So now I'm a death pit doctor?

I hate headlines like this so I’ll say it again, If an engineer builds a one winged airplane that doesn’t fly, why blame the pilot and flight crew? Our society has underresourced NH’s and responds with surveys and fines. And blame.

https://www.nytimes.com/2020/04/17/us/coronavirus-nursing-homes.html

If you want to blame NH’s, blame society for rampant ageism that allowed NH’s to be so resource poor for decades and prefer older disabled adults to be out of sight out of mind.

If you’re a doctor, blame medicine for spending money on medications and procedures that only hurt older adults. Blame US medical schools that produce less than 100 gertiatricians out of 25,000 graduates each year. Blame the lack of primary care.

Blame hospitals for getting mad at NH’s who send pts and blame NH’s when we don’t. Blame the disparity of resources between hospitals and NH’s when the virus could care less.

Blame our govt for not providing testing which makes NH’s fly blind. “Assume your whole building is infected” has been said to so many medical directors pleading for tests.

Blame @CMSGov for doing nothing but surveying and fining NH’s during this pandemic (see Kirkland).

Who is rushing to volunteer in NH’s like the hospitals in NYC? Who is coordinating meals from restaurants for NH workers? If it isn’t you, well then....

For those of us who have pleaded for change for decades, who have been so content to work without recognition, to choose to be where no one wants to be, being blamed adds to the absolute agony of this pandemic.

Every time I see a new patient in the NH I ask them how they feel about it. It’s never positive. They feel discouraged. They would rather be home. Families feel like they failed in some way. They wish they had more resources. No one has a life goal of living in a NH.

But then I look at them and say, if you had a choice you wouldn’t be here but guess what, I chose to be here to be with you and so did everyone who works here. You are not alone. We love doing our best for you and you don’t have to go through this alone.

I was the only medical student in my class who did a nursing home elective. I was the only resident in my program who did a nursing home elective. Geriatrics is the second lowest paying specialty (still well paid all things considered). But despite everything I wouldn’t change it

I stand in a gap between the medical sub specialists to one side and the proceduralists to the other. I’m outside the academic ivory towers. But I never wonder if I am making a difference.

This is awesome! Way to go Dr. Heimlich

I love this story.  Dr. Heimlich, at 96, used his namesake maneuver for the first time to save a life!  Just goes to show that old people still matter a lot!

Caregiving school scholarship

For my many caregivers who are also in school, you can click on this link to apply for a $1500 scholarship.  Only 3 awarded nationally but it is wonderful to see this.

What are the biggest risk factors for dementia?

Recently I came across this article on Nature Reviews which is a very good authoritative journal.  (article is not free).  It lists MODIFIABLE risk factors for Alzheimer's.  Guess what ranks highest?  Diabetes increases risk by 46%, hypertension by 61%, obesity by 60%, depression by 65%, smoking by 59%, low education by 59%.  But the highest risk for dementia was physical inactivity which raises the risk by 82%!!!!!!!

Therefore-WALK!

An encouraging note from your geriatrician.

ps these are relative risks.  So if your baseline risk of developing dementia is 10%, then physical inactivity will increase the risk to 18%

pps the biggest risk factor for dementia is age.  By far.  This is not easily modifiable ;)

A geriatrician's view of the SPRINT study

This is all I have for now.

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.

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).

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.

Get a flu shot

Getting a flu shot is like putting on your seat belt.  Please do it!

http://www.cnn.com/2014/12/31/health/flu-epidemic/index.html

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

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.

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.

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.

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.  

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!

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.

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.

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.

When to stop statins in the elderly

One of the challenges for me in blogging (occasionally) is that I tend to think about patients that I have just seen but due to privacy, I definitely do not want to reveal any identifying information.

One of the concepts that geriatricians get easily and intuitively is that not all medications are meant to be life long for a variety of reasons.  But that concept seems to be missed on many non geriatricians.  The following case demonstrates this point.

Recently I saw an elderly gentleman with dementia (elderly means late 80s to 90s).  He was not complicated medically. Pretty typical health issues including high blood pressure and high cholesterol.  But his major current issues was quite a sudden decline in memory, ability to care for self and weight loss.  These signs, taken together, along with his advanced age and no obvious easily reversible cause discovered leads to a very poor prognosis.  Family understood this and was asking about hospice.  The patient had a good quality of life, was comfortable and not in pain, but the family clearly wanted the goals of his care shifted to function, quality of life, maintaining independence and community at home.

