Right diagnosis, wrong treatment

This past week, frailty came out of the closet. The NY Times ran an op-ed about people who aren’t dying and who aren’t thriving. They’re old, they typically have multiple medical problems, and they need help with some of the basics we must deal with to get by every day. They are the people I write about all the time in this blog. Marcy Houle bravely brought this neglected population to public attention, telling a story about her orthopedic surgeon-father-with-Alzheimer’s disease who broke his hip. 

Kudos to Houle, a writer, wildlife biologist, and adult daughter, and to the Times for breaking a taboo and talking about frail elders. But while the diagnosis is correct, the treatment is not. The article asserts that what we need is more geriatricians. Houle's father saw a geriatric specialist who prescribed pain medication for him after he had a hip fracture, and suddenly he perked up, he was more alert and more himself. His daughter writes that he was able to “escape the land of the pink bibs,” her picturesque way of referring to the dining room table where he sat with others in his nursing home, staring into space. (In my father's nursing home, they have banned bibs, on the grounds that they are demeaning. Instead, the residents doze at the dining room table for hours, their shirts encrusted with the remains of their last meal, until it's time for the next meal.) In fact, Houle's father still had Alzheimer’s disease. He was still frail. His quality of life was better than it had been, which is terrific, but he was still in that zone between robust aging and dying, even if he had improved enough that he didn’t need to wear a pink bib. He benefited from the advice of a skilled physician with geriatric training, but for him to receive optimal treatment on an on-going basis, he will likely need more than a one-time geriatric consultation. And the kind of care that he, along with the millions of others like him, will need involves something other than just a good doctor.

We’re not going to transform the care of frail elders by increasing the number of geriatricians. As Houle rightly points out, there are fewer than 8000 geriatricians in the US and the number is decreasing, not increasing, even though by 2050, there will be an estimated 90 million Americans over age 65, of whom 19 million will be over 85. Geriatrics has been a specialty in the US since 1988—at least, that’s when the first certifying exam was offered, though that examination does not actually confer full specialty status. Passing the exam means receiving a Certificate of Added Qualifications in Geriatric Medicine, which doesn’t have quite the ring or the reputation of subspecialty status. It is analogous to subspecialties such as Nephrology or Cardiology (or for that matter, Palliative Care) without the cachet. 

The number of physicians taking the exam each year it is offered has been decreasing, reflecting the reality that fewer young doctors are seeking the extra year of fellowship training now required to sit for the test. Slots in geriatrics fellowship programs regularly go unfilled. It's just not a very attractive field to many doctors emerging from medical school and residency addicted to curing people and with a mountain of debt. Not only does Geriatrics pay poorly—internists who spend an extra year doing a geriatrics fellowship find their salary is, on average, lower than that of general internists who don’t do a fellowship in anything—but most of the healthcare systems in which geriatricians practice medicine are not conducive to providing high quality care. They should be interdisciplinary, they should have geriatric-friendly offices and examining tables, they should facilitate integration of care across multiple sites (office, hospital, rehab), and they should offer home visits. A few innovative programs do just that, including GRACE (Geriatric Resources for Assessment and Care of Elders), designed at the University of Indiana, and Guided Care, pioneered at Johns Hopkins; most practices do not.

We know how to remedy the situation. The Institute of Medicine got it right in 2008 when it issued its report, Retooling for an Aging America: Building the Health CareWorkforce. The IOM advocated a 3-prong strategy: enhancing the geriatric competence of the entire workforce (which includes lawyers, architects, and urban planners along with personal care attendants); recruitment and retention of geriatric specialists (which includes informal caregivers along with doctors and nurses); and improving the way care is delivered (redesigning the system to provide coordinated, multidisciplinary care). That's what we need to do. Some institutions are beginning the process:  the Faculty Program to Advance Geriatric Education, a novel curriculum in use at a number of medical schools, focuses on geriatricizing internists rather than on producing more specialists. 

Simply minting more geriatricians, even if we knew how to attract more physicians to the field, will not be sufficient. We all need to retool to face the coming demographic reality.

You probably didn’t know that tomorrow is World Alzheimer’s Day—I certainly didn’t. And you probably weren’t aware of the recently released report, “World Alzheimer Report 2015: The Global Impact of Dementia—An Analysis of Prevalence, Incidence, Cost, and Trends,” released last month, since it wasn’t mentioned in the NY Times or the Washington Post or the Wall Street Journal. The only reason I know about it is that I happened to see it mentioned when I was scanning the prominent British journal, the Lancet, looking for something to write about in this blog. The British seem to be far more attuned to global health than we in the US: for example, they spearheaded the “Global Action Against Dementia” G7 conference held in Geneva in May, 2015. So what exactly did the new report have to say?

Worldwide, there are now an estimated 46.8 million people with dementia. In sheer numbers, that translates to 9.4 million in the Americas, 10.5 million in Europe, 4 million in Africa, and 22.9 million in Asia. The doubling time for this relentless, progressive, degenerative brain disease is approximately 20 years. Most of that growth is due to population aging—the forecast assumes that the incidence and disease duration will remain unchanged. What is most striking is the shift towards low and middle income countries (what the cognoscenti call LMICs): right now 58% of the world’s demented people live in that part of the world; by 2050, the prediction is that 68% will. What can we do about this?

