The Deciders

Shared decision-making has become something of a sacred cow in medicine, even though few physicians actually practice it. There is certainly evidence that patient participation in discussions about their health care and patient engagement in self-care lead to better outcomes, as well as to greater patient satisfaction. Promoting patient autonomy requires that patients play a role in shaping their fate. So some kind of patient involvement is decidedly a good thing. But shared decision-making, I argue in an article just published in the Journal of Medical Ethics, needs to be re-engineered for it to work in practice.

To be sure, not everyone means exactly the same thing by shared decision-making. But most of the definitions look like this one, offered by a leading proponent and expounder of the model: shared decision-making is an approach in which the patient receives information about available treatment options (including their risks and benefits), the clinician and the patient consider each one in light of the patient’s situation, goals, and preferences, and the two parties jointly select the best option.

The focus of all this deliberation is the selection of a treatment. Which treatment to provide is what the doctor needs to know. And the reason for involving patients in the decision-making is that, unlike in selecting which antibiotic to use in the treatment of pneumonia, which is strictly a technical decision, deciding whether to use chemotherapy or radiation for the treatment of cancer, or whether to use fourth line chemotherapy or hospice for treatment of cancer when it progresses to a very advanced stage, depends on the patient’s values. But what I suggest in my essay is that respecting patient autonomy requires eliciting those values. Once the doctor understands the patient’s goals, once he or she knows what is most important to the patient, that information constitutes data that goes into the decision about treatment along with other data involving outcomes, side effects, and probabilities. To ask the patient to draw conclusions about which treatment is best, rather than to have the doctor make a recommendation based on a whole raft of information that includes the patient’s input about goals and values, makes no more sense than providing a patient with data about antibiotics and then expecting a patient to select which antibiotic he should take for his pneumonia.

I argue that despite several decades of work seeking to overcome the barriers to shared decision-making—barriers such as cognitive biases, innumeracy, and health illiteracy—and despite evidence that sophisticated decision aids can help patients, most doctors and patients don’t like the conventional approach to shared decision-making and don’t use it. Even medical ethicists who believe strongly in honoring patient autonomy and who have traditionally advocated shared decision-making balk when they themselves or their family members develop cancer and the physician tries to implement shared decision-making. 

The approach I advocate doesn't go back to the older paternalistic model in which physicians decree and patients obey; rather, it reformulates the way shared decision-making takes place by suggesting that what needs to be shared is the process of determining the patient’s goals of care, not the process of deciding how to translate those goals, along with other highly technical information, into a treatment decision.

Kissing Consent

Last week was a tough week for humankind. My heart goes out to the hundreds of refugees and would-be immigrants who drowned trying to flee oppression, war, and poverty, and to the thousands of Nepalese who died or lost everything just because they were in the wrong place at the wrong time. But I also ache for the 78-year-old Iowan man accused of rape—and mercifully exonerated—after being intimate, in some form or another, with his demented wife.

It’s always dangerous to discuss a case based exclusively on information from the media or arguments based in court. So I won’t presume to know what actually happened in the nursing home between Mr. and Mrs. Rayhons in her nursing home bed. But I do worry about the well-being of all those who have dementia. And I think that seeking to deprive people with dementia of one of the few pleasures they may still be able to experience in life is tragic.

The pundits have been pontificating that the Rayhon case is all about informed consent. But is it? Since when is informed consent required for anything other than a medical procedure or a research study? The case seems to me to be more about the quality of life of individuals with diminished cognitive capacity and the medicalization of society than about consent.

Informed consent is a tremendously important concept in medical treatment and medical research. One hundred years ago, future Supreme Court Justice Benjamin Cardozo ushered in the modern era of informed consent when he stated forcefully that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body”—and that performing surgery without consent was assault and battery.

The need for informed consent, and the devastating consequences of performing medical experiments without it, were brought home after World War Two, when Nazi experimentation on hapless prisoners was revealed. The Nuremberg Code, promulgated in 1947 in response to the horrors inflicted in the name of science, established voluntary consent as essential to the ethical conduct of research. A mere twenty years later, the anesthesiologist Henry Beecher divulged to the American medical community that research without informed consent was occurring with alarming frequency. As a result, a regulatory framework was put in place to assure ethical conduct by physician investigators, at least among those applying for NIH funding of their work. Voluntariness is the bedrock of informed consent. But what does all this have to do with intimacy between two members of a married couple?