When someone has an acute deterioration of their function, I cast a very wide net as to what is causing deterioration.  There's a lot that goes into that evaluation, but as a geriatrician, I always look at medications to see if a patient is taking a medication that is harmful or unnecessary.  Statins do cause side effects and they are often a medication that is potentially harmful and unnecessary (especially over short periods of time).  So for this patient, since there was no readily obvious cause of the sudden deterioration of memory, function and weight, it is worth trying to stop the statin to see if it is a culprit.  Several weeks later when I saw the patient back, I found out that the primary care doctor was too nervous to stop a statin because the man had a heart attack or stroke years (decades?) ago.

I get so used to stopping/holding/reducing meds in the face of side effects/unstable patients that I am always surprised (but shouldn't be) when another physician is too afraid to stop a medication despite staring at a symptom that well could be a side effect of the medication.

Reasons to start a statin are fairly clear: LDL higher than a certain level (100, 130 or 160) or someone who has had a heart attack, stroke or has diabetes.

But what are good, concrete reasons to stop a statin?  Well, there are no good published guidelines.  So here goes.  I'll write one!

First let me review what statins do and how they do what they do
1.  Statins prevent heart attacks in older adults.  While they prevent strokes and heart attacks in younger adults, in older adults that has not been shown to be the case.
2.  Therefore, statins are preventative medications.  They do not confer any immediate functional, comfort, therapeutic (fixing) benefit to the patient.
3.  The longer you take a statin the more effective they are.  So while a statin may help 1 in 45 patients taking a statin to prevent a heart attack over 2-3 years, over 15 years it may help 1 in 10 patients (a better ratio).  Statins are much more effective over decades.  Statins confer no benefit over months (unless you just had a heart attack or stroke).
4.  Statins can cause weakness, muscle ache, mild hepatitis as common side effects.  And they interact with other drugs.

So why stop statins? (not in any particular order)
1.  They are causing side effects.  General principle of life is that if a treatment is causing a side effect, then it isn't worth it.  Even in high risk patients, statins only benefit 1 in 10 patients over 15 years.  Most people don't benefit from these medications.  Taking a medication that is non beneficial and causing a side effect is the worst of both worlds.  Even for that 1 in 10 that may benefit over 15 years, I would argue that tolerating a side effect that long still might not be worth it.

2.  Prevention of heart attacks and strokes no longer matters.  This is true for people who are at the end of their life.  Keeping their LDL less than 100 is an abstract goal that does not matter any more.  This reason is true of almost everyone on hospice.  Sometimes treating medical problems that cause symptoms (COPD, CHF) is more important that treating medical problems that do not cause symptoms (like high cholesterol).  Prevention just stops being a priority because the symptoms that a person actively has is more important than an event that could theoretically happen.

3.  Other goals (like comfort, function, independence, quality of life) are way more important, higher priority, need more attention, are worth the energy etc.  You get my point.  It is amazing to me how doctors prioritize problems that don't match a patients priorities.  This is the flipside to point #2.  Sometimes goals just are not achieved by fixing a number on a blood test.  Statins never make anyone more comfortable and never increase function.  Most are achieved by methods not involving medications.  One of my pet peeves is that each specialist views their organ system as the most important organ system.  Doctors are not very good at prioritizing competing medical problems.

4.  Life expectancy is short.  Let me just say this-Statins do nothing over a timeframes of less than a year.  Statins work over years to decades.  Stopping a statin for the last 6 months of a person's life will not cause them to have a heart attack or stroke.  If they have a heart attack or stroke, they would have had one anyway.  No one NEEDS to die with a statin.  In fact, if someone does die of a chronic illness taking a statin up to the moment they died, I would argue that the physician was not appropriately tailoring the medications for the situation.

5.  2% is seen as a small meaningless number.  So over 2-4 years, in a general population of 100 older at-risk adults taking a statin, 2% will have a heart attack prevented.  This is a quantitative way of looking at the question.  The other would be, taking tons of pills is a big pain in the neck, or a person just isn't sold that a 2% reduction is enough to take a daily medication for 2-4 years (365 doses x 4=1460 pills!!!).  Now physicians are wired/taught/mandated/reimbursed/pressured into making every health issue seem like a BIG DEAL, but the dirty reality is whether someone takes a statin or not (over short time frames) will not likely affect their health (for better or for worse).  For my patients, whether to take something is a collaborative discussion.  Patients do get to have a say in these type of decisions. Guidelines be darned.  After all, patients ultimately have to live with the consequences.  Effectiveness is in the eye of the beholder.