What we can do is a reflection of the reality that dementia is as much a social issue as a medical one. In fact, only 20% of the $818 billion price tag associated with global dementia care today is for direct medical care; another 40% is for social care (nursing homes, personal care assistants, etc), and the final 40% is for informal care. But most of the lower and middle income countries do not have the infrastructure needed to care for the increasing numbers of older people with disabilities of any kind, including dementia. They don’t have the long term care institutions, the community organizations, or the assistive devices they need to provide a decent quality of life to the afflicted and support for their families. 

So what does the report come up with by way of solutions? The recommendations for action focus on prevention, treatment, cure, and palliation. We have to try to prevent or postpone dementia: lowering cholesterol and blood pressure, decreasing smoking and increasing exercise can diminish the vascular component of dementia or at least delay its onset to older ages, resulting in the “compression of cognitive morbidity.” We have to search for a cure by ramping up research and promoting international collaboration: the Global Action Against Dementia conference set as a target cure or disease-modifying therapy by 2025. And for all those who have dementia today, and those who will develop this devastating illness over the coming decades, we need housing, caregivers, and “dementia-friendly communities.”

A report  by the US State Department in conjunction with the National Institute on Aging, "Why Aging Matters: A Global Perspective," made clear that global aging, while it represents a human and public health triumph, also carries the threat of economic destabilization, as workers leave their jobs to care for aging relatives, resulting in decreased productivity and falling GDP. As I wrote in my blog post of exactly a year ago about the coming demographic shift in which the number of people over age 65 will exceed the number under age 4, “We do not need to accept the doomsday scenario of massive workforce shortages, asset market meltdowns, economic growth slowdowns, financial collapse of pension and healthcare systems, and mass loneliness and insecurity. But we do need to take steps now.”

Global aging in general and the dementia epidemic in particular demand our attention. The US can take the lead: in biomedical research, with the goal of developing treatment for dementia, in bioengineering, with the aim of designing technology to assist in the care of those with either physical or cognitive disability, and in social research, to provide the systems and the strategy needed to maximize the quality of life both of patients and their families.

Bet You Didn't Know...

Monday is World Alzheimer's Day. Read about the new report on global Alzheimer's in my next blog post.

And the Winner is...

It was fascinating to see how different media outlets responded to the latest “Globe Age Watch Index.” CBS News, which may have had rankings on the mind, given that US News and World Report just released its 2016 college rankings, leaves us dangling, entitling its article, “10 Best Countries to Live in for People Over 60.” The New York Times worries about all those countries that didn’t make it into the report—98 of them, accounting for just under 10% of the world’s population, leading off with the somewhat cryptic “Older People are Invisible in Key Data.” And the Guardian collapses the entire 29-page report to one number, telling us “It’s official—Switzerland is the Best Place to Grow Old.” So what exactly does the report say and what is there to say about it?

The rankings are based on four measures that the report’s authors say represent core issues of concern to older people. These are income security (which is a function of pension coverage, poverty rate in old age, and standard of living); health status (which is based on life expectancy at age 60, healthy life expectancy at age 60, and psychological well being); capability (which is defined in terms of employment level and educational status of older people, meant to serve as proxies for engagement and human capital); and enabling environment (which is assessed based on access to public transportation, physical safety, and social connections).

What the report finds is that among the 96 countries for which sufficient data was available, twenty are in the top quintile. The US is number 9, with Switzerland, Norway, Sweden, Germany, Canada, the Netherlands, Iceland, and Japan ahead of us, though not by much. The composite ranking is much less interesting than the component sub-scores. If you look beyond the overall ranking, you find that the US is 29 in income security (which would eject it from the top quintile if that were the sole indicator); it is 25 in health status (diito), and 17 on enabling community. In fact, the only area where the US performed very well was capability—which reflects the fact that it measures employment in people aged 55-64, and Americans seldom retire early unless they’re compelled to. So the picture for the US isn’t exactly rosy. What would be more interesting would be to look at similar indices for people who are over 70 (or at least for people over 65).

But the really important message isn’t how the US looks, however sobering that might be. The crucial message is that the rest of the world isn’t doing so well and the gap between the elderly in rich countries and those in poor countries is growing. Also disturbing although hardly surprising is how poorly countries are doing that are in conflict zones, countries including Afghanistan, the West Bank and Gaza, and Iraq. China, which is facing an imminent explosion in the size of its older population (and a dwindling supply of younger people to take care of them), is smack in the middle of the distribution, at 52. Greece, which is economically if not physically under siege, is way down at 79. Also in the fourth quintile, along with Greece, are Ukraine (73) and Russia (65). 

Yes, there is quite a bit of missing data here (though we can guess that the elderly aren’t doing well in Syria and Yemen and many of the other places that didn’t provide information) and yes, we can quibble with the specific measures that were used, although the basic categories seem reasonable. And in general, I’m not a fan of rankings (see for example, my commentary about Nursing Home Compare). But if used to identify which areas are in particular need of attention, I think the report is useful. For the US, that means health status and income.

