In the US, every year the MacArthur Foundation gives an award called the “Genius Grant”(and $500,000 with no strings attached) to, what else, but a number of geniuses. And this year it included a geriatrician, Dr. Eric Coleman!
Dr. Coleman, at the University of Colorado, is already famous in geriatrics for his groundbreaking work in care transitions. An increasingly complicated problem, the fact that older adults are more likely to be in the hospital means that, naturally, they are more likely to be discharged from hospitals. Discharged where? Sometimes they are discharged back home, but sometimes to a nursing home or rehabilitation center and then back home. Or– unfortunately– often back to the hospital. The maze of transitions is only worse because doctors, nurses and the health care systems they work in do not do it well. This is where Dr. Coleman comes in. He has created systems to help make the back-and-forth to the hospital happen less often or happen more smoothly when it does. And this is both an immensely complicated and immensely important problem to be solving– hoping to save money, lives, time and quality of life.
He joins some incredible people who have been honored in the past for their incredible work for older adults.
Last year, Marie-Therese Connolly, and elder rights lawyer was recognized for her work in elder abuse. In 2009, Dr. Mary Tinetti at Yale won for her pioneering work in falls. And in 2008, Dr. Diane Meier at Mt. Sinai in New York won for her incredible work in palliative care for people at the end of life.
The more these leaders are recognized for their committment and contribution to the care of older adults, the more the world will see the important and serious problems facing older adults today. Hooray to the geniuses working to help seniors!
In the most upcoming issue of the Archives of Internal Medicine (Sept 24, 2012), there is an article by Dr. Benjamin L. Willis and colleagues called “Midlife Fitness and the Development of Chronic Conditions in Later Life”. Their findings lend more support to the idea that being more active helps prevent chronic conditions.
It was an impressive article in that they made use of a large cohort of subjects–18,670 total– that took a physical fitness test at one point in time in middle age (average age 49 years old). They then looked at how many chronic diseases, through Medicare data, these people developed and when. They found that people who were most active, compared to the least active, were less likely to develop chronic diseases. Furthermore, when they did develop a chronic disease, they developed them later in life. This is support for what is referred to as compression of morbidity, which is the phenomenon that now that people live longer, much of the morbidity of disease is also being compressed into fewer years toward the end end of life, so that overall we live longer, less-sick lives.
Some of the specifics– They considered people’s physical fitness by a treadmill test and measured their fitness by “metabolic equivalents” (METs; a measure of intensity of activity). They looked at 8 chronic diseases: ischemic heart disease, congestive heart failure, stroke, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, Alzheimer’s, and cancer of the colon or lung. They report that for each increase in MET, men had a 5% lower risk of developing a chronic disease and women had a 6% lower risk of developing a chronic disease. And this was true when they looked at each of the diseases on their own, meaning more activity protected against all of these various conditions. (For reference: sitting watching TV is ~1MET, walking is ~3 METs, and running ~7-8 METs.)
They say that exercise did not appear to extend lifespan, but those who died had fewer chronic conditions before they did. And, of course, there were several potential problems with the study. There were more men(~80%) then women, and this was overall a white, well-educated group– so this is not representative of our country as a whole. They also cannot really say if people workout more and can attribute good health to that, if they workout more because they are fundamentally more healthy, or if they are healthier and workout for a third, but related, reason (like maybe good genes?).
Overall, this was an intriguing study and lends support the idea that activity is good for us and means we will live healthier lives, from middle age onward. Not many of us will waste much time arguing this– we would rather spend it being active!
The article: http://archinte.jamanetwork.com/article.aspx?articleid=1352789
Interview with the author, Dr. Benjamin Willis: http://archinte.jamanetwork.com/multimedia.aspx
Commentary in the same issue, “Thriving of the Fittest”: http://archinte.jamanetwork.com/article.aspx?articleid=1352790
NY Times article about the research: http://well.blogs.nytimes.com/2012/09/05/the-benefits-of-middle-age-fitness/
We all know how bad our thinking can be when we don’t get a good night’s sleep, but over time poor sleep may put us at higher risk of more profound cognitive problems, like dementia.
