Dementia Prevention Information Is Confusing

Part of the responsibility of being a physician is keeping up with the medical literature. I subscribe to numerous print and on line journals and read volumes each day. My professional email is littered with summaries of journals. As the baby boomers age and 10,000 of them are enrolled in Medicare per day the emphasis on preventing and treating cognitive impairment leads to volumes of studies and reports daily. To say it is confusing is an understatement.

A recent report from the National Academies of Sciences, Engineering and Medicine has painted a more optimistic picture of potential interventions in its current report as compared to its 2010 report. In the 2010 report they had nothing to be positive about. In the current report that negativism has changed to “inconclusive but encouraging “evidence of staving off cognitive decline. Within the geriatric care community this group’s opinion is still contested by the National Institute of Aging and the Agency for Healthcare Research and Quality but the National Academy of Sciences felt it was appropriate to share its findings with the rest of us. They believe there is moderate evidence to support being active as something that we can do to stave off cognitive dysfunction. They are not asking us to become marathon runners or tri-athletes but just get up and keep moving for ninety minutes a day. There is additionally fairly good evidence that controlling our blood pressure especially during mid-life will help your chances of avoiding dementia. The most controversial area was whether cognitive training with brain teasers, puzzles, learning a new language is of value. I will advise my patients that if they can find a cognitive training activity they enjoy then they should pursue it because it certainly will not hurt. The paper did not address issues which we know are important to control such as avoiding smoking or excessive alcohol of narcotic intake.

At the same time that the National Academy of Sciences was offering a small ray of hope we see articles on artificially sweetened drinks being associated with increased risk of dementia. Add common medications like proton pump inhibitors (Nexium, Protonix, and Pepcid) and overactive bladder medicines to the list of drugs that can increase your risk of dementia. We also can add the cholesterol lowering medications called statins to the list of drugs that can increase your risk of dementia but primarily in inactive individuals.

The information is non-stop and it is never ending. A few years ago I attended a lecture by the head of one of the Harvard Medical School’s Geriatric Programs. The speaker was a family practitioner in her fifties or sixties who stressed the importance of getting plenty of exercise, eating in moderation, cultivating and maintaining relationships with friends, avoiding smoking, controlling your blood pressure and blood sugar and playing “ brain games” if you enjoyed them . It seems that with the latest publication of the National Academies of Sciences, Engineering and Medicine, not much has changed since then.

Telemedicine and Acute Stroke Treatment

My community hospital is holding its quarterly physician staff meeting and one of the items on the agenda will be a bylaw change which will permit outside physicians, not credentialed or vetted by our hospital credentials committee, to perform video consults on patients within our hospital. Hospital administration is pushing this bylaw change, and since there has been a quiet coup which has transferred medical staff power from the community’s practicing physicians to the hospital employed and paid physicians, it is a foregone conclusion that it will easily pass.

The bylaw change is being requested because the hospital would like to continue to reap the benefits of being an ischemic stroke comprehensive treatment center and offering the health benefits to the community despite not being able to meet the criteria. If a patient presents to the emergency department within four hours of developing ischemic stroke symptoms they must be offered the administration of a “clot busting “drug Alteplase (t-pa). The patient must not have any bleeding tendencies and no evidence of active bleeding or a mass or tumor on head CT scan and must be examined by a neurologist within 45 minutes of arrival.

The problem is that most community based neurologists with outpatient office practices and hospital staff privileges cannot and will not drop everything they are doing and run to the emergency department to evaluate a new patient each time a stroke protocol patient arrives. When given an ultimatum by the hospital administration, that they must take call and be available within 45 minutes, our community neurologists en masse relinquished their hospital privileges.

The hospital countered by bringing in several research oriented academic neurologists and neurosurgeons to man the beautiful new Neuroscience Institute and provide coverage of the ED for the stroke protocol. Few if any of these physicians were able to develop and maintain a practice within the community and they have since left. The Emergency Department is staffed by employed board certified emergency physicians who are well qualified to diagnose an ischemic stroke and administer t-pa. They refuse to do so citing the liability of a poor outcome as the reason. Despite data indicating the benefits of t-pa administration in these situations, the 6 out of 100 chances of a bleed in the brain plus the 1 in 6 chance of death is enough to deter their participation.

You would think that since the hospital hires these physicians the logical choice would be to fire them and hire a group that will provide the state of the art care in a timely fashion. This has not occurred. You would think that the state legislature would grant the ED physicians sovereign immunity from medical malpractice suits if the patient meets the criteria for the ischemic stroke protocol and the patient is given appropriate informed consent for the procedure but this common sense legislation has not been developed or passed.

The hospital has chosen a different pathway. They are opting to hire neurologists from a university medical center who will provide video consults on ischemic stroke patients from an offsite location. Robots will actually examine the patient and televise the data back to the telemedicine center after an emergency department physician performs a brief initial evaluation. The neurologist off site will then provide the needed neurology consult to proceed with the injection of the clot buster.

I suspect the mechanism will work like this. A patient or family member will call EMS via 911 and be taken to the Emergency Department. A triage nurse will ask all the questions to qualify the patient for the t-pa protocol; a robot will examine the patient and transmit via TV the data to an offsite neurologist while an ER physician does an exam. A CT scan of the head and brain will be performed. If no bleed is discovered or tumor or mass that could bleed, t-pa will be administered by the pharmacy and nursing staff. Further intervention by an interventional radiologist and or neurosurgeon may then occur.

At no point in this protocol does it call for the patient’s primary care doctor or cardiologist or usual neurologist to be called. We will be called once the procedure is complete because neither the ER physician or the neurosurgeon or the interventional radiologist will want to admit the patient to neurology ICU. While our surgical ICU and Medical ICU/CCU are covered 24 hours per day by an outsourced hired intensivist group, the neuro ICU does not have that type of coverage.

I can hear it now, my phone ringing and upon picking it up I hear the voice of a clerk in the Emergency Department, “Hello Dr Reznick, Dr. Whateverhisorhername wishes to speak to you about patient Just Had A Stroke.” I get put on hold for five minutes and then in a flat nasal voice, “Hello Steve your patient came in earlier by EMS with symptoms of an acute ischemic stroke. They met the t-pa ischemic stroke criteria and were treated. Unfortunately, they had a major hemispheric bleed with mass effect and edema and are now unresponsive and intubated on a ventilator. We need you to come in and admit him and care for him.”

I will vote in protest against this bylaw. I will lobby for recruiting neurologists who are hospital based who will actually see the patient and care for them. I will lobby for a new state law to provide sovereign immunity for ED physicians treating ischemic strokes according to the internationally recognized protocol. I will lobby for our medical and surgical residents on site and in the hospital to be permitted to administer t-pa after meeting the appropriate criteria. I will not support out of the area physicians making the final call and leaving our local physicians to deal with their results.