Paradise on Earth?

Where's the best place on earth for older people?
Coming soon...

Paradigm Shift?

The most powerful explanatory model in medicine is the germ theory of disease. It’s simple and it’s elegant: find the offending microbe, kill it, and cure the disease. This approach has led to some of the most dramatic and effective advances in medical history: identifying the leading cause of pneumonia (the pneumococcus bacillus), finding a chemical that kills the bacteria without harming people (penicillin), diagnosing disease (by some combination of physical examination, a chest x-ray, and examination of sputum under the microscope), and treating the patient with antibiotics. The result?  Pneumonia cedes its place as the leading cause of death in older people to heart disease. 

Life has turned out to be a bit more complicated than the germ theory suggests. Expose a group of people to exactly the same dose of a microbe and not all of them will get sick. Of those who do become ill, not everyone is equally sick. Other factors proved to matter, ranging from the vigor of the patient’s immune system to socioeconomic status. And pneumococci were not the only causes of pneumonia: all kinds of other bacteria can cause much the same clinical and radiographic picture, as can a whole host of viruses. Even with our enhanced understanding of the causes of disease and of how and why illness develops in different individuals, we haven’t been able to eradicate pneumonia. Together with influenza, it’s still the seventh leading cause of death in older people.

These caveats mean we’ve had to refine the model, to elaborate on it. But the germ theory of disease still stands as the gold standard for all of medicine. Doctors in areas under than infectious disease seek to find a similar master key that unlocks the diseases of their particular organ system. Cardiologists have focused on atherosclerosis as the unifying feature underlying coronary heart disease; neurologists have seized on amyloid as the basis for Alzheimer’s disease. But the reductionist view of the world seems to break down when it comes to geriatric syndromes, problems such as falls and incontinence that are responsible for so much misery in older people. What seems to explain reality more effectively is a multifactorial understanding. Maybe that’s why even though last week’s JAMA includes two reports of failed efforts to stave off Alzheimer’s disease, one with anti-oxidants taken as nutritional supplements, and one with exercise, the editorial accompanying the articles optimistically maintains that we can make a difference. We just have to eat well and exercise and play mind games.

Now there are a number of possible reasons that the JAMA studies may have been unable to find any benefit of their interventions. The anti-oxidant study was carried out in older patients with macular deterioration, a chronic eye disease. Its main hypothesis was that supplements would stave off progressive visual loss—preventing cognitive impairment was a secondary aim. Conceivably, people with macular degeneration are sufficiently different from the general population that what works, or doesn’t work, for them may not be the same as for everyone else. The trial used pills, not diet rich in anti-oxidants, and there are at least some nutritionists who maintain that the purified version of a chemical won’t work the same way as that chemical in combination with food. The exercise study used moderate intensity physical activity such as walking, it used resistance training, and it used flexibility exercises, which it compared to an educational program. It’s at least possible that other kinds of exercise, or exercise of different intensity or duration, would have been more effective. 

The commentary in JAMA, written by a psychiatrist and an internist from Ontario, Canada, mentions these possibilities. But it also seizes on a different study, one of the few encouraging ones in a field littered with negative results. And that is the FINGER trial, a multifaceted intervention involving diet, exercise, and cognitive training in Finland in people aged 60-77. After two years, there were measurable benefits to the study population as determined by psychological testing. So despite the negative findings of the two studies they are charged with reviewing, the editorialists put on their rose-colored glasses and assert that “it is still likely that lifestyle factors such as diet and physical activity have important roles in the prevention of cognitive decline, dementia, and performance of the activities of daily living.”

There is precedent for a multifactorial intervention working when no single approach succeeded. In her path-breaking work on falls, Mary Tinetti of Yale found that fall rates in community dwelling older people could be significantly decreased if they had an evaluation that focused on physical hazards (throw rugs or poor lighting), on a medication review (getting rid of drugs that cause orthostatic hypotension or confusion), and on strength training. Similarly, Sharon Inouye, now at Harvard, recognized that delirium in the hospital is difficult to prevent, but found the most effective strategy involved a multi-component intervention targeting sleep, mobility, vision, hearing, cognition, and fluid intake. 

So maybe we can make a difference in preventing dementia or delaying its onset or slowing its progression. Maybe the recent meta-analysis that was widely quoted in the media (published in the somewhat obscure Journal of Neurology, Neurosurgery, and Psychiatry) as claiming that “modifiable risk factors” are responsible for 2/3 of the risk of Alzheimer’s disease is onto something. Or maybe it’s all wishful thinking and we should redouble our efforts to look for the magic bullet, the switch that we can turn off amyloid deposition in the brain, stopping dementia before it starts. Or maybe we just have to do something. Eating vegetables, going for walks, and doing crossword puzzles won't hurt. They don't cost a lot of money. They won't jack up the cost of American health care. And in combination, they just might help.

La Vie en Rose

Seeing life through rose-colored glasses. For more, see blog post this weekend.