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.

They All Add Up

With so much attention rightfully devoted to big ticket items in medicine such as the new drug for hepatitis C that costs $1000 a pill or high tech devices such as the continuous flow left ventricular assist device, which costs on average about $200,000 to insert, not many people are talking about the little ticket items. But the reality is that spending a small amount per person on a huge number of people adds up to just as much—or maybe more—than spending an enormous amount  per person for just a few individuals. So I was very pleased to see a research letter in JAMA Internal Medicine about that lowly test, the urinalysis. 

I was pleased that the authors looked at the consequences of the rampant ordering of urine tests in people with no symptoms suggestive of either an infection in the bladder or kidneys or acute kidney dysfunction, the only circumstances in which urinalyses have been found to be meaningful. The reason, quite simply, that most urine tests are useless or, as the article suggests, actually harmful, is that the majority of older people have bacteria in their urine. What this means is that the injudicious ordering of a urine test will far more often produce a “false positive” result than a “true positive.”

It so happens that twice in one morning of seeing patients this week, I was asked to order a urine test for no good reason. To be fair, the well-meaning daughters of the patients who requested the test, quite insistently, I might add, thought it was with good reason. Their mothers were being diagnosed with dementia, a condition that had developed insidiously over a period of at least a year and probably several, and they were hoping I would identify a “reversible cause” of this otherwise progressive, ultimately fatal illness. Neither patient, however, had any symptoms to suggest a bladder infection: they did not have burning on urination, they did not have urinary frequency, they had no fever or flank pain. One lady was 96; the other was 91. Since the majority of elderly women have bacteria in their urine, I was concerned that if we got a sample from these two (no mean feat if we wanted a “clean catch” specimen, uncontaminated by bacteria from the surrounding skin and from stool), it would show bacteria. But if we did anything with the result—and what was the point of getting the test unless we were planning to treat the ladies in the vain hope that a course of antibiotics would cure their dementia—we would do little more than expose them to a risk of another problem such as clostridium difficile colitis, a potentially serious, occasionally lethal infection common in debilitated older people that typically results from killing off other bowel bacteria with antibiotics.

So what did the new study find? The authors looked at 403 consecutive adult patients admitted to the general medical service of a hospital in 2014 and 2015. They found that in this group, who somewhat surprisingly had a median age of 79, 62% had a screening urinalysis at the time of admission. Fully 84% of these individuals lacked any symptoms suggestive of a urinary tract infection. Of the asymptomatic patients who were screened with a urinalysis, 30% had a positive test. Of those with a positive test, 22% were treated with antibiotics.

Maybe this is actually reassuring: only 30% of asymptomatic patients had bacteria in their urine, not the 90% the authors quote from the literature. And only 22% of the asymptomatic patients with a positive test were given antibiotics, not everyone. 

The research letter in JAMA Internal Medicine leaves many questions unanswered. We don’t know why so many asymptomatic patients had a urine test ordered—perhaps the physicians believed that the fall or fainting episode that triggered the hospitalization was in fact caused by a bladder infection, which is conceivable, even if dementia (what my patients suffered from) is not. We don’t know what proportion of those who were needlessly treated developed complications because of the antibiotics they received. We can’t measure just how much the injudicious use of antibiotics in situations such as this contributes to the development of bacteria that are resistant to multiple antibiotics, bacteria that go on to cause real disease that is phenomenally difficult to treat. 

We do know that there are over half a million people age 65 and over hospitalized each year according to the National Hospital Discharge Survey. If over half of them have an unnecessary test, and if a third of those tests are positive, and a fifth of those positive tests lead to potentially risky treatment, that’s still a lot of bad decisions. All those small ticket items add up, and we need to pay attention to the little decisions we make every day, not just to the big decisions we make once in a while.

Those Small Ticket Items

Those small ticket items can really add up--see blog post coming this weekend.

Palliative Care Comes of Age

Last week, the New England Journal of Medicine published a short review article entitled “Palliative Care for the Seriously Ill.” Eleven years ago, the NEJM also published a review of “Palliative Care,” at that time putting it in the section of the journal called “Clinical Practice.” What has changed over the decade? What has remained the same?

