Tuesday, November 18, 2014

New trials

I read a lot of journal articles (hundreds per year).  I keep an eye out for research that either shows a concrete clinically meaningful benefit for older adults or studies that show a lack of benefit.  At the end of the day, that's all I care about.  Studies that show an intermediary benefit or a lack of it (like a blood test result, an imaging result) are interesting but show me nothing.

A couple of things:
Aspirin is falling out of favor for preventing a first heart attack or stroke.  A Japanese study showed that for low risk patients who have not had a heart attack or stroke, taking an aspirin did little to prevent a first event and the benefits were outweighed by having a bleeding stroke or major intestinal bleed.

Most older adults with heart failure due to stiffness of the heart (Diastolic CHF) are often tried on medications called betablockers or ACE inhibitors because they are wonderfully effective for heart failure due to improper squeezing of the heart (Systolic CHF).  Unfortunately, they don't do anything for Diastolic CHF.  And it contributes to polypharmacy.

For Diabetes, many people think of sugar like they think of taxes.  The lower the better.  Unfortunately while that may make sense in theory for Diabetes, it simply also isn't true.  A new study continues to hammer away that lower is always better.  The benefit has diminishing returns as A1C gets below 9.  The pain of getting to an A1C below 9 involves more medications, hypoglycemic episodes and isn't safe.  So for the risk of adding dangerous side effects, with minimal benefit, most patients older than 50 experience a net harm for getting their sugar less than 9.

Finally for something that actually is beneficial, a new report that has yet to be peer reviewed shows that maybe Xetia does something after all.  Go figure.  About 10 years ago, a study showed that Xetia did not reduce the thickness of cholesterol plaques.  But what do you know, it prevents heart attacks anyway.  And that is what matters.

Sunday, November 16, 2014

Are pet scans good enough to diagnose dementia?

I recently had the opportunity to speak at the national American Academy of Family Physicians annual meeting (called the AAFP Scientific Assembly).  I spoke on dementia from a primary care perspective. One question that came up was that a previous speaker stated the PET scans could be used to diagnose dementia.

Now I work at an academic setting and I have only ordered a PET scan once (and in retrospect I should have referred the patient to a memory center instead of ordering the PET scan).  And it was kind of interesting to me that there were primary care docs who order these things.  I see a lot more patients with dementia than the average primary care doc by far.  Probably half my patients have dementia.  It's one of the main reasons I get consulted and yet I never (ever) order PET scans.  So I decided to do some math to figure out why.

So some basic starting points-according to the Alzheimer's Association, PET scans to make the diagnosis of dementia are 95% sensitive and 75% specific.  Sensitivity means that if someone has dementia, the test will pick it up.  Specificity means that the test doesn't pick up other things like depression.  For more info you can look on google or wikipedia.

While the sensitivity seems great, the specificity is the achilles heel.

The next numbers are so key. It has to do with positive and negative predictive value.  Again, look on google.  Or you can use this handy dandy calculator.

Let me cut to the chase:

3 scenarios:
High likelihood.
If a clinician has a high suspicion that a person has dementia (let's say they are 75% sure), then if the test is positive (suggests dementia) then the likelihood increases to 92%.  If the test is negative then the test has an 83% chance that the person does not have dementia.  In other words, for patients for whom dementia is strongly suspected, then the test will be great and strengthening the diagnosis (but it still will be wrong nearly 1 in 10 times).  If the test is negative, it is good and making everyone rethink the tentative diagnosis.

So for patients for whom dementia is already strongly suspected, adding a test that agrees may add a shade of confidence which may not be terribly useful.  What is more useful in this setting is that if the test is normal, then there needs to be a re-evaluation of the cause of the cognitive deficits (memory loss)

Low likelihood
If the clinician thinks the pt does not have dementia (25% chance of having dementia), then a negative test essentially rules it out (98% chance that the person does not have dementia).  Again useful maybe but not terribly.  If the test is suggests dementia, it is only right 55% of the time which is a pretty horrible result for a test.  It means it's barely better than a coin flip.

