Osteoporosis

One of the things I did last year was complete a project on Osteoporosis for a Master of Public Health degree. In the process I learned quite a bit. The statistics are sobering:

1 in 2 women will have a fracture after the age of 50
1 in 4 men will have a fracture after age 50.
Each year there are 300,000 hip fractures and 700,000 spine fractures from osteoporosis.

That's a lot of people! That's a lot of fractures!
It's also a lot of pain and a lot of people ending up in nursing homes from hip fractures.

In any case, you would think that this is a big deal among patients and physicians but it continues to be a very silent epidemic.

For example, most women get a mammogram at least every 2 years (over 65%). Most women never get a bone density scan (DXA scan) more than once (less than 35% get a DXA scan more than once). Yet women are much more likely to get a fracture than breast cancer.

Even after a hip fracture, most patients never get put on calcium and vitamin D (only 35% do) and most patients never even get a prescription for a osteoporosis medication (less than 15%).

About half of people who are prescribed an osteoporosis medication stop in within the year and of the half who continue it, on average they take half their medication.

In other words, the take home message is that Osteoporosis is severely underdetected and undertreated. Probably no more than 5% of people in the United States with osteoporosis are taking their medication regularly to maximally prevent a fracture.

So what can you do?
1. Ask for a DXA scan to be detected
2. Read this website to calculate your own fracture risk.
3. Take calcium and vitamin D every day if you are older than 13.
4. Take a bisphosphonate like Actonel, Fosamax or Reclast.
5. Exercise and don't smoke.

On the 4th point, I actually do not care a whole lot which Bisphosphonate a person takes. People often ask me what medication is better than another and what type of calcium is ideal. I hope I've convinced you that that does not matter. It's better to take anything than nothing. I would take whatever is cheapest myself and what is covered on insurance. And for sure, I would take the generic over the brand because like I said I'm cheap. For those who are forgetful, Reclast which is a once yearly bisphosphonate is wonderful. I'd recommend it.

That's my 2 cents on Osteoporosis!

H1N1 and the regular Influenza virus

I've gotten my flu vaccination, have you?

This year is a little confusing because there are two flu vaccines to get. The first one is the regular influenza vaccine that everyone older than 6 months should get yearly. Kids 6 months to 8 years old who are getting their first vaccine need two. The high risk targeted groups for this vaccine are 1. children 6 months to 4 years old

2. children 4-19 with chronic illness

3. all adults older than 50

4. pregnant women

5. nursing home residents

6. adults with chronic illnesses/compromised immune systems

7. adults who are in close contact with kids listed above

8. Health care workers.

The H1N1 vaccine recommendations are different. The CDC lists it in order of importance.

1. Kids 6 months to 24 months

2. Pregnant women

3. People who care for kids birth to 24 months

4. health care workers and emergency personnel

5. Anyone 6 months to 24 years old

6. Anyone 25-64 who are at increased risk for complications due to chronic illness.

The big differences between the two vaccines is that the H1N1 vaccine targets young people, not geriatric patients. If you have grand kids, should you get vaccinated? If you provide a significant amount of child care then yes, you should get both.

How effective are these vaccines? I'm not sure about the H1N1 vaccine, but for the flu virus it depends on the year. Sometimes the vaccine correctly predicts the version of the flu and sometimes it doesn't. Each year anywhere between 25-75% of the population gets the flu of varying severity. The flu vaccine can prevent the flu (when it is effective) about half the time. So you would need to vaccinate anywhere from 4-15 people approximately to prevent 1 case of the flu.

I do wonder if this means yearly vaccines with two flu vaccines. Maybe they can combine it one year. We'll see!

Diabetes and geriatrics

Uh oh, I've been getting behind on my blogging. I still have to make this part of my routine. I see interesting things almost every day, and I've been thoroughly enjoying reading http://thealzheimerspouse.com/. It's a great blog and I've realized that folks will discuss tons of tough tough issues online with peers over talking to their physician (which is fine of course). But I think I will make this mandatory reading for the medical students, residents and fellows that I teach. One example was a forum post that asked when other spouses started sleeping in separate rooms because their spouse's dementia progressed to the point where they weren't recognized in the middle of the night. Not a question that I've ever been asked in the office.

