Good Medical Care for the Elderly and How to Get It

Living with Alzheimer's

On March 29, 2007, the New York Times published an article about “early Alzheimer’s” disease. The article—Living with Alzheimer’s before a Window Closes—describes this as a period “when short-term memory is patchy, organizational skills fail, attention wanders and initiative comes and goes. But there is still a window of opportunity — maybe one year, maybe five — to reason, communicate and go about [one’s] life with a bit of help from [others.]”

A recent study done by the Alzheimer’s Association reveals that about 5 million Americans have Alzheimer’s and that about half of them are still in the early stages. The New York Times article discusses coping methods and also contains lots of resources for caregivers.

Aging with Down syndrome--A cruel complication

A report on March 12, 2007 in the Atlanta Journal-Constitution states that researchers believe they have identified the link between Down syndrome, a disorder that is the most common genetic cause of mental retardation, and Alzheimer's, a progressive brain disease that destroys a person's memory and mental ability.

Persons with Down Syndrome have an extra copy of chromosome 21 in their DNA. An excessive amount of a substance that accumulates as plaque in the brains of people with Alzheimer's is caused by this abnormality.

Neurologist Jim Lah of Emory University School of Medicine states that the brains of almost all people with Down syndrome will exhibit some of the changes associated with Alzheimer's by the time they are in their 40s. That's about 20 years earlier than in the general population.

People with Down syndrome usually died young until recently. (In 1983, for example, the life expectancy of someone with Down syndrome was just 25, according to the National Down Syndrome Society). However, advances in medical care and better overall health now mean that someone with Down syndrome can live to the age of 50, 60 or even longer.

But people with Down syndrome "end up developing Alzheimer's with virtually 100 percent certainty if they live long enough," said Lah. "If all Down syndrome victims lived to be age 80, I think you could say with confidence that all of them would develop outward signs of dementia."

The entire article may be read here.

Techorati tags: Down syndrome, Alzheimer's, caregiver, caregiving

Congress investigates safety of drug-coated stents

The Boston Globe reported on March 6, 2007 that Congress has sent letters to Boston Scientific and also to Cordis Corp., the division of Johnson & Johnson that makes the only competing drug-coated stent in the United States. Congress is investigating "concerns about the safety and off-label use" of the stents. In December, the Food and Drug Administration held a two-day hearing regarding the issue.

According to the Globe, Congress has requested information about whether the Boston Scientific’s marketing department funded any clinical studies on its stents, whether it paid any of the studies' authors or doctors, and whether it withheld the results of any studies.

The drug-coated coronary stents, introduced in 2003 are big business. They’ve become the fastest-selling medical device in history. Boston Scientific and Johnson & Johnson reap approximately $5 billion/year for the stents. Stents are tiny wire-mesh tubes that are implanted to hold open cleared heart arteries. Guess who pays the bulk of the $5 billion bill.

Read the entire article here.

Dying? Experimental Medications Not an Option

The U.S. Court of Appeals for the District of Columbia on March 1 will reconsider a case dealing with the FDA's regulatory authority covering pharmaceuticals to permit expanded use of experimental medications. The case against the FDA before the Court was filed in 2003 by the Abigail Alliance for Better Access to Developmental Drugs and the Washington Legal Foundation. The litigants seek to obtain access to experimental medications for terminally ill cancer patients. The court is asked to order the FDA to provide a special initial approval of experimental medications that appear effective and to allow their sale and distribution to terminally ill patients who have no other approved treatment options.

The FDA opposes the relief requested, stating that programs currently exist to provide experimental medications to terminally ill patients and that increased access to such treatments would lead to unacceptable risk. In May 2006, a three-judge panel of the court ruled that terminally ill patients have a "right of self-preservation" and should have access to experimental medications that have not reached Phase II clinical trials. According to the 2-1 decision, which reversed the dismissal of the lawsuit by a lower court, "barring a terminally ill patient from the use of a potentially lifesaving treatment impinges on this right of self-preservation." FDA appealed the decision and asked the full court to rehear the case. In November 2006, the court vacated the decision and agreed to rehear the case

Why it's difficult to attract doctors to geriatrics

According to the New York Times on February 6, 2007, Veterinarians who care for the animals that provide the United States with food are in increasingly short supply. The answer? The pay is better if the patients are dogs and cats; the hours are better. Thus it’s difficult to attract veterinarians to large animal practice.

In A New Problem for Farmers: Few Veterinarians, a recent survey by the American Veterinary Medical Association found the median starting salary of large-animal veterinarians to be $60,500/year, $11,000 less than that of small-animal veterinarians. The gap was even wider for veterinarians practicing 25 years: $98,500 for large-animal practitioners, $122, 500 for small animal practitioners.

One veterinarian told why she shifted from caring for farms animals to caring for family pets: She’d get paid $50 to do a C-section on a cow. But for the family pet, she’d earn $300. “It’s the money. I hate to say that.”

