Tuesday, December 22, 2015

A geriatrician's view of the SPRINT study

This is all I have for now.

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.