In any case, we had an interesting journal club yesterday. An article in JAMA is one of a growing body of literature that simply debunks the idea that all people with diabetes need to have tight control of their sugars (defined as a HbA1C <6.5 or fasting sugars less than 100 and after meal sugars less than 140). In this article it states that having one low sugar episode (< 70) which is common in people trying to maintain tight control, can increase the risk of Dementia by about 2-3% per year. This adds up quickly. While the stats are somewhat debatable, I think it adds to other articles that came out last year showing that low sugars increase the risk of death in hospitalized patients. The known risks of low sugars includes death, dementia, falls, confusion, hospitalizations etc.

So to review, what's the benefit of lowering sugars? Is it worth the risks in elderly patients? The answer is surprising: while high sugars increases the risk for heart attacks and strokes, lowering sugars does not reverse the increased risk. So what does it do? It decreases the risk for complications like kidney failure, blindness and nerve damage to the feet. Those aren't small complications but it may take over 8-10 years of tight control to see those benefits. Many of my patients are not going to live that long. And even if patients do have 10 years ahead of them, is the small decrease in blindness worth the increased risk of hospitalizations, death, dementia and falls? I doubt it.

At least among geriatricians, there is a large resistance to putting people on multiple oral medications and complicated insulin regiments to achieve tight control that has little or no benefit for the majority of our patients but carries significant risks of serious medication side effects.

I think the challenging aspect of geriatrics is every patient has different goals. It's important to remember not all geriatric patients are the same. I saw an 80+ year old female the other day who wakes up at 6:00 am to do aerobic exercise at a local gym. I have 70+ year old patients with end stage dementia in a nursing home. Tight control of sugars may be reasonable for some patients, but for many it is not. It needs to be considered thoughtfully.

Am I that scary?

I have not been following the Obama health care debate very closely, but a friend of mine on Facebook posted some questions so I looked up some info about Obama's health care plan. The first link in Google points to this CNN article. The second points to this article on Salon.com. It refers to comments by Sarah Palin regarding "death panels."


These articles point to a couple of fears that people have: the government is going to force people to have a primary care doctor and the government is going to force people to discuss end of life care.

What's amazing to me is that being a family doc, I am a primary care doc and as a geriatrician, I regularly have discussions with patients and/or families about end of life issues. I never thought that I was so scary!

All kidding aside, I'm such a believer in both primary care and clarification of end of life issues. I can't tell you how many times I've had a patient who's primary care doctor was a cardiologist who tried to manage their depression/overactive bladder/dementia and how badly that has gone. Or how many patients have ended up getting CPR and put on a ventilator when that is not what they had wanted. The purpose of having a primary care doc and having end of life care is to make sure that every patient has someone who is responsible to knowing them and their preferences. There's no reason that should be all that scary!

I'm not ready for hospice!

This morning we had a discussion in the department about how to have the ideal hospice discussion. The author of this article was the presenter. It was an interesting thoughtful discussion based on the premise that doctors and patients often have a tough time communicating. One of the ideas that I really try to teach medical students is that the key to being a good doctor has to do with normal people skills.

The most important thing that I try to teach is that physicians don't need to know what to say, or how to have a conversation but how to listen (actively). In some ways, it is not all that different from being married. I don't need to do studies to research why my wife is angry at me, or figure out what has worked for most angry wives, I just need to ask her what's wrong and listen. Or if she's happy, what's right!

So here's my list of things doctors should do when discussing something difficult like hospice:
1. Listen, don't talk
2. When the physician is talking, the goal should be to seek further clarification of what the patient (and/or family member) was saying
3. Figure out what the patient's goals are
4. Discuss goals of care all the time, not just when the physician has a goal for the patient
5. Emphasize that the physicians goal is to help the patient carry out his/her goals.
6. If you're not sure how a patient is going to react to something, be honest about that. i.e. I'd like to bring up the issue of hospice but I'm not sure how you're going to feel about that? Or how do you feel about discussing hospice?

The goal at the end of the day is to not cram anything down a patients throat in a manipulative fashion but empower the patient by helping them maintain autonomy and control. Communication can achieve either the former or the latter. Somehow in this day and age, with all the pressures (legal, financial etc.) that doctors face, listening has become a lost art.

Is surgery safe for older patients?

Today I saw a patient for the first time. Because of a condition, she will require bilateral hip replacements. Cardiology cleared her for surgery and ortho believes it will significantly help the patient. The surgery, however, requires 2-4 weeks of bed rest afterwards for optimal healing. And orthopedics wants to do one hip at a time. In a frail elderly patient who is bed-bound (due to her hip problem), the issue is not the surgery itself, but the recovery. This is something often missed by nongeriatricians. One number that I always remember is that an elderly person who is on bed rest for four weeks will lose 50% of their muscle mass and 75% of their strength. Joint contractures (permanent stiffness of the joints) can occur in as little as a week in an elderly patient and sometimes as little as 24 hours. Bed rest can cause a loss of calcium, and nitrogen that may never recover and new onset diabetes after 8 weeks of bed rest. In someone who is already cognitively impaired, pyschosis is not uncommon or infections such as pneumonia and urinary tract infections.

