June 10, 2019

Caveat Emptor!

Quite by accident, I stumbled upon Kurt Eichenwald’s memoir in the new book section of my local library. I remembered the author from his work as an investigative reporter who uncovered massive white collar crime. His book, The Informant, about just such a scandal, became a best seller and a movie starring Matt Damon. When I realized the new work had a medical theme, I was intrigued; when I discovered that much of the story unfolded at Swarthmore College, where Eichenwald had been a student, and where I had been a student some years earlier, I decided I had to read it.

At first glance, you might think that A Mind Unraveled has no relevance for geriatrics. The diagnosis and misdiagnosis of Eichenwald’s temporal lobe epilepsy as well as the shockingly misguided treatment by ostensibly reputable physicians all took place in the early 1980s, when the author was a teenager or in his early twenties. Unfortunately, the book’s messages are all too relevant for older patients today. Distilled to their essence, those messages are first, that not all doctors are created equal and second, that communication is key. The long, complicated, and riveting story of lying, arrogance, and sheer incompetence that led to those conclusions is worth reading. I read the entire 380-page book in a single weekend, devouring it much as I would a spy thriller.

The not-all-doctors-are-created-equal conclusion is particularly relevant to older individuals because even physicians who are competent within their sphere of expertise often have little knowledge or understanding of geriatric issues. In my last post, commenting on recent data indicating that despite all we have learned about preventing falls, older people are falling—and injuring themselves—at higher rates than ever before,  I suggested that a critical weakness of prevailing fall-prevention systems is that they hinge on the knowledge and interest of physicians, both of which are often absent. Identifying a physician who is a good diagnostician, a kind person, and who actually knows about falls, confusion, polypharmacy, cognitive impairment, incontinence, and other common geriatric syndromes is imperative, particularly for frail older people. Finding such a person can be challenging, and being confident s/he has the requisite expertise is also challenging. Board certification in geriatrics is one indicator; working with a multidisciplinary team including a nurse practitioner is another; word of mouth is a third. Trial and error may prove the only way to be certain you have found the right person: come to your first appointment with a checklist of topics the physician should be sure to address such as functional status and advance care planning. If the physician doesn’t address those issues during an annual physical exam, absent a compelling need to focus on an acute medical problem, it’s probably time to find someone else.

The communication-is-key conclusion is relevant to all physician/patient interactions, but is especially important for older people, many of whom have hearing problems or cognitive impairment. It took multiple tries before Eichenwald found a neurologist who understood that given that all the medications used in the treatment of epilepsy have potential side effects, choice of which drug to use involves balancing risks and benefits. The patient’s preferences, which side effects s/he finds tolerable in exchange for how much benefit, are essential in making a choice of drugs. For geriatric patients, the role of preferences is often paramount in medical decision-making. The assumption that the goal of treatment is cure may simply not apply to an 88-year-old with multiple medical problems; maintaining or bolstering his ability to remain independent may, for example, outweigh the benefits of disease eradication. Or cure may be irrelevant, as with some cases of prostate cancer, if the odds are that the patient will die of some unrelated problem long before his prostate cancer metastasizes, but the risk of surgical treatment causing incontinence or impotence now is great. 

Regrettably, the dismissive attitude of Eichenwald’s physicians to him as a person are all too familiar to many older individuals. Just as many of the neurologists in A Mind Unraveled failed to take their patient seriously as a person with anxieties, concerns, and understanding, so too do physicians often neglect to treat their older patients with respect and sensitivity. To find a physician who listens you cannot rely on board certification. Word of mouth can help (if the mouths belong to people you trust, preferably people whose personalities and medical problems are similar). But once again, trial and error may be the best path. Don’t hesitate to use yourself as a barometer. Only you can gauge whether you “clicked” with the physician. Just as you should be reluctant to listen to the shoe salesman who assures you that those very uncomfortable shoes will improve with time, you should ignore at your peril the internal voice that tells you to stay away from a particular physician.

I would like to believe that Eichenwald’s experience was highly unusual. Most physicians who treat epilepsy know that a negative EEG doesn’t mean there’s no seizure disorder (but the presence of characteristic electrical changes indicates there is). Most physicians would monitor blood counts when prescribing a medication that has a “black box warning” from the FDA stating that the drug can cause life-threatening bone marrow depression and that regular blood tests are required. No competent clinician would offer a diagnosis of a brain tumor based solely on a few of the patient's behavioral quirks. And I haven’t even touched on the arrogance and prejudice that animated members of the Swarthmore administration, leading to their expelling young Eichenwald—and then readmitting him when faced with the prospect of what for them was an unwinnable suit charging civil rights violations (in particular, violation of Section504 of the Rehabilitation Act of 1973 requiring educational institutions to meet the needs of students with disabilities). 

We can only hope that the behavior described in this memoir is extraordinarily rare in colleges and universities today. But we do know that just as systematic racism persists today, so too does systematic ageism. Caveat emptor! 

June 06, 2019

Our Downfall

Falls have long been known to be a major problem among older people. Even when they don’t cause chronic disability or death, a single fall can lead to paralyzing anxiety. The medical costs alone, for hospital care, rehab, and post-acute care, are enormous: one estimate is that they reached $50 billion in 2015. But despite significant advances in knowledge about fall prevention, new data indicate that the problem is getting worse. In fact, a short “research letter” in JAMA indicates that age-adjusted mortality from falls among people aged 75 and older roughly doubled between 2000 and 2016. 

