Tuesday, October 6, 2015

Should I get a PSA?

The decision to screen for prostate cancer seem so obvious.  For men, it is the most common cancer, and the second leading cause of cancer death.  For year, it was assumed that every man after the age of 50 would get a Prostate Specific Antigen blood test (aka PSA) every 1-2 years.  Ideally this would lead to a decrease in cancer deaths.  Unfortunately this has not turned out to be the case.

The US Preventive Services Task Force is a body that is funded by us (taxpayers) to look into health issues with objectivity (they're not physicians/drug companies who will profit off of treatment or even advocacy groups that are wired to make their issue the most important in public discourse or health insurance companies who are looking to save money).  You can see their most recent statement here.

In the past, if a man wanted to get screened, I would caution them that even if the PSA is normal (<4 abnormal="" and="" cancer="" could="" f="" get="" ignore="" nbsp="" not="" psa="" should="" still="" symptoms.="" the="" they="" were="">4), they should not panic because most of the time, a PSA>4 does not represent cancer anyway.  Great test right?  If they could live with the fuzziness of the PSA test, willing to not panic with every test >4 then maybe it would be useful for them.  If it was high (>4), I would recheck it in a matter of months.  If it were high again, I would refer for biopsy and then we could stop and make a decision about how aggressive to treat AFTER the biopsy.  I have a cousin (not a physician) who advocated on a blog post that patients should decide if they want to pursue screening and how aggressive to treat but physicians should not decide ahead of time paternalistically.  I agree with this on face value but when looking at the data, it becomes much messier.  

So looking at the data
For every

1000 men who under go screening for 10 years,
5 will die from prostate cancer if not screened
At most 1 will have their death prevented by being screened

Harms are significant
100-120 men will get biopsies (1 will get hospitalized from complications)
110 men will get a diagnosis of prostate cancer (and the accompanying worry)
29 will develop erectile dysfunction due to treatment
18 will become incontinent (lose control of bladder function)

So the ration is for every 1 person helped by screening
100-120 men get a procedure they don't need
110 will get a diagnosis and worry
29 will get ED, 18 will get incontinence.

The problem with this is that for the 110 men diagnosed with prostate cancer, it is very difficult to hit the brakes and not pursue further treatment.  In some ways, the guys who know they won't do anything about it should not get screened in the first place.

So this is the dilemma of prostate cancer screening-it is an emotional dilemma with physical outcomes.  Most men, clearly would be better off without being screened.

Wednesday, September 30, 2015

Why see a geriatrician?

It's not just patients, but other physicians, who have trouble figuring out what I do and when I should do it.  Is it when a person turns 65?  Or when they develop problems with memory like dementia?

Here are a list of reasons
1.  The patient has multiple medical problems.
At some point managing multiple medical problems becomes an art in itself.  A typical patient might see a specialist for every one of their medical problems, with the inevitable increase in the complexity of managing them.  A geriatrician might take that patient, put it into a big picture and treat the big picture.

2.  The patient has functional decline.
Geriatricians know about mobility issues, health implications of falls and how to collaborate (not just refer) to physical therapists and rehab physicians.

3.  Age
This seems obvious but what geriatricians understand about aging is that it can modify the benefit and harms of what we do in medicine.  Understanding how age and future prognosis modifies risks/benefits is a geriatric skill.  Decisions like when to stop cancer screening or what is the ideal blood pressure or sugar target, the decision to treat or not treat a disease (like surgery for a back problem or blood thinners for an irregular heart beat) all have age as a consideration

4.  Geriatric syndromes
Geriatric syndromes are multi-organ.  Geriatricians specialize in multi organ stuff.  Falls, incontinence, memory loss, psych issues, polypharmacy, pain, wounds etc.

5.  Patients who have mixed palliative / therapeutic goals
Some patients want to pursue therapeutic/curative care for some of their medical problems and forgo aggressive treatment on others.  Some docs want pts to be all or none (full code or hospice).  Geriatrician (ideally) would be able to straddle the sometimes messy space between full therapeutic care and hospice.

6.  Pt's who transition between health systems
Geriatricians receive training in hospitals, offices, house calls, assisted living facilities, rehab facilities etc.  We know the pros/cons/limits of each and how to make things work.  Ideally these transitions are not stressful.

7.  Pts who need collaborative interdisciplinary care
A large part of what we do is working with other disciplines such as physical therapy, occupational therapy, speech therapy, nutritionists, wound care nurses, social workers, home health aides, medical supply companies, hospices.

8.  Caregiver support
This is something assessed (I feel) better by geriatricians than non geriatricians.  It's not just the patient we care about but also the support team (family and friends).

Saturday, July 4, 2015

Alzheimer's Reading Room-Understanding the person with dementia

Bo DeMarco is a blogger who started blogging when his wife developed Alzheimer's disease.  He writes good stuff and is quite connected to recent developments.  My favorite topics of his are when he writes with insight into what the experience of Alzheimer's is like.

He writes a wonderful post on the conflict surrounding feeding issues but the feeding is almost a side topic when he gets down to it.  My favorite quote:
While a person living with Alzheimer's can't remember, they are full of feelings and emotions.
Here are some others
Why is it so hard to understand that a person living with Alzheimer's forgets? A person living with dementia is deeply forgetful.
I feel confident when I say this -- you won't be able to convince a person who is deeply forgetful that they are wrong, and you won't be able to convince them that your reality is the true reality. They can't remember like you or me, so they really cannot comprehend your point of view.When you do this you are asking the person who is deeply forgetful to come back into your world. They cannot do this.
One of the most difficult  aspects of caregiving that I see, is trying to understand the loved one from a new point of view.  It is so easy for me to say so as a clinician but really hard to do in daily life.  I get it somewhat but on another level, only the caregiver really gets it.  This post is well worth reading.