I have not met with the family yet, but a surgery requiring prolonged bed rest may still be very risky even if the surgery itself is not terribly risky. One thing to remember though is that not all people who are 85 are the same. The best predictor of outcome after a surgery is how functional a person was before the surgery. But a frail cognitively impaired older adult is going to have a very though rehabilitation course after a prolonged period of bed rest.

In other news, I may not be able to continue this blog after all. I have to clear this with the legal folks of the University of Pennsylvania. We'll see what they have to say!

How do you pick a good doctor?

My family and I just moved to Philadelphia where I will start work on Monday at the University of Pennsylvania. My brother in law and his pregnant wife just moved here this last week as well. Between the 4 adults, 2 kids, and one kid in utero, we're looking for primary care doctors (pediatric and adult), a specialist, and an OB. We're also picking benefits such as deciding between PPO insurance vs HMO insurance (which costs at least $300/month more than an HMO insurance). So we have some decisions to make.

The funny thing to me is that the dilemma in picking a good doctor on an individual level is the same dilemma that the federal government has (and all health payers) on a large scale level: how does one determine the quality of a health care provider and whether they are worth the cost?

Most people want to know if their doctor is a "good doctor." Sometimes people mean whether the doctor knows and practices up to date medicine. The problem with that is if you could truly tell if a doctor practiced up to date medicine, then you wouldn't need that doctor. I believe that it is nearly impossible for a non physician (and very difficult even for a physician), to be able to know if a doctor practices up to date medicine.

So what else is there to go by? Here's a list
1. You click with the doctor. Never underestimate the power of a good warm relationship with a physician. The physician will think harder, listen better and care more. You will be more open, more trusting and less fearful. It's a good thing.

2. The office staff is professional. My wife and I took our newborn to a doctor once. One of the worst experiences we ever had. The office staff would unlock the front door at 9:02 for a 9:00 appt. The phones were often not answered. And they were rude. A good doctor will care about the professionalism of his office staff.

3. The doctor is accessible. The Institute on Medicine defines quality medicine as what you need, when you need it and how you need it. If you can't easily get an appointment or talk to the nurse or even the doctor, either the doctor is too busy or has an adversarial relationship with patients. Not a good idea.

4. The doctor answers questions (and is not in a rush). This is the most important for me. A good doctor shouldn't be afraid to answer questions and sometimes say, "I don't know" or "I'll get back to you later." No doctor is omniscient, should not pretend to be omniscient and should be honest. Humility is a key trait. A doctor who takes the time to draw out questions and answers them to the satisfaction of the patient will go a long ways towards building trust. They won't make things up (fellow doctors have done that to me a lot which I hate).

5. The doctor seems to take your concerns as his concerns. This goes along with the last one but makes it more personal. I hate it when a doctor blows off a patients concerns and I see doctors do it all the time. Medicine is serious. There's no room for belittling the concerns of patients and families.

6. The doctor uses an electronic medical record with a disease registry (icing on the cake). For economic reasons and tech reasons, there are plenty of docs who are great but because of a lack of finances (some EMR systems cost hundreds of thousands of dollars), some great docs don't have this. But to take medicine to the next level, you want a doc who audits themselves. This can't be done (very easily) without a disease registry. You don't a want a doc who assumes they are a good doc, but measures themselves to find out reality.

The last note is that there is no such thing as quality by association. A partner of a good doc is not necessarily a good doc. I've noticed a lot of University of Pennsylvania advertisements now that I'm in Philly and starting work there on Monday. They want people to assume that any doc at Penn is an amazing doc. I've been around long enough and in enough places to know that that is wishful thinking.

Anyway, these is not meant to be a comprehensive list, but these are some of the things I'm looking for for my family.

Faculty listing

On a personal note, I saw that I was offically added to the Penn Faculty listing in the Geriatric Division. If you want to check it out, it's here.

What is old?

I still take care of young patients sometimes. Today I was chatting with a 27 year old patient and his twenty something year old wife. I was telling them that at least he's doing better than a 30 year old patient with the same problem but has much much more severe deficits. The nice wife looked at me and asked (seriously), is it because he is old? I couldn't help but laugh out loud.

hint: if you ever feel old, talk to a geriatrician. Virtually everyone seems young to us.