Not much. Sexual intercourse is not a medical procedure. Deciding whether or not to engage in intimacy is not like deciding whether to participate in medical research. It is something that is normal and expected within the context of the marital relationship. Nor do we expect people with Alzheimer’s disease to sign an informed consent form before they have dinner, acknowledging that they are aware of the risks and benefits of the meal they are about to eat. We don’t ask people with Alzheimer’s disease to formally agree to wear a coat when it’s cold out. What business do doctors, nurses, and nursing home administrators—let alone courts and juries—have interfering in the private relationship between two adults? To be sure, not all sexual relationships are voluntary, even within a marriage. People who have dementia are vulnerable and need protection against abuse. But to apply the standard of informed consent to everyday life, a standard meant for people undergoing cardiac catheterization or surgery, or for taking experimental medications of no proven benefit, is profoundly misguided.

We need to broaden our view of how best to approach people with dementia to go beyond a narrow focus on safety. Of course  physicians and nurses and social workers want those in our care to be safe. But many vulnerable older people do not consider safety their paramount concern. They would rather take the risk of falling than be confined to bed. (It’s worth noting that while conventional restraints do not necessarily prevent falls and are in fact associated with injury, surely it would be possible to tie people down using four-point restraints in such a way that they could not possibly get up and fall.) They would rather live on their own, even though they might become ill and have no one with them, rather than forgo their independence. The interest of many, quite likely most, frail or demented older people, is in maximizing their quality of life. And that means interaction with other human beings.

We know that people with dementia experience emotions long after they have lost much cognitive function. We know they respond to a smile or a hug even if they cannot tell you the full name and birth date of the person who is hugging them. Surely to deprive people with dementia of the possibility of intimacy if they are fortunate enough to be in a relationship with a loving spouse, is cruel and unusual punishment. There are other, better ways to protect the vulnerable.

Helping the Other Half

There’s nothing much new in the latest edition of the Alzheimer’s Association Alzheimer’s Facts and Figures, which came out last month. Once again, the report documents that about 43% of people age 75-84 have Alzheimer’s. Since no more than 75% of all dementia cases are due to Alzheimer’s disease, that means that over half of  people in this age group have dementia of one kind or another.

The proportion varies depending on how dementia was assessed and on the ethnic, geographic, and gender composition of the people studied. But despite an enormous amount of effort and much progress in the domain of understanding the pathophysiology of Alzheimer’s disease, the Alzheimer’s Association reminds us that there is no drug available today that slows or stops the death or neurons that causes Alzheimer’s disease.

The federal government’s National Alzheimer’s Project Act and Obama’s BRAIN (Brain Research Through Advancing Innovative Neurotechnologies) initiative are redoubling the effort to find a cure. That would be terrific—though we should remember that the last concerted effort to wipe out a chronic disease, the War on Cancer, was launched in 1971 and is still being fought.

But what about the other half—those older people who don’t have dementia? Is there anything that medicine should be doing special for them?

A new report from the well-respected, non-governmental, non-profit Institute of Medicine released last week addresses this question. Entitled Cognitive Aging: Progress in Understanding and Opportunities for Action, the report makes ten recommendations for collecting data, engaging in research, developing programs, and providing resources that seek to maximize cognitive function in older people who don’t have dementia. It’s an intriguing report, principally because it focuses on what is most important to older people and is the essence of geriatric medicine—function, rather than disease. The authors cite an AARP survey of members in which fully 87% identified “remaining sharp” as one of their major concerns. Older individuals and their families are concerned with optimizing mental performance. They are alarmed by the recently described disorder, “Mild Cognitive Impairment,” a condition that does not meet the criteria for dementia but affects the ability to function in day to day life, whether or not it progresses to full-blown dementia.

The study is also of interest because of it public health angle—it draws attention to the major societal consequences of age-related cognitive decline, things like traffic accidents (as people with impaired judgment or slow reflexes continue to drive) and financial fraud (resulting from impaired decision-making on the one hand and minimal consumer protections on the other). The recommendation to develop assessment tools, educational programs, and improved regulations, as well as alternative means of transportation, have the potential to maintain quality of life for older individuals and to lower costs.

The report makes common-sense suggestions for preventing age-related cognitive decline: being physically active, remaining socially and intellectually engaged and getting enough sleep. Unfortunately, there is no more evidence that these measures will maintain cognitive function than there is that they will prevent dementia. That is, they might help and they can’t hurt. But to suggest that they are proven to be effective is, alas, to overstate the case.

