offer older people discounted or free rides and training in using its smart phone app; Philips announced the creation of its “AgingWell Hub,” a collaboration with caregivers, older adults, academics, and companies  to identify new technologies and services that promote successful aging.

All in all, the Conference gave a boost to ongoing efforts in its four main topic areas: healthy aging, long term services and supports, elder justice, and retirement security. It was not an opportunity for brainstorming or for developing bold, radical new ideas. But it was a pragmatic approach to a pressing problem, undertaken with a paltry budget. And maybe, just maybe, Congress will be moved to do more in the coming years. After all, the average age of the current senators is 62, which means that before their term is over, the majority will be eligible for Medicare.

A longer version of this post appeared on the bmj blog. 

What's Up, Doc?

Every week I scour the medical literature and the media in search of something newsworthy to report about aging and old people.  I discover and sometimes read all kinds of reports—often I wonder whether these reports will have any effect at all or whether they will collect dust in a file cabinet somewhere, though with the internet, there probably aren’t even any physical copies of most of them. There’s the annual report on dementia from the Alzheimer’s Association, there are reports from the Institute of Medicine, surveys from the Pew Center, research papers from AARP. I read and reported on white papers and position papers (I never have known the difference) from organizations such as the FrameWorks Institute and from the British Geriatrics Society. I’ve blogged about important books, not so much on best sellers such as Atul Gawande’s “Being Mortal” as on equally important but less celebrated works such as Angelo Volandes’ “The Conversation” and Sharon Kaufman’s “Ordinary Medicine.” And then there are the medical journals. So it occurred to me to ask what journals publish articles about aging that I think are of interest to both the geriatrician and the general reader?

Just for fun, I looked at what recent articles were cited in either my blog, Life in the End Zone, or in the one other blog that I read regularly, GeriPal, which stands for Geriatrics and Palliative care and is run and largely written by Alex Smith and Eric Widera, both physicians. What appeared in these two blogs reflected my biases and those of my colleagues at GeriPal. A little introspection about my blog reveals that I try to avoid discussing articles that are getting a lot of publicity already, pieces that have already made it into every leading newspaper unless, of course, I have a dissenting view on those studies. I like looking for interesting sounding articles in journals that most doctors don’t read and for reports on relevant topics that were ignored by the mainstream press. As to GeriPal, the authors describe the blog this way: “It is a forum for discourse, recent news and research, and freethinking commentary. Our objectives are: 1) to create an online community of interdisciplinary providers interested in geriatrics or palliative care; 2) to provide an open forum for the exchange of ideas and disruptive commentary that changes clinical practice and health care policy; and 3) to change the world.” Here’s what I found.

In the six months since the beginning of 2015, GeriPal has posted clinical vignettes and personal ruminations along with summaries and commentaries about new research findings. I counted 13 discussions of articles—11 of them newly published studies. Of these 11, 6 appeared in JAMA Internal Medicine. The others were from 5 different journals: the CDC’s Morbidity and Mortality Report, the Journal of Clinical Oncology, the Journal of General Internal Medicine, and the Gerontologist.

During the same 6 months, I discussed 12 newly published articles (along with various books and reports). My most cited journals were JAMA Internal Medicine (same as GeriPal, but by and large, different articles), with 3 studies quoted, and the New England Journal of Medicine (another 3). The remainder were from 6 different sources: the Gerontologist, the British Medical Journal, the Journal of Medical Ethics, JAMA Neurology, Aging Cell, and Health Affairs.

Are there any conclusions from all this? If you are interested in issues affecting the older population and you only have time to look at only one medical journal, you should concentrate on JAMA Internal Medicine. (Remember that while I only discussed 3 articles from this journal, I deliberately avoided focusing on articles that GeriPal had already referenced.) All told, 9/24 articles were from this one journal. Not a single article from the Journal of the American Geriatrics Society, the flagship journal of the leading American professional society for geriatricians, made it into the list.

Now this is a rather eccentric perspective. Remember that I didn’t survey all articles on geriatric topics and then decide in some systematic way which were most important. All I’m asking is what articles happen to have been chosen by one or both of two blogs, one of which is my own, over the past six months. Just thought you might be interested. And kudos to JAMA Internal Medicine!

Get Old? Who, Me?

Yes, Virginia, there will be a White House Conference on Aging (WHCOA) this year—this July 13. Well, sort of. Congress never re-authorized the Older Americans Act, which provides the statutory framework for the conference. That means no financing and no legislative backing. So just as he’s done with immigration reform, raising the minimum wage, and new automotive fuel standards, President Obama is going it alone. He’s using his limited discretionary funds to host a one-day event at the White House. No delegates traveling from around the country, no opportunity for networking, and probably no major new initiatives. Just a handful of invited speakers and a few webinars with interested individuals calling in from their “watch party” to ask questions.

It’s innovative, capitalizing on technology, social media, and the internet. It’s efficient—no air travel or hotel reservations necessary. It will shine a light on four important areas: healthy aging, long term supports and services, elder justice, and retirement security. The Gerontologist published papers on each of these areas in a special April issue. These papers will serve as the major input, and probably also the output, of the conference. They are thoughtful, articulate articles that collectively offer a vision for geriatric health policy.

It would be small-minded to be critical of what’s not on the WHCOA agenda, given the limited resources available for the conference. Dementia, the single greatest threat to quality of life in advanced age and one of the chief drivers of expensive medical care, didn’t make the cut—but then again the White House already announced the BRAIN initiative (Brain Research through Advancing Innovative Neurotechnologies), an ambitious public/private cooperative enterprise intended to treat, support, and perhaps one day cure, Alzheimer’s disease. Technology in old age—from assistive devices to smart houses to robots—isn’t on the docket. But the very existence of the conference is an impressive accomplishment. It shows ingenuity, imagination, and determination in light of the congressional just-say-no attitude.