Recent studies presented at the Alzheimer’s conference this summer show that sleep disruptions of different kinds– like sleep apnea (abnormal periods of obstructed breathing or stopping breathing), decreased time sleeping, or waking up often– can lead to real cognitive deficits.
Dr. Kristine Yaffe, from Univ of California, San Francisco, directs a clinic that evaluates and treats patients with memory disorders. Her research makes an important contribution because it looks at direct measures of sleep by observing people’s sleep quality and their subsequent development of cognitive problems 5 years later. Many other studies have looked at people’s self-report of how they sleep, which is notoriously inaccurate, and the concurrent presence of memory or cognitive problems. Such an approach does not address the question of which came first, the cogntive problem or the sleep problem, but Dr. Yaffe’s work suggests that in some people sleep problems may come first. Persons with disordered breathing (like sleep apnea) had more than 2 times the risk of dementia later on.
Let’s not all stay up even later worrying that by not getting good sleep we are imperiling our brains. The lesson is yes, get good sleep (that’s an order)! And for us that take care of patients, we should be asking them about their sleep and daytime functioning– daytime sleepiness can be an indicator that someone’s sleep at night is not adequate– and get them tested for sleeping problems. Many sleep problems can be treated, and doing so may save precious brain function.
NPR interview with Dr. Yaffe and news story: http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=159983037&m=160095742
I went Friday night to see a movie just released here, Robot & Frank. I knew I would love it just based on the premise, but it may just be my favorite movie in the last couple years.
Set in the “near future”, it tells the story of Frank, an older man suffering from early dementia, who is given a robot by his children to help take care of him. The man, bored and isolated in a country town, gradually comes to enjoy the company and stimulation the robot provides. The story gets moving when you learn that before his retirement he was a professional jewelry thief and now, with the encouragement the robot provides to be active, he realizes he can get back in the game and teach the robot to help him steal. It’s a movie, so inevitably they get into trouble.
I am a sucker for movies about dementia because it is complex and a hard topic to do sensitively and well. But Robot & Frank is about more than the vanishing mind. It is about the person Frank was, is and always will be, and how dementia is just a part of that. The movie and the actor, Frank Langella, make him shine as a character. It is also about the stress that an aging and vulnerable parent puts on children, especially in the US, who live far away and have their own families or geographically distant careers. In this way it touches on the way Americans in particular are dealing with dementia.
But it went from good to great because it got how we treat dementia right (Sadly, in the near future we still don’t have better medication to treat dementia it seems). Now we largely treat dementia with lifestyle changes and support via caregivers and adult day programs. The robot is basically a lifestyle manager– he gets Frank on a routine; he makes sure he sleeps enough; he keeps the house clean and orderly; he cooks and serves him well-balanced meals at regular times. He endlessly proposes activites: let’s garden, let’s go for a walk, let’s play a game. He knows that to keep Frank well he needs to keep him as physically and mentally as active as possible and keep a routine. And then when Frank gets upset or angry, naturally he does not take it personally and can continue to work with Frank. He does not get upset or burnt out — an unfortunate reality for many human caregivers. By the end I was intrigued on how robots could be the perfect treatment to help people with dementia have the best functioning possible.
I would even suggest that Frank gets the idea to have the robot help him with burglaries because his brain is working better at this point, after the robot’s interventions have made him sharper. This is not unusual. When someone with dementia starts getting good care, they start doing better in many ways– mentally, socially and physically.
No matter, it’s all a movie anyway and such sophisticated technologies, while present in small ways– eg. alerts installed at home to help family monitor their loved ones from afar, small fuzzy robots to help demented patients with behavior issues (see this prior post)— are a long way from being fully autonomous beings that can live with otherwise independent elders. But I was impressed with how the screenplay and the movie treated the tangled issues of dementia, aging, and family tension and made it fun and funny. Like anyone with dementia, Frank never stops surprising everyone, even the robot, who he reminds that “the human brain, it’s a lovely piece of hardware.” Indeed.
See other reviews:
Including all generations may be best for some
While I had high hopes for a scientific blog today, I find myself more reflective on a wonderful experience I had this weekend and its impact on the work I do.