Despite succumbing to the temptation to offer a little bit of hype along with a lot of wisdom, the report’s authors make a valuable contribution by reminding us to pay attention to the other half. Its broad societal focus is welcome, as is the recognition that it is function rather than disease that matters most to the majority of people as they age.

What We Believe

Kudos to the Huffington Post for running an article about the new report from the FrameWorks Institute, “Gauging Aging: Mapping the Gaps Between Expert and Public Understandings of Aging in America.” And shame on the NY Times, the  Washington Post, the Wall Street Journal, and the other major newspapers in America for ignoring it. That’s not entirely surprising since the report is all about the disconnect between public perception and reality, and the media are to a large extent responsible for shaping popular understanding.

The new study does not report the results of an opinion poll. It is not based on trendy focus group analysis. It seeks to understand what both geriatric experts and the lay public believe about aging and the “assumptions and thought processes” that underlie their opinions. The authors, supported by funding from AARP and a variety of foundations including the John A Hartford Foundation and the Retirement Research Foundation, use a “cultural-cognitive approach” to their work. That means they probe, they explore, they question. They do not rely on “big data.”

So what did they find? They learned a great deal about the gaps between the scientific understanding of aging (by which I mean physiologic, medical, psychological, and sociologic) and the public’s view. They learned so much that I will just touch on some of the highlights here.

Attitudes toward aging: the experts see aging as presenting challenges, but also an opportunity for growth and the possibility of continued contributions to society. The public sees aging as the enemy, to be combatted rather than embraced or supported. In particular, aging is thought to bring with it decay and disability; in fact, older people are very heterogeneous.

Root cause of aging: Americans tend to believe that what happens to them is entirely within their control. If they eat right, exercise, and lead a virtuous life, they can avoid the aging process entirely. The truth is more nuanced, with both genetic and external factors playing a significant role. In a similar vein, the public tends to believe that if older people do become disabled or demented and cannot take care of themselves, then their family rather than the government has an obligation towards them.

What we need in order to age well: The experts see a need to create structures to facilitate older engagement—whether opportunities for part time work, better transportation, or more volunteer positions. A related theme is the need, recognized by experts, for new public policy initiatives to modify today’s reality. The public, by contrast, takes the status quo for granted and assumes it’s up to older people to avail themselves of existing options.

There’s more. Maybe I will write more about this subject next week. Better yet, just read the study. And I look forward to future work from the FrameWorks Institute addressing how to change popular perceptions. Maybe they will shed some light on how to modify the public view of climate change and evolution, too.

Chemotherapy for Alzheimer's?

A provocative opinion piece in JAMA Neurology offers new hope for the treatment of Alzheimer’s disease. University of California Santa Barbara neuroscientist Kenneth Kosik begins by acknowledging that recent drug trials have all failed, this despite the fact that that were designed based on the latest understanding of the pathophysiology of Alzheimer’s disease. The most spectacular recent failures were studies of two separate monoclonal antibodies that were expected to selectively attack amyloid deposition in the brain. This approach was so intriguing that scientists haven’t given up on it yet, despite the lack of success so far—just a few weeks ago the drug company Biogen announced the results of a Phase I trial of yet another monoclonal antibody, this one evidently quite promising. But Kosik has a different idea.

Kosik comments that the typical response to the drug trial failures is either to question whether our understanding of the mechanism by which Alzheimer’s is produced is correct or to conclude that treatment of the disease will need to begin before symptoms develop. He suggests that perhaps where we have gone wrong is in believing that Alzheimer’s disease is homogeneous. In fact, he argues, there are many genetic variants. The best known is the APOE alleles, with the APOE4 allele conferring particularly high risk. And of course there are the relatively rare familial forms of Alzheimer’s disease, which involve mutations in any of several chromosomes. Perhaps if we identify a person’s genome, we can find a particular therapy that will work for that person.

This is the approach that is increasingly used in the treatment of cancer, with a handful of notable successes. In non-small cell lung cancer, for example, there are several mutations typically found in younger patients with no history of smoking. Drugs targeted against these mutations have produced excellent results in patients with the relevant mutation: the drugs Erlotinib (Tarceva) and Crizotinib (Xalkori), when used in appropriate patients, can convert what was previously a uniformly lethal disease (usually within a year) into a chronic illness. Will the same strategy work for Alzheimer’s disease?