Rather than regretting what the WHCOA is not, we should celebrate what it is. It is a testimonial to the recognition that aging is important, that old people matter, and that the US has a responsibility to promote a society to conducive to leading a fulfilling, meaningful life for all our citizens. Congress deserves public castigation for its failure to re-authorize the Older Americans Act which, in addition to providing support for WHCOA also subsidizes home delivered meals, adult day care, congregate meals and caregiver support programs. The average age of the members of the House of Representatives in the 114th Congress is 57. The average age of members of the Senate is 61—which means that before their term expires, many will have reached the age of Medicare eligibility. Dissing aging reveals yet another truth about our do-nothing Congress. It is engaged in a massive denial of aging. 

The denial of aging persists

Congress is still in denial....See upcoming blog post.

Shocking News

Much has been written lately about over-treatment of older patients. Only rarely does anyone suggest that older patients are getting too little treatment, but a new study in JAMA does just that. The reality isn't quite so clear.

The treatment is the implantable cardioverter defibrillator (ICD) and the patients are people over the age of 65 who have had a heart attack and are found afterwards to have a weak heart (defined as an ejection fraction less or equal to 35%). These patients are at risk of sudden death, of an irregular heart rhythm such as ventricular tachycardia, and the ICD is designed to deliver an electric shock if that happens, effectively bringing the patients back from death. By looking at the National Cardiovascular Data Registry, which keeps track of heart attack patients, the authors of the article found that only 8.1% of “eligible” patients actually received an ICD. As a result, they claim, the 92% of patients who didn’t get an ICD were more likely to die than their counterparts who did.

This is a surprising finding in light of the persuasive and cogent argument made by Sharon Kaufman in her recent book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where To Draw The Line. Kaufman makes the case that many high tech treatments come to be seen by physicians and patients as normal and necessary once Medicare agrees to pay for them. The end result for many marginally beneficial, burdensome, and expensive treatments, including the ICD, is that patients just can’t say no. If that's true, why are so few older people getting an ICD? 

Now it wouldn't be the first time that ageism or misinformation prevented older people from getting beneficial treatment. Many years ago, patients who were over a certain age were precluded from receiving clot-busting drugs (thrombolytic therapy) because it was widely assumed that in older age groups, the risks outweighed the benefits. It turned out that clot-busting drugs were actually more beneficial in older patients, basically because their heart disease tended to be severe which meant they stood to gain a great deal from treatment. Elevated systolic blood pressure was likewise once assumed to be normal in the geriatric population, or even desirable in order to improve blood flow to the brain. Studies eventually showed that elevated systolic blood pressure, even in older patients, predisposed to stroke and other unfortunate outcomes, and warranted treatment—though the recommendations about just how much blood pressure should be lowered have evolved over time. Is the ICD implantation rate just another case of bias or ignorance at work?

Dr. Robert Hauser of the Minnesota Heart Institute, writing an editorial published alongside this article, blames our fragmented health care system. He speculates that primary care physicians may not realize that their patients were supposed to get an ICD. The fact that there's supposed to be a 40-day waiting period between the onset of the heart attack and implantation of the ICD contributes to the problem. Hauser suggests that the primary care physician is so frazzled and overburdened that he is apt to neglect to send his patient to a cardiologist. Is this the explanation?

It can’t be the whole story. While patients who saw a cardiologist after hospital discharge were more likely to wind up with an ICD than patients who didn’t, only 30% of the patients who saw a cardiologist had an ICD implanted. Recall that 100% of them were, technically speaking, “candidates” for an ICD. So what else is going on?

Hauser hints at another explanation: “It is possible that some older patients may refuse ICD treatment for personal reasons or because comorbidities such as endstage kidney disease or advanced frailty were considered in the decision regarding ICD implantation.” He doesn't accept this explanation as sufficient, rightly recognizing that patients are very likely to accept whatever technological intervention their physician recommends and that shared decision-making, if it takes place at all, is apt to reflect the physician’s preferences as well as the patient’s. So the problem, if it is a problem, must lie with doctors, too. Physicians are not systematically and emphatically recommending ICD implantation to their older patients. Even the most technologically sophisticated academic medical centers only implanted ICDs in 16% of their eligible older patients. But is this a problem that needs fixing, like under-treatment of heart attacks with clot busters and inadequate treatment of high blood pressure in the past?

Dr.  Hauser believes it is, saying “even though the use of ICD for primary prevention may not seem to make as much sense for an 80 year old patient as it does for a patient in his 50s or 60s, an older patient at risk for sudden cardiac death should have the same opportunity to choose potentially lifesaving therapy.” But the benefits of ICD in those over 80 are far from clear. The studies include very few people in this age group. What data there is indicates that there is little if any survival benefit. Moreover, ICDs implanted in older people fire erroneously half the time. That means they deliver a very unpleasant electric shock to the hapless patient. In addition, if the ICD does work as intended, what that means is the abolition of sudden death. 

Maybe, just maybe, the low rate of ICD implantation in older people is a refreshing instance of massive civil disobedience—of both patients and doctors refusing to abide by prevailing clinical guidelines. We all have to die of something. An ICD virtually guarantees that the something will involve a protracted period of decline and suffering. If you had to choose between cancer, Alzheimer’s disease, and sudden death, which would you pick?