6.  Lastly, it never hurts to take a break.  This isn't a reason more than it is just a plain truth (from my perspective).  Yes, for those who just had a stroke or a heart attack, there is an increase risk for another event if a statin is discontinued in the first year.  But for long term patients, stopping a statin for a short period of time (4-6 weeks) is perfectly safe (http://www.ncbi.nlm.nih.gov/pubmed/15477411).  Yes, after months and more likely years of not taking statins, there will be differences in heart attack and stroke rates (maybe strokes) but it will be minimal.

So there you have it, my reasons for stopping statins.  There are logical, concrete reasons that a person should stop taking their statin based off of ideas such as avoiding side effects, reduced efficacy, goal directed medicine and life expectancy.

CPR outcomes-how do I decide my code status?

So I finally got around to my literature review on CPR outcomes in older adults.  Cardiopulmonary resuscitation status (or code status) is asked at every hospital admission as required by law.  But how does one make a decision regarding whether or not CPR is right for them?  Understanding CPR outcomes is a starting point.  Having an accurate understanding is the anchor for deciding fit between values and the procedure (in this case CPR).

In a nutshell:
1.  CPR achieves

• Nothing for 50% of patients in the hospital
• For around 35%, the patient has a prolonged death in the hospital
• For around 15% the patient survives to leave the hospital.
• About 8% leave the hospital about the same as when they came into the hospital.

            For those with end stage anything disease (end stage heart failure, COPD, renal disease on dialysis, severe dementia, metastatic cancer), survival rate are easily less than half of that (so 7.5% survive and 4% survive to be about the same).  Because of the way these studies are done, the number could be cut in half again.

So for sick patients, older patients, the best number to use would likely be

• About 1-3% with severe disease will leave the hospital about the same as when they came in.

2.  There are risks.

• Trauma.  1/3 break ribs for example.  More as you get past 70 years old.  CPR can hurt.
• Prolonged death that is more painful.  Some people, instead of suddenly dying peacefully in their sleep from their heart stopping, will die from not being able to breath on a mechanical ventilator.  (about 35% of those who get CPR).  
• Living more dependently.  About half of survivors who were at home need to go to a Nursing home after CPR.  
• If a person is full code, then by definition, CPR will be the last thing they experience on this earth.  

So what to make of all this?  Everything is in the eye of the beholder.  For some people, having a 2-3% chance of living longer (even if it is just a couple of months) is totally worth it.  For others, it seems like a vanishingly small percentage and a complete waste.  There is no right answer.  For others, the trauma, risk of prolonged death, or the absence of a peaceful death is something worth avoiding at any cost.  For others, it is no big deal.  

So this is how I think about it:

CPR is good for you if ALL of the following are true:

1. Longevity is still an important goal
2. Dying peacefully is not a goal
3. Avoiding a prolonged death is not a goal
4. Comfort is not an important goal
5. You have a high tolerance for trauma
6. You're okay with living very dependently in things like bathing, dressing, toileting and feeding.
7. You are a gambler/risk taker.  Although you're hoping that after CPR you'll be the same, you won't regret your decision if you end up with a feeding tube for example because you're happy you went for it.  

If one of the above is not true, well then you have a decision to make right?  Is the tiny chance to living longer worth the pain?  No one wants pain but is the chance worth it?  Not to be too glib, but to quote Clint Eastwood, "you've got to ask yourself one question: 'Do I feel lucky?' Well, do ya, punk?"  There's a certain amount of gambling optimism to be full code.  Or absolute fear of dying where you're willing to take risks.  The chances of coming through is a little better than playing the pick 3 lotto.  So if you're really ticked off every time you don't win after playing the pick 3 lotto, well, then, you'd probably not be too happy after you get CPR. 

Onwards:  CPR is not a good choice for you if any one of the following is really important for you

1. Longevity is no longer a goal at all
2. Dying peacefully is very important (i.e. without painful procedures, with family present)
3. Comfort is a non negotiable goal
4. Avoiding a prolonged death is vitally important
5. Living very impaired is to be avoided if possible 
6. You have no desire to put up with any more pain
7. You're not a gambler.  

Anyway, it is up to the patient and physician to work together to figure out the fit between a patient's goals/values/limits and what CPR can realistically achieve for that patient.  It is much more complicated than "I'd like to live longer so let's go for it."  CPR is likely to make a person worse (all good intentions aside) and I would not want a person to be surprised or regret it.