Comparing and contrasting the two short articles, both of which emanate from the Mount Sinai School of Medicine, reveals some interesting changes. Perhaps the first change worth noting is that the Mount Sinai School of Medicine is now the Icahn School of Medicine at Mount Sinai. That a venerable school of medicine should now be named after a business magnate known as a ruthless corporate raider instead of after the alleged birthplace of the Ten Commandments says worlds about developments in the field of medicine. Palliative care itself has been affected by the widespread corporatization of medicine, with 2/3 of all hospice providers for-profit in 2013, compared to 5% in 1990. But the article rightly concentrates on describing the field of palliative care rather than one specific program, hospice care. The authors carefully distinguish between the population who stand to benefit from palliative care--those with serious illness--and those who may benefit from hospice care--those who are in the last months of life.

What stood out reading the new and older articles side by side is that in 2004, Morrison and Meier were at pains to explain the rationale for the very existence of palliative care. They emphasized the under-treatment of symptoms such as pain, delirium, and nausea in very sick patients. They discussed the fixation of American medicine on cure, even when cure was not possible, and the false dichotomy between cure and comfort. In 2015, Morrison, writing this time with Kelley, a young colleague (also a marker of change as a new generation of physicians rises to prominence in palliative medicine), do not feel the same need to justify palliative care. To the extent that they do feel obligated to explain why palliative care should exist, they provide data, itself a welcome development over the past decade, offering a graph showing the prevalence of ten specific symptoms in advanced illness, broken down by disease category (cancer, congestive heart failure, chronic obstructive pulmonary disease, advanced kidney disease, dementia, and AIDS).

Another area discussed in some detail in the new article but scarcely mentioned in 2004 is the various delivery models for palliative care. Ten years ago, palliative care consisted principally of in-hospital consultation and of home-based hospice. Today, it is both of those but it is also increasingly provided in the outpatient arena and in the nursing home.

The discipline of palliative care is much the same today as it was a decade ago: it is based on the three-legged stool of communication (which includes establishing the goals of care and planning for the future), symptom management (which addresses symptoms from pain to constipation), and psychosocial and spiritual support (which is targeted to families along with patients). But it has grown into a mature field with a small but robust and burgeoning research base. It is an interdisciplinary form of care that offers an “added layer of support” to conventional care (words chosen from market research done by the Center for the Advancement of Palliative Care); it is for the “seriously ill,” (as the authors quietly insert into the title of their article), not just for the dying; and it is for people of “any age,” not just for older people (who seemed to be the primary target in the earlier article that emphasized the graying of the population).

The field has made remarkable strides. I have just one nagging concern. In its eagerness to view palliative care as a supplement to rather than a replacement for conventional care, the field has a tendency to ignore the important truth that when palliative care clinicians review the prognosis and the options with patients, the conclusion may well be that less is more. And in its excitement over the surprising finding in one important study that patients with palliative care may actually live longer than those receiving usual cancer care, the field glosses over the importance of making trade-offs between life-prolongation, comfort, and maximizing function. Sometimes, to be sure, there are no life-prolonging options: the aggressive chemotherapy that oncologists offer and patients seize upon simply won't work and may paradoxically shorten life. But sometimes--and I would argue more often--there is a potentially life-prolonging option. That course of treatment, however, is typically very risky. Its likelihood of succeeding may be extremely small and its probability of causing misery extremely high. What palliative care does in this scenario is to lay out the alternatives and figure out which makes most sense for a patient and family in light of their goals of care. What palliative care does not do, however, is deny the importance of making trade-offs. 

Perhaps when the New England Journal publishes a review article about palliative care in another ten years, the authors will not feel the need to view the field as an add-on, but rather as the more realistic and comprehensive approach to the management of advanced illness. The truth is that most of the diseases that kill people today--heart disease, many cancers, and dementia, for example--are chronic diseases. They cannot be cured. All treatment for these conditions is inherently palliative. Cardiologists, oncologists, and neurologists all practice palliative care all the time; they just don't do as good a job as they might. Here's to Palliative Care 3.0!