I was lucky to attend the wedding of a close friend and his new bride. It was under the relentless but magnificent sun in the scenic foot hills of Mt. Hood, Oregon. We were hot, some of us even burning, but we joyfully celebrated with the graceful couple, twice– once with her family’s religious traditions, and once with his family’s religious traditions (welcome to the US!). Beautiful, inclusive, rowdy and sweet, it was a wonderful series of events over two days.
I noticed, too, that the couple was fortunate to have, along with nephews and nieces and friends and parents, many of their grandparents and older relatives there. I couldn’t help but notice one older gentleman who attended every event. He walked formidable distances to the meals and the ceremonies, but often one or two relatives would help him. He walked slowly but deliberately. And if anyone looked over at him, he smiled from ear to ear. Despite clear difficulty, he was an undeniably positive force and seemed to spread cheer. The groom acknowledged this man, his grandfather, in his wedding speech. He said despite a recent broken bone in back and being 95 years old, he got up every morning and declared, “I’m going.” And he was very grateful that his grandfather had come. And I was amazed that, as far as I could tell, his grandfather stayed later than I did at the party!
As I watched the groom’s grandfather enjoy and take part in the exhaustive events of the weekend, I had a couple thoughts.
- Many of my patients, when faced with difficulties that come with aging– pain, mobility issues, health problems– will talk about what they look forward to as what keeps them going, and it is commonly a grandchild’s graduation or wedding. I thought I understood this, but it was beautiful to see. And many of the other bloggers on this site have written about how having things to look forward to maintains psychological health and well-being. That was clear to me this weekend.
- For so many reasons– physical and cognitive function among the most important– I routinely try to identify and encourage patients to stay as socially engaged as possible. Watching the engagement and joy of the groom’s grandfather, I thought about the recent and influential article by a colleague of mine at University of California, San Francisco, Dr. Carla Perissinotto. She found that feelings of loneliness led to a higher rate of death and functional decline in a cohort of elderly US adults, independent of whether or not these adults actually lived alone. This finding means that for us as geriatricians, knowing that our patients live alone is one thing, but actually asking them if they feel lonely and trying to find ways to help them feel less lonely is just as important.
At this spectacular wedding it was wonderful to see everyone of all ages celebrate and be together, but for one person, the groom’s grandfather, it may have actually prolonged his life.
So, this is a not an entirely new phenomenon, but it is new to me.
Every Friday I have clinic at a community clinic in Berkeley, California and last week we were visited by a local organzation, PD Active, a group that does advocacy and programs for people with Parkinson’s disease (PD). If you don’t know much about it, PD is a brain disorder that causes difficulty with movement and usually affects older people (Michael J. Fox is unusual in that he developed PD very young). It is characterized by slow movements that get worse– hand and arm tremors, trouble buttoning a blouse, walking very slowly, talking slowly and losing the ability to make facial expressions. As the disease progresses, people can suffer from frequent falling and ultimately dementia.
Needless to say, thinking of people with PD dancing is an incredible thought as they are often thought of as stiff and slow, even unbalanced. Our visitor explained the incredible things PD Active does for people in the area– yoga classes, dance classes, support groups and advocacy events. I am sure I will be recommending it to some of my patients with PD. However, one thing he mentioned really caught my attention. When he started to do Dance for Parkinson’s (a registered trademark), which was originally developed in Brooklyn at the Mark Morris Dance Group, he felt “graceful”.
Looking at their website and videos, I was incredibly moved. Not only does it seem to get people to use their bodies in ways they did not think they could, it improves their mobility and safety. Music and dance open up their brains and ability to move more. See if you can bring it to your city!
PD Active in Berkeley, CA: http://pdactive.wordpress.com/
Picture from Dance for PD (R) website: http://danceforparkinsons.org/
Some wonderful concepts in patient-centered care were the topic of several pieces in this week’s New England Journal of Medicine (March 1, 2012). Overall, they discuss its critical role in the future of US health care reform. One key article was co-authored by two of the US’s most prominent geriatricians, Dr. David B. Reuben, Chief of Geriatrics at University of California, Los Angeles, and Dr. Mary E. Tinetti, Professor of Geriatrics at Yale University.