The data are shocking. The age-adjusted mortality rate from falls for men over 75 went from 60.7/100,000 in 2000 to 116.4/100,000 in 2016. For women, the numbers are even more dramatic, with age-adjusted mortality for those over 75 going from 46.3/100,000 in 2000 to 105.9/100,000 in 2016. 

To understand just how bad things are, it helps to break down the statistics by both age and gender. The overall crude mortality rate for individuals over 75 (2016 data) was 122.2/100,000. For the youngest cohort, those ages 75 to 79, the age-adjusted rate is 42.1/100,000 (52.3 for men). For the 80 to 84-year-old set, the age-adjusted rate doubles to 88.9/100,000 (105.8 for men). For the oldest old, the numbers are extraordinary: going from 171.2/100,000 for those 85 to 89 to 362.5/100,000 for the 90 to 94-year-olds to 630.8/100,000 for those age 95 or older. And the corresponding age-adjusted rates for men are even worse, ranging from 205.2/100,000 to 762.8/100,000.

With statistics like these, you might think no one has a clue as to how to prevent falls. You would be mistaken. Entering “fall prevention in the elderly” as a search term in Google Scholar for the period 2000-2016 yields 18,000 hits. The articles have titles such as “randomized controlled trial of falls prevention” and “falls and their prevention in elderly people: what does the evidence show?” The American Geriatrics Society and the British Geriatrics Society issued a joint clinical practice guideline for the assessment of fall risk and preventive strategies in 2010. Two years later, the CDC decreed falls in older people a major public health problem issue and released a variety of evidence-based materials to help physicians, patients, and families address the problem. Calling their program STEADI (Stopping Elderly Accidents, Deaths, and Injuries), they offered, at no charge, a provider tool kit, a detailed algorithm and a handy pocket guide for clinicians, and a patient information sheet. 

Strategies to diminish falling in older people continue to proliferate. The American Hospital Association along with two other organizations came out with recommendations for addressing the problem in hospitals, where falls are also a major problem: between 700,000 and one million people fall in US hospitals each year and about one-third suffer injuries from their falls. As many as 11,000 people die as a result of the fall.  

The Centers for Medicare and Medicaid Services concluded that falls are preventable—and decided to penalize hospitals if a patient falls and either dies or sustains a serious injury as a result. Medicare considers such falls to be “never events” and will not reimburse hospitals for any additional costs associated with falls.

And yet, despite the research, the policies, and the programs, fall rates are rising, not falling. The burning question is, why?

Analyses of the obstacles—and successes—encountered when health systems tried to implement STEADI are revealing. When Oregon Health Sciences University introduced the program in their primary care clinics, they found the single most important factor conducive to adoption was the presence of clinical champions at each site. These clinicians spearheaded a team effort to develop a clinical workflow, customized for their site. They were also empowered to commission the development of electronic health record tools to document screening and assessment of falls. Other programs similarly reported that without strong endorsement by clinical leadership and the resources to implement and document fall-related activities, the initiatives were dead on arrival.

But if we examine the STEADI algorithm for fall risk screening, assessment, and intervention, we can identify other barriers. 

Falls often have multiple interacting causes and the most successful interventions tend to be correspondingly multidisciplinary. But medicine is much better at dealing with isolated problems than with messy, multifactorial ones: high blood pressure? Take a pill. Pneumonia? Use an antibiotic. 

Now look at the screening that the clinician is supposed to carry out. If a patient answers yes to any of a few key questions, the clinician is supposed to evaluate gait, strength and balance. That means performing a “timed up and go” test and possibly a 30-second chair stand or 4-stage balance test. How many internists or family physicians know what these tests are, let alone routinely perform them.

Then consider the kinds of interventions that STEADI suggests. For high risk patients, the recommendation is to refer to enhance mobility and improve balance, optimize vision, optimize home safety, and address foot problems. For all practical purposes, that means referring the patient to physical therapy, to ophthalmology, to occupational therapy, and to podiatry. Only rarely will a physician be equipped to do any of these things themselves. What’s left? Educate patients—another activity that physicians often delegate to others. Prescribe vitamin D and calcium—controversial these days. Manage and monitor hypotension and medications—the only activities that fall within the orbit of the typical internist or family physician.

What we see here is a profound educational deficit. What’s worse, few of these deficits are skills that physicians are likely to find interesting to acquire. I would argue that what most physicians are excited about is learning about prescribing new medications and using nifty new technology. As a whole—and of course there are exceptions—physicians are less enamored of low tech, low complexity interventions, especially when they deem them to lie outside the bounds of medicine. Advance care planning, which rests on communication skills, has similarly been an area that physicians have been reluctant to engage in. So, if the problem is largely cultural, then strong leadership and a supportive electronic health record, while necessary, are not going to suffice to fix it.

What is the way out? I think two strategies could make an enormous difference. First, nurse practitioners and physician assistants should educate themselves in fall risk screening, assessment and intervention and medical practices should gratefully turn to them for help. Second, patients and families need to clamor for falls assessment. In this era of consumer pressure, what the customer wants may be the key to change.