Future hope

Well, I've realized that blogging successfully means some serious time which I did not have over the last several months, but I'm hoping to get back into it. I love geriatrics and it's such a developing field.

In any case, I came across this article in the NY Times. There are over 70 medications under development. There are only 4 that are FDA approved today. It provides some hope that we will have some medications for geriatrics that will do more than just give minimal improvement on research studies. Ideally something that will allow a person to stand back and say, yeah I see the difference. One day......

I also read this in the NY Times about an elderly man who ended up having a pacemaker and the craziness that developed when it was time to shut it off. Unfortunately, without a geriatrician or a geriatrician perspective among the specialists, this is what can happen.

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!