In this article, “Goal-Oriented Patient Care—An Alternative Health Outcomes Paradigm”, Drs. Reuben and Tinetti discuss the movement in US health care to make patients’ values guide clinical care in a more meaningful way. This is now an explicit aim of our ever-powerful Center for Medicare and Medicaid (see a prior post re Medicare, the US’s largest insurer). Yes, patients’ values should guide decision making, but they begin to answer why and how it can be achieved.
As someone training in geriatrics, it did not surprise me that geriatricians wrote this succinct and timely article. In our field, we frequently care for patients whose medical complexity makes it difficult to pursue the “standard of care” for many conditions. (Which looks bad on many traditional quality measures. For example, the measure of average blood sugar considered optimal for diabetics is not helpful for older adults in whom it is dangerous to keep at such low levels, but many quality measurements do not take this into account.)
One example might be a patient who is older, not very healthy, and who has a newly discovered kidney cancer that may take longer to grow and cause a problem than she is likely to live. Should she choose surgery to remove it when she may take months to recover and never get back to her prior state of health? The decision of what to do must be a carefully considered one between the patient and her doctors. The right answer lies in the complex mix of what the medical problem is, what is realistic, and what the patient wants based on understanding the medical options and her preferences. But how do you measure this? Should we even try?
Drs. Reuben and Tinetti suggest we should work with patients to understand their goals, and document this. We should then measure whether or not the patient’s goals were achieved with such techniques as “goal-attainment scaling,” or other measures of how well a patient’s goals were met. This should be part of how we look at quality in health care in a rigorous way.
The future is understanding that meeting patients’ goals are absolutely a critical part of how our health care system can be considered to be high quality. And the future is finding ways to measure how well we actually meet patient’s goals so we can value those physicians and systems of care that do it well. It will be very interesting to see how effective we are at doing this, and if indeed our paradigm shifts.
Reuben DB, Tinetti ME. Goal-Oriented Patient Care– An Alternative Health Outcomes Paradigm. N Engl J Med 2012; 366:777-779.
I do not usually jump to take a test. However, a kind email invited me to take The Medicare Quiz written and promoted by the Kaiser Family Foundation. Many of my patients rely on Medicare, the main provider of health insurance for adults over 65 in the US, and a problem for our nation as our demographics shift to an older population and health care costs rise and rise. (The official Medicare website.)
I felt I should see how much I really knew about this critical program, especially since right now Medicare and its payment structure stands to be affected by the ongoing rollout of President Obama’s healthcare reform act, the Affordable Care Act. Not only that, but Medicare is enmeshed in Washington’s politics and a daily news item. On Monday, the President announced his 2013 budget, and part of the savings he proposes comes from changes in Medicare. Today, Wednesday, Congress agreed to changes in a payroll tax change that somehow also included NOT allowing payment cuts to doctors who take Medicare payments, making many doctors organizations very happy.
So, Medicare is part of our politics and our massive health care spending crisis, and what else do I know?
Turns out, little. I scored 4/10. Devastated. But I did know (or learned) that it is ~15% of our total budget and that 50 million people are insured by Medicare. Somewhat astounding figures.
But, in a way I felt better. The quiz gave me information and I rediscovered the Kaiser Family Foundation website. It has incredible information and educational items, for example on all issues relevant to Medicare or health reform, and their news website that has a section on aging. They have an incredibly clear lecture on the basics of Medicare on their education website and interactive tools throughout their websites that make learning easy. For understanding health policy and Medicare, right now I have nothing better to recommend. (In California, the California Healthcare Foundation provides many helpful resources, too.)
Everyday the news brings a new Medicare gem. Now if I could only understand how Congress works…
Will you take the quiz?
Kaiser news on aging: http://www.kaiserhealthnews.org/topics/aging.aspx
Kaiser Family Foundation: http://www.kff.org
Medicare Quiz: http://quiz.kff.org/medicare/medicare-quiz.aspx
California Healthcare Foundation: www.chcf.org
A new tool to help doctors and patients discuss life expectancy.
From my posts, I hope my bias for my home institution is not too burdensome. Unfortunately, I cannot help it if the Geriatrics faculty at the University of California at San Francisco churn out an innovation a week. This week? A major advance in how we can prognosticate for our patients.