What makes a geriatrician different?

In the United States, there are approximately 300 geriatric fellowship positions. Many of them go unfilled. In fact, less get filled every year. I heard that only about 200 positions are filled. From talking to one fellowship director, many fellows are just killing time until they get another fellowship that they really want like cardiology or heme-onc. Fewer medical students and residents express interest in primary care (1, 2, 3, 4), much less geriatrics. According to the Institute of Medicine's report (Retooling for an Aging America), there were just over 7,000 geriatricians in 2007 (not all of whom went through a fellowship). And at the American Geriatric Society meeting, I heard that most geriatricians are choosing not to recertify as geriatricians. My main point is that every year, there are fewer geriatricians, both new grads and practicing physicians, not more.

So the question is, does this matter? What makes a geriatrician different? Right now I'm working for a group practice of physicians as their hospitalist. There is one patient that I saw there that provides a good example.

An 85 year old female who came in with an intestinal infection, developed pneumonia, sepsis, respiratory failure, a urinary tract infection and renal failure and 45 days later she is still immobile, has a feeding tube and requires 5 L of oxygen. While all her specialists have written that they think she's getting better, no one has addressed her immobility. After 28 days of bedrest, a geriatric patient will have lost 50% of their muscle mass and 75% of their strength. Like an astronaut, she will have a component of low blood pressure whenever she tries to get upright (even in a wheel chair). This patient has been bed bound for 45 days. Geriatricians excel at not only coordinating complicated care, but also thinking about the patient as a whole with an eye towards geriatric syndromes. Things like delirium, pressure ulcers, deconditioning, malignant effects of bedrest are issues that are best prevented. Treatment is very very difficult. Would a geriatrician made a big difference in this lady's hospitalization? Maybe, but it definitely would have given her her best chance for getting out with the fewest complications.

Somehow, I hope to see the state of geriatrics take a turn. I hope to see more and more students choosing to go into geriatrics as a career. I think it is clear that there is a huge need for more professionals in this field who have a passion for making sure that older patients get the care they need and deserve.

Weighing options of treatment

While I don't plan on writing daily updates until August, I figure that I want to get in the habit of writing thoughts down when they occur. Over the weekend I met a lady who is 73. She has severe osteoporosis but because she has bad side effects to oral bisphosphonates, she does not want to try even an intravenous bisphosphonate. Instead, she was trying an unproven combination of Evista and Calcitonin nasal spray. This lady is not one of my patients. She told me she has lots of medical people in her family and on their advice, she decided that the risks of using an IV bisphosphonate like Boniva or Reclast was not worth the benefits. It's not clear to me what she perceived the risks and benefits to be or how she came to that conclusion. She may be right, she may not be but it did make me reflect that how people make medical decisions is really really interesting.

The way physicians make decisions is they use studies to try to quantify the risks and benefits and if the benefits outweight the risks (and don't cost too much), then it's the right decision to try the treatment. If the risks outweigh the benefits, then it isn't. There isn't a lot of emotion in the decision. In the situation that there is no evidence, or poor evidence, then the situation is tricky.

The way I see it, which is limited I'm sure, patients make decisions quite a different way. Most patients don't have access to the studies, or have trouble making sense of the medical literature. There are several categories of decision making process that I see patients go through: some try to weigh risks and benefits as interpreted by their physician, some decide based on what they fear more (fracture or side effects), some by gut feeling, some by cost, some by what somebody famous says or by what family says. In other words, patients look to a different source of authority for decision making information.

What's challenging for the physician (and patient) is to bridge this gap. As I write about different issues, I hope to give the information needed to help any person make an educated decision regardless of decision making style. We'll see how it goes!

What is Axona?

I hope to write some critiques of treatments that are in advertisements to give some perspective to claims. So one thing that I get is called Clinical Geriatrics. It's a subscription I get from my membership in the American Geriatric Society. This last issue there was a supplement (i.e. advertisement) about a new nutritional supplement called Axona that will help patients with Alzheimers.

So what is Axona?
Axona is essentially a variety of fatty acids (fats) that get metabolized to ketones. So what? Well the brain can use ketones as well as glucose in helping us think. Since the brain that has Alzheimer's has trouble using glucose, maybe supplying some ketones will provide more energy to the brain.

