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Showing posts from March, 2011

Management of COPD: Lets Just Pretend Older Patients Don't Exist

We have previously discussed on GeriPal how the exclusion of older persons from research has left us clueless about how to treat many of the most common conditions in older persons. (see here and here and here)

Well here we go again. A recent article in the New England Journal of Medicine on the management of COPD is a rather stunning example of how ignoring the health needs of older persons and not incorporating even the most rudimentary principles of Geriatric Medicine make a large and expensive clinical study virtually meaningless for the majority of patients with COPD.

COPD (sometimes referred to as emphysema or chronic bronchitis) is one of the most common diseases in older persons. Persons with COPD have reduced lung capacity which leads to decreased exertion tolerance and symptoms such as shortness of breath and coughing. Superimposed on chronic symptoms, persons with COPD have "exacerbations" characterized by acute worsening of symptoms such as shortness of breath…

A Matter of Life-and-Death: The Ethics of End-of-Life Care

GeriPal recently conducted a poll to ask readers if they would take a pill to add 500 years to their lives. The question of quality versus quantity was raised – would extending one’s longevity with a compromise to quality of life be worth it?

I recently came across an article that addressed this issue on both sides. In Ontario, Canada, the provincial Consent and Capacity Board is reviewing a dispute over Desmond Watson's life. The 87-year-old suffers from advanced dementia and was admitted to the hospital 14-months ago with pneumonia. According to the doctors, treatment should cease because “Desmond is suffering without any prospect of long-term improvement.”According to the wife, “People look at him as a vegetable. But he isn’t. He’s a person with dignity. Don’t take that away from him.”Who is “right” and what will be the outcome of this ethical conflict? This is an end-of-life question that Canada has not yet established "clear provincial, federal or medical protoco…

American Geriatrics Society’s Palliative Care SIG

We need you input. The American Geriatrics Society's (AGS) Annual Meeting in Washington, DC, is only about a month away. Importantly for our GeriPal community, the palliative care special interest group (SIG) at AGS is scheduled for Wednesday May 11 from 5:45 to 7pm in the Maryland 1 room. We have a couple topics that we are planning to cover, but we wanted to see whether you want anything else.

Here are three items that we are planning for this years agenda:
We have asked Christine Ritchie to discuss her work in creating collaborations between AAHPM/AGS. Many of us may have heard some portions of this collaboration but may be unsure what it is doing and where is it going. This is an opportunity to find out more about this fascinating collaboration and what it means for us.We have asked Paul Tatum to discuss where we are with the creation of the Geriatrics SIG at AAHPM.  For those of you who don't know, there isn't yet a geriatrics SIG yet at AAHPM.  Paul though is spearh…

Prognosis is Unimportant

I wanted to highlight a recent article in the NYTimes by Peter Bach entitled, "After a Diagnosis, Looking for a Magic Number" He recounts how after his wife was diagnosed with breast cancer, as a cancer epidemiologist himself, he arranged to see a breast cancer oncologist and researcher and asked him about her prognosis. This researcher refused, saying that as soon as the patient and husband could point to a "probability of recurrence would cause us to make different choices", he would not provide them this information.

The comments seemed quite divided. Some respondents thought the doctor was wise, that providing a "number" would only distract from the goal of doing everything you can to maximize your life in the limited time you have. Others thought that the doctor was condescending, that the doctor wasn't treating these patients as adults.

As a researcher who thinks about prognosis, I am clearly not unbiased in my views, so would love folks th…

Poll: Will You Take a Pill That Adds 500 Years to Your Life?

Will you take a pill that adds 500 years to your life?
I have a pill that will add 500 years to your life (OK, I don't really, please don't email me asking for one).  But let's say I did.  Would you take it?  Yes or no?  You have 1 minute to decide, then answer the poll above.  If you have any conditions to your vote, post them in the comments. 

Why ask this question?  The question is - to what extent should we be focusing our research dollars on therapies that extend life.  Of course, the question is not this simple - 500 years at what quality, at what cost, where will the centenarians live?  But the basics of the question rest on this primary question, not the details.  Or maybe you want to disagree. 

It's up to you.

You still have 30 seconds.

by: Alex Smith

Doris and Alice on Big Pharma and Motorized Scooters

We had dinner with family friends Doris and Alice last night.  Doris is 90 and Alice is 91.  They have some strong opinions (they always do).  Doris and Alice gave permission for sharing their opinions on GeriPal, with their picture.
Big pharma is taking a hit, according to recent headlines.  Lots of drugs are going off patent and becoming generic.  Few new drugs are in the pipeline. Should we feel sorry for big pharma? Doris and Alice:  "No! We have enough drugs already."  The relentless profit incentive of big pharma drives up costs of drugs to levels that are bankrupting seniors and our economy. "They make too much money already."  "Motorized scooters are a scam!"  Of course motorized scooters are a good thing for some folks who really can't walk.  But Doris and Alice find themselves bombarded with advertisements for motorized scooters.  They feel that the advertisements are disingenuous when they advertise themselves as "free" or "at…

The Past is Hard to Forget when Evaluating New Dementia Screening Tests

If we care about primary care physicians actually using the screening tests we develop, then we should care about their accessibility to those clinicians. To put it simply, the more barriers we put in place, the less likely anyone will use them to assess cognitive status in the elderly.

The prior gold standard for cognitive screening was the mini-mental status exam (MMSE). This test used to be freely available online, in books, and on pocket cards that were distributed to medical students and residents throughout the country. This all changed in March of 2001 when MiniMental, LLC (the current owners of the MMSE copyright) granted Psychological Assessment Resources (PAR) the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE. Suddenly, after decades of neglect, PAR began enforcing the copyright on the MMSE (see "stealth patents"). Now physicians would have to pay about $1 per test, and importantly, another barrier to cognitiv…

A New Treatment For Atrial Fibrillation in the Elderly?: The (IR)relevance of Clincial Resarch to Geriatric Populations

Atrial Fibrillation is a very common heart rhythm that substantially increases the risk for stroke. The likelihood of having atrial fibrillation increases markedly with age. In Geriatrics practice, where many of our patients are in their 80's and 90's, we see patients with atrial fibrillation all the time.

The good news is that there is a treatment that has been available for many years that dramatically reduces the risk of stroke in patients with atrial fibrillation. Warfarin, an anticoagulant or blood thinner, is very effective at stroke reduction. However, warfarin can be hard to use. If too much is given, the risk of bleeding complications becomes high. If too little is given, it becomes ineffective at preventing stroke. Some studies have suggested that when warfarin is properaly dosed, almost all of the excess stroke risk of atrial fibrillation goes away with only a modestly increased risk of bleeding. Unfortunately, in many patients, it is hard to continuously properaly d…

Palliative Care Consultations: An Answer to Medicaid's Woes

With Medicaid spending ballooning to $381 billion in 2009, states are considering a lot of different ways to decrease costs associated with this program. Some of these ways include reducing payments to providers, reducing or eliminating services not mandated by the federal law, and narrowing Medicaid eligibility criteria. A new study released by Health Affairs though suggests that maybe there is one program that increases services to medicaid beneficiaries while still reducing medicaid spending. That program – hospital based palliative care consultations.

The Health Affairs article, authored by Sean Morrison, Jessica Dietrich, Susan Ladwig, Timothy Quill, Joseph Sacco, John Tangeman, and Diane E. Meier, evaluated whether hospital palliative care consultation teams reduced hospital costs for Medicaid patients in New York State. The authors used hospital administrative data from four urban based NY state hospitals to compare hospital costs of Medicaid patients receiving palliative care …