Prognosis is an inherently difficult process for doctors. How do we, as a medical community, really know how long a patient has to live? What should we tell her about what we do know? It is often difficult to determine a person’s prognosis if she does not have one specific disease that can guide us. It would be helpful to always be able to say something specific; for example, “We know that women with your stage of lung disease generally live another 6 to 8 months with the treatments we can offer you.”
The difficult place for doctors to prognosticate accurately is when a patient has many diseases, none so severe that one overshadows the others. And sadly, many doctors do not, as a result, discuss life expectancy with their older patients who often have multiple diseases. Despite this, we increasingly have evidence that patients and their families want to know what the future holds so they can plan and make medical decisions accordingly. And that doctors should start these conversations. Drs. Alex Smith, Brie Williams and Bernard Lo made this case quite convincingly in a recent New England Journal of Medicine article.
Now we have a tool to help us and patients discuss prognosis and overall life expectancy. And it’s publically available!
Uniting different research done on larger populations and tools developed from this research, eProgosis.org, is a platform for using 16 different estimators of life expectancy for older adults in different settings—nursing homes, hospital, the community—and it leads you through each calculator. In the end, you get an estimated life expectancy. And anyone can use it.
The media buzz around this tool (see articles listed below) has emphasized what should be understood well by anyone using it—this is not a crystal ball. These are tools based on studies of groups of people, and therefore cannot be exact with an individual. Also, because certain populations are used in the studies to derive the tools, it may not apply to everyone who plugs in his or her information. It is unclear, for example, how this extends to international populations, which were not studied. Therefore, the results should always be discussed with a doctor.
Regardless, ePrognosis is a remarkable leap forward. It is an accessible and useable tool that uses the best information on how to predict life expectancy in complicated older adults. It creates a way for patients and doctors to begin these critical conversations with real information. Explore it, and see what you think!
ePrognosis website: http://www.eprognosis.org/
Blogs and articles mentioning ePrognosis:
3) NY Times, New Old Age Blog: http://newoldage.blogs.nytimes.com/2012/01/10/how-long-until-the-end/?scp=2&sq=eprognosis&st=cse
4) NY Times article on JAMA paper: http://www.nytimes.com/2012/01/11/health/using-interactive-tools-to-assess-the-likelihood-of-death.html?scp=1&sq=eprognosis&st=cse
Recent academic articles on prognostic indices:
1) Yourman LC, Prognostic Indices for Older Adults. Journal of the American Medical Association (JAMA), 2012;307(2):182-192, http://jama.ama-assn.org/content/307/2/182.short
2) Smith AK, Williams BA, Lo B. Discussing Overall Prognosis with the Very Elderly. New England Journal of Medicine (N Engl J Med), 2011; 365: 2149-2151. http://www.nejm.org/doi/full/10.1056/NEJMp1109990
The weighty issue of preventive health in the elderly.
When someone says preventive health, many things might come to mind: eating right and exercising, screening for pre-cancerous lesions, and getting a yearly flu vaccine. Doctors also often address secondary prevention measures, which are the prevention of further complications of a disease such as preventing a second heart attack or stroke. A comprehensive approach to preventive health care in adults needs all these strategies. However, the holy grail of medicine is prevention that also improves mortality. That is, effectively extending life for people because they did not get the disease we prevented.
The straight line from preventive action to actually preventing disease may still exist in the elderly. Certainly, we can say that the influenza vaccine and the pneumococcal vaccine (against a bacteria that causes pneumonia) provide protection from these diseases or their complications. Figuring out what also prevents death is increasingly complex in the world of geriatric medicine since the most powerful predictor of death is age, not a specific disease. At a certain point, if you prevent one cause of death, people will die of another.
If this is the case, the important question is what should be the focus of preventive health in elderly? Cancer, heart disease, vaccine-preventable diseases are all uncontroversial as critical diseases the elderly. But increasingly the best approach is to ask, who is the patient? As with everything else in the elderly, the individual is the important guide to knowing how to proceed.
