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.....

http://www.aafp.org/news/health-of-the-public/20140827pcv13vote.html

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
Agree
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.

Priorities
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.

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 older adults 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.