Maybe. It’s certainly worth pursuing. And Kosik also has ideas about how to proceed with this kind of targeted, individualized treatment—he recommends what are known as “N of 1 trials,” tests of a potentially useful drug in a single patient rather than the conventional strategy of testing a drug in a large group of people. The proposed strategy would both revolutionize the treatment of a particular disease (Alzheimer’s) and change the search process for new drugs. It’s not likely to change the epidemiologic reality any time soon, but it’s more promising than many radical new ideas. Let's hope NIH or other funding agencies have the wisdom to provide the support needed for this innovative work to go forward.

When Push Comes to Shove?

There’s been a lot of talk about advance care planning lately, with Ellen Goodman’s Conversation Project, Atul Gawande’s book, Being Mortal, and very recently, Angelo Volandes’ book, The Conversation. The message: think about what matters to you and discuss with your physician and with your family the approach to medical care that makes sense for you if you become very ill. We know that these kinds of discussions may not lead to the patient’s directive being followed when he or she actually does get very sick—sometimes the advance directive does not travel with the patient to the hospital, often the directive is difficult to interpret in practice (what exactly does “no heroic measures” mean?), and in some circumstances physicians or families override the directive. We know that patients with a medical order such as a POLST (Physician Orders for Life-Sustaining Treatment) are more likely to get what they signed up for than those with a wish statement (for example a living will). What we don’t know much about is whether patients change their minds when faced with an actual illness. A new study examines how often patients admitted to an ICU with some kind of “treatment limitation” in effect nonetheless received the treatment they previously had said they didn’t want.

The answer: about one-quarter of the time.The most common treatment that people specifically said on admission to the hospital they didn’t want was attempted CPR (accounting for 77.4% of the limitations expressed), but 24.6% of them ended up having CPR initiated. Another 21.3% of people said they didn’t want specific therapies such as dialysis or artificial nutrition, but it is not clear from the study just what proportion of them received those treatments. Finally, 3.9% of those admitted said they wanted a focus on comfort. We don’t know what kind of treatment those patients in particular received. All we know is that of the 13,405 patients admitted to one of 141 ICUs at 105 US hospitals between 2001 and 2008 with some kind of treatment limitation request in place, 3123 ended up getting attempted CPR, 3841 got intravenous medicines to maintain their blood pressure, 2660 were put on breathing machines, and 283 got dialysis. Finally, we know that there was considerable variability between hospitals, both with respect to the rate of treatment limitation expressed initially (from 1% to 30%) and to the rate of treatment limitation reversal (2% to 76%). So what does this all this mean?

Since we don’t know what led to the changes that occurred, we can’t know for sure. What is clear that these were not cases where the doctors simply never saw the advance directive. These are all cases in which the plan was not to provide a specific treatment (principally CPR) but the reality was that the order was rescinded and the forbidden treatment was actually administered. So somewhere between entering the ICU and leaving it (whether alive or dead), a major change took place. It could be that when push came to shove, patients changed their minds. When confronted with their own mortality, they chose to have a shot, however small, at living longer. It could be that most of the patients were incapacitated by illness and the actual decision to reverse course was made by a health care proxy or family member—we know from other studies that fully 70% of patients in whom a decision about life-sustaining treatment needs to be made are cognitively unable to engage in decision-making at the crucial moment. It might be that the limitation-of-treatment directive didn’t really reflect the patient’s goals—perhaps what they meant was they didn’t want to spend their life as a vegetable, not that they didn’t want a trial of life-prolonging treatment—and they came to understand that their directive as written should be revised.  Or it could be that patients and families were persuaded to change course because the environment of the ICU promotes life-prolonging treatment and it is very difficult to stick to a plan of care that violates the raison d'etre of the ICU. 

In all likelihood, the answer is all of the above. This study does not imply we should abandon advance care planning. It’s worth pointing out that 75% of patients with treatment limitations in place retained those restrictions. But it does raise questions about whether patients really know what they are signing when they complete an advance directive—whether a traditional living will, a detailed instructional directive, or a POLST form. It makes me even more convinced than ever that we need to focus more strongly on ascertaining the patient’s goals of care when we engage in advance care planning, and leave the translation of those goals into medical treatment to the moment when an actual decision must be made. And it does remind us that hospital culture in general and ICU culture in particular are very powerful. When an institution is structured and staffed to provide life-sustaining care, then treating some patients without using life-sustaining care creates cognitive dissonance. If patients truly want a different approach to care, we should provide an alternative environment in which to deliver that care, either the home or an intermediate facility such as a skilled nursing facility.