For example, in the field of cancer screening Dr. Louise Walter of University of California, San Francisco has shown that not everyone of all ages is created equal. For those adults in the healthiest bracket for their age that have at least 10 more years to live, it would be reasonable to offer them colorectal screening that takes at least that long to have any benefit. But for a frail older woman in the nursing home, she may not need such screening as it will be unlikely to impact her life or life expectancy. And furthermore, colorectal screening – which includes a colonoscopy and medications she would need to go through the procedure—might cause her more harm than good. Lastly, the patient’s preferences should be considered, not just the guidelines. Does she want to know if she has a tumor in her colon even if it is unlikely to cause her death, or not? Increasingly, preventive health guidelines with strict age cutoffs are meaningless as the diversity of people at different ages is more powerful than age alone. Life expectancy should be a far more practical guide for a physician and patient to making decisions about what screening to do.
What can we say is universal? For everyone, young and old, being as functional and independent for as long as possible is generally a goal. To that end, the obvious applies: counseling older adults to remain as physically, mentally and socially active as possible. Physical activity helps with mood and depression, weight control, falls and all those pesky diseases that are so prevalent in the elderly—bone disease, heart disease, stroke, diabetes and cancer. Being mentally and socially active also helps maintain cognitive function. Checking hearing and vision and making sure any deficits are corrected is key to preventing falls, social isolation, depression and cognitive decline. Quitting smoking at any age is hands down the best thing you could do for your health, and this applies still in older age (though I have one patient who is 98 who understandably wants to enjoy his pipe a few times a day without me constantly nagging him to stop). Watching how much you drink as you get older is also highly advised as alcohol can affect cognition and falls. Getting an annual flu vaccine and other recommended vaccines are just as important as when people are younger, if not more important. Disease and cancer-specific prevention requires an individual approach, especially in the oldest old. Life expectancy and weighing harms and benefits with our patients should be our guide there.
1) Day LW, Walter LC, Velayos F. Colorectal cancer screening and surveillance in the elderly. Am J Gastroenterol 2011; 106:1197–1206
2) Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750-2756.
Improving care after hospitalizations
In the US, one of the most dangerous times for an older person is being discharged from a hospital. After even a brief stay in a hospital, often many things have changed: important medications, disease-specific care plans (for example diet or activity), or follow-up plans with doctors. And a bad discharge can mean readmission to the hospital in less than a month for as many as 20% of patients.
Assimilating new and critical information at discharge can be difficult. For one thing, an elder may have reversible cognitive dysfunction, which is memory and thinking difficulty during an acute illness that improves over the course of weeks to months. This is not to mention those elders that we know already have cognitive problems, eg. dementia.
However, a known and likely more potent contributor is how badly discharges are done—hastily, without communicating to the patient’s outpatient doctors, and sometimes without caregivers there to help process information. I cannot say how many times I have seen a patient in clinic who was recently discharged from the hospital and I have no record of the hospitalization, medications changes made and what, if anything, I was supposed to follow-up on.
This needs to change. In 2013, US health care reform will mean that for certain conditions hospitals and their affiliated systems (clinics, medical centers) will be penalized for “unnecessary readmissions”.
This is an added push to innovators to work now on the issue of transitions. One approach is the Support from Hospital to Home for Elders (SHHE) Project at the San Francisco General Hospital where they have a nurse visit the patient before discharge to make an individualized plan and follow-up with them afterward for several weeks. Another is to standardize how the discharge is done through a checklist, one way that Better Outcomes for Older adults through Safe Transitions (BOOST) in Atlanta tackles the problem. Further still, some programs focus on providing a new team of providers—doctors, nurses, social workers—who will take over care of the patient during the critical transition time and do all that is needed to make it a success, for example by doing more home visits. This is the model that GeriTraCCC has started in San Francisco for heart failure patients.
There is no right way to improve hospital transitions in all systems and for all patients, but more innovations surely will follow as we feel the pressure to change over the next year.
1) General information on innovations in health care to improve quality: http://innovations.ahrq.gov/innovations_qualitytools.aspx
3) GeriTraCCC: http://geriatrics.medicine.ucsf.edu/care/geritraccc.html
Like any doctor, geriatricians use lots of specific terms. Below, I explain a few to help you venture into their murky literature and professional articles.
Firstly, geriatrics versus gerontology. Geriatrics is the medical specialty that treats older adults and focuses on clinical care. Gerontology is related but broader and refers to the study of aging—including social, biological, and psychological inquiry.