So for patients for whom dementia is not suspected, it is good for confirming that (which is not terribly useful) and if it disagrees, it is no better than a coin flip (also not terribly useful).  In other words, for patients with a low suspicion of dementia, this test is not terribly useful.

For an intermediate likelihood.
Let's say the clinician has no idea.  The patient could have dementia but they might not (50% likelihood=coin flip).  If the test is positive, it means the person has dementia 80% of the time which may seem pretty good but it's wrong 1 in 5 times.  That's a lot of people to freak out.  If the test is negative, it is correct 94% of the time which is good for a rule out.

In other words, for a random probability, a PET scan can be used as a rule out but not so much to make the diagnosis.

Let me put this is in a chart if I can…
So summarizing, I would say that the test is useful as a rule out type of test for those who have an intermediate or low suspicion.  Not so much to make the diagnosis.  I wouldn't be comfortable telling someone they have a fatal neurodegenerative disease when I have a 20% chance of being wrong.  Or even 8% chance.

The second point is that the test is only useful in the setting of a clinical suspicion.  You can see how the characteristics of the test change depending on clinical suspicion.  However when people talk about PET scans, they imply that maybe it would be useful BEFORE a person has clinical symptoms.  It's not there yet. Maybe the new Amyloid PET scans but not the tagged glucose pet scans.

After going through the math, this is why I don't use PET scans.  I think it's more useful to hone my clinical skills than use a test to compensate for poor clinical skills.


Thursday, November 13, 2014

How to help an older adult eat more and gain weight

Older adults lose appetite and weight for a number of reasons.  And it drives families crazy and sometimes the patient themselves.  There's a whole host of reasons and for every reason there's a number of solutions and medications are always the option of last resort.

Without getting into it too much, there are "normal" and "abnormal" reasons to lose appetite.

Normal reasons have to do with the normal aging process:
Losing the sense of smell
Losing sensitivity of taste buds
Dentures (which cover taste buds)
Decrease digestion ability and speed which leads to early fullnesss

Abnormal reasons include
Medications (meds are always first for abnormal anything)
Dry mouth (and dentures that are not cleaned)
Dementia (leading to problems of coordination, attention, awareness)
Cancer
Congestive heart failure
and on and on.

What I wanted to do with this post is write about what I recommend as general recommendations for weight gain regardless of cause.  Ideally you remove the barrier/obstacle.  (i.e if there is a medication causing a side effect, then stop the medication).

Anyway, here are my tips....

To stimulate your appetite try changing the variety in your food.  Specifically change the 
1.  Taste-Salty, sweet, bitter, sour, spicy
2.  Temperature-Hot or cold
3.  Texture-Crunchy, soft, chewy, liquid
4.  Smell (for taste issues)

Make sure your mouth is clean to improve taste
Make sure your mouth is moist
Eat with others

To increase calories
1.  No restriction on diet:  No limits on salt, sugar, fat, or carb restriction.  Eat anything you want:  Bacon, sausage, bread, ice cream, candy, cookies, cheese etc.
2.  Increase the calories in your food by adding:  Heavy cream, cheese, sugar
3.  Buy Carnation Instant Breakfast instead of Boost or Ensure because it is cheaper.  Drink them between meals, not with meals.  

Friday, December 6, 2013

Getting better with age

Being a geriatrician, I am eternally optimistic about aging.  Therefore I love this article on coaches in the NFL.
The Cardinals' Secret: Elderly Coaches!!

Go Cardinals!

Friday, November 22, 2013

How to think like a geriatrician

So hopefully (optimism), I'll write a series of articles about how to think like a geriatrician.  Geriatricians deal with a specific patient population that is unique-but not just because the patient is old.  Age is just a number (seriously).  But there are other things that go along with aging.  This graph/powerpoint of how I think about things.  All of us, whether we like it or not, are moving from the left side to the right side.  Exercise, living right can delay that.  But eventually, as long as we are not hit by a car, will make it to the right side.  The purpose of this picture is to show how the practice and application of medicine fundamentally changes as one becomes more frail and as goals change to being more palliative.  Medicine becomes more collaborative, more of an art.  Standard medicine begins to fail.  The picture shows why that may be.