Thursday, December 4, 2014

New vaccine recommendation: Prevnar and Pneumovax

So this came out in August, but I don't have time to read everything.  There's some data showing that giving a vaccine called Prevnar (which is used for kids currently) then giving a vaccine called Pneumovax (already recommended for all > 65 years old) prevents more pneumonias.  Sounds great!  Except Medicare doesn't cover it yet.....


Wednesday, November 26, 2014

How to manage multiple medical problems (also known as "do I really need all these medications?")

(PS this post ended up being longer than I thought.  Skip to the end for the punch line)

Too many times, older adults have a lot of medical problems that get treated by a lot of doctors with a lot of medications.  (I'm tempted to say too many but that would simply reflect my bias).  For example, I once had a patient with 3, THREE, neurologists!!  I asked him, "What for?" and he said, "1 for my stroke, 1 for my seizures and 1 for my memory issues."  Just between those three neurologists, he was put on 7 medications!  (2 seizure drugs, 2 memory drugs and 3 for preventing strokes).  That type of craziness I expect out of cardiologists.  The more docs you see the more meds you get.  (that's a true statement by the way, I didn't make that up).

Some doctors haven't the faintest idea what to do either.  The organologists (cardiologist, pulmonologist, endocrinologist) often just buckle down and do what they do, just harder.  This is simply avoiding complexity instead of managing it.  (and it often makes the problem worse or kills the patient)

The American Geriatric Society, as experts in managing complicated older adults, put out a paper on the topic.  From my humble perspective, it adds to complexity instead of reducing it.  Here are the steps suggested in the paper....
1.  Elicit the chief complaint of the patient (or family).  
Sounds good.  I'm on board with this one.
2.  Either review the whole multimorbidity picture or focus on just a part
Yes, these are the obvious choices of agenda for a visit.  The difficult part is how to figure out which one to do.
3.  Ask:  What are the current medical problems and interventions combined with is there adherence/comfort with the treatment plan?
So this is taking option #1 from the previous question.  I like it.  But why are we doing this, what will we do w/the info?
4.  Consider patient preferences.
While important, there are medical issues that are obvious priorities that are not subjected to preference.  Managing multimorbidity is not just an art or emotional or value based.  There are concrete priorities.  See below.
5.  Is there evidence available related to important outcomes?
While this makes sense to ask, there are two problems.  You can't ask a practicing clinician to stop and review evidence in the middle of making a clinical decision.  The process would grind to a halt and no decision would ever be made.  Second, when reading the article they talk about how poor the evidence is in the setting of multimorbidity so the proper answer to this question may be simply "There isn't any."  (per authors)
6.  Consider prognosis
7.  Consider interactions within and among treatments and conditions.
Agree but if you have someone with afib who has GI bleeds there are principles that guide priorities that this article doesn't discuss.  Asking a question without good guidance leads to random outcomes.
8.  Weight benefits and harms of components of treatment plans.
Agree.  Harms are like a another problem on a patients problem list.
9.  Communicate and decide for or against implementation or continuation of intervention/treatment
Fish or cut bait.
10.  Reassess at selected intervals
Everything is a time limited trial to quote an esteemed geriatric expert.  Or to quote Mike Tyson, "Everyone has a plan until they are punched in the face."  That's a better quote.

10 steps.  TEN.  For crying out loud.  How does managing multimorbidity with questions that simply bring up complexity (2, 7, 8, 9) or are unanswerable (5) or are exceedingly difficult to apply (4, 9) help simplify multimorbidity?  My head spins looking at this and I do this every day.

So here is my cheat sheet. It is simple.

1. Active symptoms
         Pain, nausea, constipation, dyspnea, delirium
2. Multiorgan frailty syndromes: 
         Falls, weight loss, cognitive decline, functional decline
3. Secondary prevention/chronic diseases: in this order
         Congestive heart failure>Hypertension>Osteoporosis>>>High cholesterol>>>>>Diabetes
4. Primary prevention
          Vaccines>>aspirin for preventing heart attacks, colon cancer screening>>Prostate cancer screening

Repeat after me: "Active symptoms are more important than preventing symptoms."  No point in worrying about what can happen years into the future if you're going to ignore a problem hitting you in the face.  (see Mike Tyson quote-I quoted him because he is right, if you are getting hit in the face you should change your plan.  In my case run and scream).

Example of application....
So if a patient is having active symptoms (ie Pain) then treat it.  Until you get those symptoms under control, what difference does it make if their blood pressure is 160 instead of 140?  Or if pain meds put them at risk of constipation or delirium even?  Active symptoms=active suffering.  Treat it!

Why this medically makes sense.
Generally speaking, if you are trying to get a higher priority issue under control, then don't worry about the lower priority issue.  Especially if worrying about the lower priority issue got you into having the higher priority issue in the first place.  What do I mean?  If tight control of diabetes is leading to hypoglycemia and falls, then by all means, BACK OFF THE INSULIN.  Multiorgan frailty syndromes pose a much greater threat to quality of life, health, safety than anything in 3 or 4.  As patients have higher priority issues, the efficacy of lower priority issues starts to disappear and harms of lower priority issue start to appear.  These are medical principles.

Why this makes patient sense as well.
By prioritizing active symptoms, you are prioritizing what bothers them most.  #1 takes precedence.  Second, this list automatically prioritizes what is the biggest danger to a persons life and health and function.  3rd, a patient can decide how far down the priority list they want to go.  It gives them a (logical/clear/structured) sense of how to be aggressive if that's what they want.

So there you go.  This is how you manage multimorbidity simply.

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.