Putting the Genie Back in the Bottle

You can’t put the toothpaste back in the tube. You can’t put the genie back in the bottle. You can’t turn back the clock. We have lots of expressions denoting the irreversibility of certain actions. Getting patients to stop taking a particular medication or to abandon a procedure—and persuading doctors to stop prescribing it—seems to be in the same camp. Unless something comes along that’s much better, or at least that the pharmaceutical or device manufacturing company says is much better, we are extremely reluctant to change. A series of articles in JAMA Internal Medicine

discuss this phenomenon, calling it “the undiffusion of established practices.”

One article reports that physicians gradually adopted the practice of tight control of blood sugars in the ICU after a single study showed that patients did better when their blood sugars were as close to normal as possible, but then abruptly gave up the practice after a later study drew the opposite conclusion. A second article describes how physicians jumped on the bandwagon of ordering noninvasive  screening for coronary disease in patients scheduled for non-cardiac surgery, only to discover later that the screening was not beneficial—and the routine use of such testing decreased. A third article discloses that professional medical societies tend to continue to support practices that have been challenged or even debunked if their members believe the practices to be useful.

What does all this tell us about “undiffusion?”  How do we change behavior? One answer is that we should move slowly to adopt something new, whether a medication, a procedure, or a process. We should exercise caution, given the reality that the best new thing often turns out not to be the best. A second answer is to design studies that are better at looking for subgroups that may benefit from a new approach—even if the approach doesn’t make sense for everyone. But I think there’s a lot more to be said about putting the genie back in the bottle, particularly as we begin to recognize that less may be more.

It’s instructive to look at the cases where the genie did go back in the bottle and compare them to the cases in which he didn’t. Consider, for example, the process of tightly controlling blood sugars in the ICU, a practice that physicians readily abandoned. What’s striking about this is that controlling blood sugars very tightly is a nuisance—it means checking the blood sugar four times a day and adjusting insulin doses every time. That’s labor intensive—someone has to do the tests and someone else has to respond to the results. And there’s nothing sexy about pricking a patient’s finger to get a drop of blood. It’s not nearly as exciting as seeing the patient’s organs in color on a CT-scan image—a test that was not so readily abandoned. Finally, there’s no drug company or device manufacturer that stands to gain from widespread use of fingersticks, though there is from diffusion of 128-slice CT scanners, not to mention 256-slice machines.

What about the recent example in which use of antidepressants in young people decreased after the FDA issued a black box warning about potential side effects? Some critics argue that in this instance, putting the toothpaste back in the tube was wrong-headed: many more people suffered from not being treated than from the side-effects of treatment. Whether or not it was a good idea to cut back on antidepressant use, the major driver of the behavioral change appears to have been the media. Newspapers reported that antidepressants were bad; they were dangerous; they killed people. They presented a far less nuanced picture than the original article. But the combination of publicity and fear-mongering was effective and antidepressant prescribing rates fell significantly.

Finally, the most dramatic, if obvious, examples of turning back the clock occur when the FDA orders a drug company to recall its drug. When Vioxx was taken off the market, after revelations that it significantly increased the risk of heart attacks, use of Vioxx plummeted. In a similar vein, when health insurance companies decide not to pay for something, use generally falls. Bone marrow transplantation for the treatment of metastatic breast cancer ceased when, based on revelations that an earlier study had been fraudulent, coverage was halted.

Going back is hard. Commenting on the articles in JAMA Internal Medicine, Frank Davidoff quotes David Hume: “Men generally fix their affections more on what they are possessed of, than on what they never enjoyed. For this reason, it would be greater cruelty to dispossess a man of any thing, than not to give it to him.” Likewise, research in cognitive psychology confirms that people are far more distressed by what they perceive to be losses than they are ecstatic about what they see as gains. So reversing course is likely to require a multi-pronged approach. We need to have more solid evidence to adopt change in the first place and we should be looking more carefully at subgroups of the population when we draw our initial inferences about efficacy and we need more measured and judicious reporting by the news media and we need to use the nuclear option—removing ineffective or harmful interventions from the market or from third party coverage. Only then will we gain control over the phenomenon of persistent use of established but suboptimal treatment.