Thursday, November 21, 2013

Generic drugs are good! Don't listen to drug companies

I enjoyed reading this.  It's always amazing to me how many people think that if they care about their health they need to get a brand name drug.  It's scary how effective drug companies are at marketing and how much people are willing to listen to drug companies.

Friday, November 15, 2013

An ICD: A $30,000 mistake that shows what's wrong with health care

So I previously wrote about a patient of mine who got an Implantable cardioverter-defibrillator (ICD).  To recap, he was a 92 year old gentleman, with metastatic melanoma (choosing not to pursue chemotherapy), Class 3, Stage D heart failure (end stage CHF) and worsening frailty with a fall and minor hip fracture (no surgery required).  When he was in the hospital for a CHF exacerbation, his ejection fraction was found to be less than 30%.  When someone's ejection fraction is less than 30%, they are at increased risk for sudden cardiac death and insurance will cover the cost of an implantable defibrillator (ICD).

In my previous post, I discussed the utility of an ICD for this patient.  To summarize, his cardiologist had visited him in the hospital (for a CHF exacerbation) and told him an ICD would "help his heart."  The patient understood this to mean that it would help his heart pump and he would feel better.  The doctor meant it would help restart his heart were he to die of an arrhythmia (which was not something the patient was trying to avoid).  When I saw the patient, his wife and daughter, listened to their goals and explained this to them, they realized it was a mistake and they wanted it shut off.  The patient actually wanted to sign on to hospice, prioritize having a peaceful death and feeling as good as possible.  None of these could be accomplished by an ICD.  In fact, an ICD would be an obstacle.

Geriatricians (apparently), are known for complaining about the health system, and well, yes, I am going to do that.  So what did this "oops" cost?

Well the hospital gets a fee of $26,000-30,000 for the 10 year device.  Some of that is profit.  Some goes to the device manufacturer.  The consulting cardiologist gets paid a fee of about $100.  The cardiologist inserting the device gets paid a fee of about $1,500.  I get paid $80 for having a 45 minute conversation with the patient, wife and daughter, to explain the risks and benefits, discuss goals and help come to a shared decision about the appropriateness of an ICD.

Again, I get paid $80, everyone else gets >$30,000.  For the "oops," everyone keeps their money and profit  No one has to pay anything back to Medicare. The hospital, the device company and the proceduralist make out like bandits.

Conclusion:
Reimbursement needs to change in order to achieve good quality care for patients and minimize waste.

Specialists who do procedures get paid too much (yes I said it) and need to be held accountable for wasting resources.

Somehow I (and geriatricians in general) need to get credit/paid for helping patients achieve their goals through appropriate medical interventions and saving money while doing so. What would have happened if I had met with the patient before the placement of the ICD so that when the cardiologist suggested it, he said no?  The hospital would have lost money, the cardiologist, the proceduralist and the device company would have lost thousands.  Medicare would have saved >$30,000 but none of that would have been credited to me or even recognized that I had a role.  Everyone gets paid thousands for a 2 second statement "this will help your heart," but I get paid $80 for a 45 minute discussion.  In other words, guiding the medical care that a patient gets, to make sure it is appropriate, does not get reimbursed.  Saving money (not that that is necessarily the main goal but it's not a bad secondary goal), is also not reimbursed.  Doing more, risking more, spending more gets reimbursed tens of thousands.  This is why sometimes older adults feel like they are on an express train of medical care that they can't exit.

Good communication should be reimbursed.  It leads to better care.  It is a skill just like putting in an ICD or consulting on a patient or making a device.  I would argue that for this patient, the key skill he needed was communication.

What is wrong with health care in the United States is how medical care gets reimbursed.  They system is geared to providing inappropriate, useless care.  And nothing being proposed in Washington is changing this disaster.