What does this have to do with Aging in Place? First, what the Times calls a “seismic shifts in farming, veterinary medicine, the economy and American culture” is much the same kind of problem America is seeing in its failure to attract medical students to the practice of geriatrics. This is a critical problem given the coming of age of the Baby Boomers. See the Alliance for Aging Research 2002 report: Medical Never-Never Land: 10 reasons why America is not ready for the coming age boom, 2002. Last accessed March 1, 2006 at http://www.agingresearch.org/advocacy/geriatrics/02016_aar_geriatrics_text.pdf

More on delirium: A "red flag" signaling a medical emergency

In August 2005, Dr. Margaret Rathier and her colleague Dr. J McElhaney, published a review study on delirium, its causes, the fact that it should be managed as a medical emergency, and how important early detection and treatment of the underlying causes of delirium will improve both short-and long-term outcomes. Rathier, Margaret O, McElhaney, J. Delirium in Elderly Patients: How You Can Help. Applied Neurology. August 2005. Last accessed February 1, 2007. http://appneurology.com/showArticle.jhtml?articleId=170100541

Dr. Rathier wrote that because delirium represents one of the nonspecific presentations of illness in elderly patients, the disorder can be easily overlooked or misdiagnosed. She states that misdiagnosis may occur in up to 80% of cases, but it is less likely with an interdisciplinary approach that includes input from physicians, nurses, and family members. Successful prevention of delirium requires systematic evaluation of hospitalized elderly patients. In this article, Dr. Rathier identified key risk factors to be alert for in the evaluation. She also outlined a multidisciplinary approach to diagnosis and management.

[Note: Misdiagnosis rates of 80% are too high. Misdiagnosis rates of 95%, as in the study I cited in my earlier Aging in Place article, are too high. Dr. Rathier relied upon different studies, most by Dr. SK Inouye. Dr. Inouye’s studies dated from 1990 to 1996.]

Death rates for cardiac bypass surgery

The Boston Globe today reported that the state of Massachusetts will soon allow Internet access to statistics on patient death rates -- mortality rates -- for cardiac bypass operations. Called quality of care information, the statistics will be available not only for hospitals and physicians' groups. The Web site will also give mortality rates for individual doctors.

Massachusetts plans to post a website by December 18, 2006 where anyone will be able to look up the mortality rates for 55 surgeons who perform cardiac bypass operations. The most recent figures in Massachusetts date to 2004 when approximately 4,000 patients had bypass surgery at 14 Massachusetts hospitals in 2004.

Shortage of Doctors Trained in Geriatrics

Taking Charge makes clear that a major reason why it's so hard for the elderly to get a correct diagnosis and the right medication is the fact that there is a tremendous shortage of doctors and nurses trained in geriatrics. The major point of Taking Charge is that the family caregiver is the one person in contact with the elderly patient who can provide the continuity of care and quality of objective observations -- the one person able to tell the medical team what is normal for the patient -- so that changes in status are red flags that medical intervention needs to occur.

A report published in 2002 by the Alliance for Aging Research revealed:

Only 9,000 of the 650,000 licensed physicians are certified in geriatrics – that’s fewer than two percent. Worse, this number is shrinking as older physicians retire or choose not to be re-certified.

This report also makes clear that most doctors and nurses lack any training at all in geriatrics.

At the time Taking Charge was researched, only 3 of the nation’s 144 medical schools had a department of geriatrics. Today, there is an increase -- 145 medical schools, 9 of which have a department in geriatrics.

In 2002, only 14 medical schools required a course in geriatrics; 86 medical schools offered electives in geriatrics, but only 3 percent of medical students choose to register for these courses.

Worse, only 720 of the nearly 200,000 pharmacists in the U.S. have geriatric certifications. And we all know that the elderly take most of the prescription medications.

It’s difficult to attract new doctors to geratrics because of the low reimbursements by Medicare and Medicaid.

Jane Gross told a compelling story about how this affects the nation's elderly in her article published on October 18, 2006 in the New York Times. "Geriatrics lags in age of high-tech medicine."

Reading this news article makes one realize how important the observations of a family caregiver can be when doctors try to diagnose medical problems in the elderly.

Current Issues Arising in Science of Aging

The New York Times has recently run a series of articles addressing issues of importance to baby boomers. These Articles look at the science of aging, and how humans are growing old in ways they never have before.

All articles will remain on the New York Times website at http://www.nytimes.com/ref/health/newage_index.html

Old but Not Frail: A Matter of Heart and Head
A central issue only now being systematically addressed is why some people age well and others do not. (Oct 5, 2006)

Live Long? Die Young? Answer Isn’t Just in Genes
Recent studies find that genes may not be so important in determining how long someone will live. (Aug 31, 2006)

So Big and Healthy Grandpa Wouldn’t Even Know You
The past 100 years has seen a change from small, sickly people to humans who are so robust their ancestors are almost unrecognizable. (July 30, 2006)