You Can't Put the Toothpaste Back in the Tube

Why is it so hard to get people to stop taking medications--even if they're shown not to work? See forthcoming blog post.

No Quick Fix for Mortality

Quercetin hit the airwaves this week, when the media reported that scientists have found "a new class of drugs that dramatically increases healthy lifespan.” Not to be confused with Coenzyme Q10, another naturally occurring compounded touted as an antioxidant that delays aging, Quercetin is a “natural compound” sold in health food stores as an anti-inflammatory agent. But now it is has been dubbed a “senolytic,” a drug that slows aging by alleviating symptoms of frailty, improving cardiac function, and extending a healthy lifespan. Sounds great. But before you rush to buy some, lets look at the evidence.

The article on which this promising claim is based is a highly technical paper in the journal Aging Cell entitled, “The Achilles’ Heel of Senescent Cells: From Transcriptome to Senolytic Drugs.” The authors argue that aging is due in large part to cellular senescence, which in turn means the process by which cells lose the capacity to grow. These senescent cells secrete all kinds of chemicals that are hypothesized to produce decline and death. But not all the cells in an organism become senescent at once. In fact, only 15% of the cells of very old primates are “senescent.” The idea is to kill off these senescent cells, thus preventing them from making those disease-making chemicals. 

It turns out that a variety of drugs, all belonging to this new class of “senolytics,” selectively kill senescent cells. And indeed, when a combination of two drugs, a known cancer drug and the compound Quercetin, were given to old mice, they lived longer and had lower rates of “age-related symptoms and pathology” compared to old mice that didn’t get the cocktail. The two drugs worked especially well together, but each drug alone was effective. So where’s the rub? Why not rush out and buy some Quercetin, which is available now and without a prescription?

It’s not that Quercetin might be harmful. The FDA has studied the compound and determined that it has no significant toxicity because it is destroyed in the intestinal tract--before it can even get into the bloodstream. So while the drug might in principle do something if given intravenously, taking the currently available formulation won’t. Parenthetically, you certainly don’t want to buy some Dasatinib either, the other drug used in the study. Dasatinib is a “targeted chemotherapy” drug, used to treat the relatively rare blood cancer, Chronic Myelogenous Leukemia (CML), when the preferred drug, Gleevec, stops working. It costs roughly $10,000 for a thirty-day supply. It is approved only for use in blood cancers, though in principle it could be prescribed off- label for other non-proven indications.

Another reason for holding off on your Quercetin purchase is that its effectiveness has been demonstrated only in rodents. Using mice to explore the genetic underpinnings of mortality has a venerable history: the gerontologist David Sinclair, for example, has been using a mouse model to study Sirtuin genes, genes that appear to protect against aging. He has discovered "sirtuin-activating compounds," small molecules that decrease frailty--in mice. These frail mice exhibit muscle weakness, they get heart disease, and they die earlier than their non-frail counterparts. But whether frail mice are truly analogous to humans, in whom frailty entails heightened vulnerability to stressors, and in whom frailty translates into an increased risk of falls, delirium, and disability, is another matter.

The main reason for skepticism about the latest claims about an immortality pill goes back to the article written by Olshansky, Hayflick and Carnes in 2002 and republished by Scientific American in 2008 that debunks all claims to have discovered the fountain of youth. These scientists take seriously the desire to promote healthy aging. They see the virtue in postponing the aging process altogether rather than tackling the diseases of old age one at a time: if aging is a zero-sum game, then curing cancer, for instance, would simply mean that more people will die of Alzheimer’s disease. But they are horrified by the amount of money desperate people spend on anti-aging products that are no more likely to be beneficial and just as apt to be harmful as many of the quack nostrums of the nineteenth century.

Today, a number of companies are peddling “anti-aging” drugs. Elysium, cofounded by Lenny Guarante of MIT (David Sinclair’s mentor), makes “Basis,” a mixture of nicotinamide and pterostilbene (an anti-oxidant), which it sells on line. Even Novartis, a major drug manufacturer, is trying to get into the anti-aging market with rapamycin, as Bloomberg News reported with enthusiasm.

None of these drugs has been proven to work. Some may be harmful. All are costly. It's not necessary to discuss  the ethical concerns about trying to lengthen the human lifespan to have an opinion about Quercetin. It's an interesting chemical for scientists to study in the laboratory, but it's not ready for prime time.

Queuing up for Vitamin Q?

Can Quercetin Cure Frailty? See this weekend's blog post.