So does Axona work?
That depends on what the goals are. If the goal of an Alzheimer's patient or family is to keep the patient functional, out of a nursing home, engaged in hobbies and relationships then the answer is unknown. If the goal is to see a miniscule improvement on a research cognitive scale (ADAS-cog), then the answer is, according to the manufacturer's 1 study, yes. At 45 days there was a 1.91 point difference between the two groups (out of 70 points). By 90 days this improvement disappeared.

Conclusion
Axona may have an effect on cognition that a researcher may be able to detect, but I am doubtful that any family member or patient would notice. In any case, the benefit disappears by 90 days according to the manufacturer's own data. And according to the data, for every 8-9 patients treated, 1 will get a side effect (like diarrhea).

My conclusion is that this nutritional supplement is interesting, but not worth trying yet.

edit: As one comment points out, this medication/food supplement is a single triglyceride (>95%). But I think it is made from a variety of oils (palm oil and others) due to the warning on label regarding food allergies.

Edit (6/12/2011)
I realized that this is my most viewed post on my blog and I would like to update it a little. There are several things I would like to see studied/researched about any specific intervention for dementia before I get too excited about it: The intervention has to
1. Show a difference between placebo and treatment in long term studies (i.e. more than 6 months)
2. It has to show an effect in both research scales and clinically oriented outcomes
3. Clinical significance (as opposed to statistical significance) has to be defined separately from the study
4. The study has to be large enough to define subgroups (i.e. those who achieve the threshold of clinically significant change/improvement)
5. A Number Needed to Treat needs to be able to be calculated
6. Ideally a way to tell if the treatment is working or not working would be researched along with effectiveness
7. Discontinuation studies need to be done that are not simply open label studies in order to allow people to feel comfortable stopping a med that will likely not benefit the majority of subjects.

These seven criteria will allow a patient/physician to know what a medication is supposed to achieve and whether it is clinically meaningful, what percentage of people actually achieve it, when it is not working so it can be stopped and the risk involved of stopping it.

To be fair to Axona, no medication/treatment meets these criteria so it is hard for me to get excited about any pharmacological intervention. I'm not a fan of starting a medication without knowing if it is working, whether it is doing anything clinically meaningful, how likely someone is to get benefit, when to stop it and risks involved.

Introduction

Blog entry #1

Geriatric Issues: A blog of questions and answers

After being a practicing physician for four years, I decided to go back to training to do a Geriatric Fellowship. I'm finishing my fellowship on Tuesday and after that I'm joining the University of Pennsylvania as a faculty in Geriatrics.

Geriatrics is something that has been on my heart since before starting medical school. I love the interaction with families and patients. Geriatrics is a field of change and transitions and one thing I find rewarding is helping patients and their families anticipate, adjust, and succeed in the transitions of getting older. In order to do this, one thing I have found myself doing very frequently is having family meetings, but the problem is that the more patients I get, the more family meetings I need to do and I end up having difficulty trying to communicate everything that I want to to patients and their families.

In many ways, I find that geriatrics is a lot like pediatrics-a lot of the transitions are predictable and if information can be given out in time, patients and families can plan for the future instead of waiting for crises moments like a hospitalization or a hip fracture. One of the purposes of this blog is to provide a forum to distribute good, accurate anticipatory guidance to patients and families to allow everyone access to the medical knowledge needed to make good decisions and to plan. The goal of this blog is to make sound medical information fully accessible to patients and their families to allow them to become as informed as a physician. In this day and age of Internet and the world wide web, I believe fully that nothing should stand between patients and medical information.

My second purpose behind this blog is to allow patients and families to ask me questions to challenge me. I find that patients often ask the best medical questions (usually something that begins with "why") and it pushes me to learn more, read, and be much more precise in my medical knowledge and practice.

I haven't done a blog like this before so this will be a work in progress. The format will be fairly straight forward-I will post entries and will come up with future topics from comments, emails, and things I'm learning from my practice. While there are many web sites to serve as resources on the Internet, I hope this blog takes on the flavor having geriatrician in your own family. I really hope to make this blog and my answers very interactive, personal and relevant to you. So, please feel free to ask questions and I hope you enjoy my blog!

About me:
I started my medical career at the University of Michigan where I received my B.S. in Biomedical Sciences in 1997. In 2000 I received my M.D. from the University of Michigan as well. From 2000-2003 I went to MacNeal Family Practice Residency Program-University of Chicago in Berwyn, IL and from 2004-2008 I worked as a solo practice physician in Shickshinny, PA. In July of 2008, I started my Geriatric Fellowship at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson. Starting August 1, 2009, I'll be on faculty at the University of Pennsylvania.