Remote Care for the Elderly, Choosing the Right Care Team

Senior Couple At HomeMy elderly and infirm parents live 15 minutes south of my home in an assisted living facility.  They moved there after it became apparent that they could not manage their affairs in their own home, have some degree of independence and socialization with friends and receive the care and supervision they needed to stay out of the hospital.  Their cognitive impairment and dementia made it necessary for me to be in contact with their personal physician and to be able to reach him if he is needed.

It would be far more difficult if I did not live close by.  What would I look for in a physician for my elderly parents if they did not live close by? I would want the physician to have some experience in geriatric medicine. That would include being fellowship trained in geriatric medicine or having some training and certification from the American Geriatrics Society.  A board certified internist or family practitioner with experience in caring for the elderly could do fine as well. The doctor would need to be available by phone for questions and available to see my parents on the same day that they develop a medical problem needing the doctor’s attention.  That physician should have hospital privileges at a local facility where my parents might be taken to by ambulance in an emergency so that he could follow them into an acute care hospital if necessary.

I also would prefer a doctor that had a professional relationship with a rehabilitation or skilled nursing facility so that they could be treated as they recover from an acute hospital stay in a rehab setting.  I love physicians who make house calls if the situation calls for it. While much more can be accomplished during most office visits than a home visit, sometimes the illness dictates the location where the care is provided.

The doctor should be a compassionate individual who is a great listener and who relishes the responsibility of being an advocate and champion for his patients.  It’s commonplace for the elderly to languish waiting for evaluation in the emergency department or to be put off when trying to make an appointment for a test or specialty visit.  Patients need a doctor with a staff who will help them through this process.

To find such a doctor I suggest you start by asking at the local hospital medical staff office. They know who does what and who is accepting new patients. Word of mouth is the best advertising so a testimonial from a friend familiar with the doctor and the practice is priceless.

While Internet rating services provide some information they are less valuable than a personal reference. Local and County Medical Societies are another great starting place in the search for a physician.  If you are looking for a direct pay or concierge type practice, I suggest you perform a thorough Internet search and interview any physician you are considering.

Three More Strikes Against Smoking

There is no doubt that cigarette smoking is a practice that contributes to poor health and earlier death. Despite this, the practice is still popular among the young. Over the last three weeks several new research articles have been published that support the concept that smoking is severely detrimental to your health.

An Australian study published in Stroke: Journal of the American Stroke Association pointed out that individuals who had a stroke at the time they were active smokers had a far worse outcome and long term outcome than non- smokers. It additionally showed that smokers had the stroke at a younger age than nonsmokers. The group was followed for another 10 years and had a higher incidence of strokes, heart attacks and deaths than the nonsmoking group. The study emphasized the devastation and cost of “healthy years of life lost” as a consequence of continuing to smoke.

In an online publication in the Lancet, researchers working in the “Great Britain Million Women Study” noted that women who quit smoking lived longer than women who continued – irrespective of the age they decided to stop smoking. They additionally lowered their chances of dying from lung cancer.

A study out of the Mayo Clinic in Rochester, Minnesota looked at the effect of indoor smoking bans on heart attack rates in a community. This study looked at the effect of secondhand smoke on individuals. The Mayo Clinic has an exhaustive and large data base of individuals in the Midwest who have come to their clinic for health care for generations. They believe that in their study population, the number and extent of cardiovascular risk factors has remained fairly constant but, since the institution of strict bans on indoor smoking, the number of heart attacks has dropped dramatically.

Do Routine Physical Examinations Save Lives?

Lasse T. Krogboll, of the Cochrane Nordic Center in Copenhagen, Denmark and coauthors published an article in the online edition of the Database of Systematic Reviews that suggests that routine examinations do not save lives.  The material was reviewed in the University of Pennsylvania Medical Center online periodical Medpage Today and was critiqued by a physician at the Harvard Medical School.

The study was a systematic review of 16 clinical trials involving 183,000 patients followed for a median of 9 years. The review concluded the risk of mortality in individuals who had regular checkups, compared to those who did not, was not statistically different.  “General health checkups did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased.”  “With the large number of participants and deaths included, the long follow-up periods used and, considering that cardiovascular and cancer mortality was not reduced, general health checkups are unlikely to be beneficial.”

In commenting upon the study, Doris F. Zaleznik, MD, Associate Clinical Professor of Medicine at Harvard Medical School and Dorothy Caputo, MA BSN RN admitted that “most of the trials were old, which makes the results less applicable to today’s settings because the treatments used for conditions and risk factors have changed.”  They additionally noted that one reason for the lack of efficacy of routine general checkups might be that “primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.” They additionally suspect that “those at high risk of developing disease may not attend general and health checks when invited.”

The release of this online study was dramatically promoted. One must embrace evidence based data but keep in mind that there is a strong push in the USA to reduce health care spending overall as a percentage of the gross national product.  Anything that seems to say, “Do not seek evaluation “seems to garner more attention than it is due these days.

The study did not clearly define what a general health checkup includes.  I still believe that finding a good doctor and seeing that doctor annually for a benchmarking session to review your health wellness and habits by performing a thorough history and physical examination and, comparing your habits and findings to current recommended guidelines and treatments, is a worthwhile endeavor.  The general health exam does not need to include numerous and expensive laboratory and imaging studies unless the history and examination suggest the need to pursue those options.

As medical science identifies genetic and molecular mechanisms of disease, I am sure the next long-term Cochrane Review will show the efficacy of these annual general physical examination sessions in limiting disease and extending life.

 

Multivitamins in the Prevention of Cancer in Men

Vitamin, mineral and supplement use in the United States is a multi-billion dollar industry. Despite many testimonials extolling the benefits of supplemental vitamins, there has been very little research that actually provides evidence that these supplements are beneficial. However, there is abundant evidence that over consumption of the fat soluble vitamins, A, E, D and K results in accumulation of the substances and eventual toxicity.  The 2010 Dietary Guidelines for Americans says, “For the general, healthy population, there is no evidence to support a recommendation for the uses of multivitamin or mineral supplements in the primary prevention of chronic disease.”

The Physicians Health Study II (PHS II), a randomized controlled study, followed 14,641 male U.S. patients initially aged 50 or older for a median of 11.2 years. Their results showed that “daily multivitamin supplementation modestly but significantly reduced the risk of total cancer.”  The study could not clarify or specifically define which nutrient or nutrients in their supplemental multivitamin were responsible for the effect in reducing cancer.

The study used the multivitamin Centrum Silver.  However, it did not examine the effect of multivitamins in women.  Nor, did it did allow participants to consume additional vitamins, minerals, supplements or herbs.

The message to individuals is clear. Eat a healthy and balanced diet that is prepared in a manner that does not destroy the nutrients.  A multivitamin such as Centrum Silver will reduce your risk of cancer minimally. There is no proof that taking additional products with the multivitamin will have a more positive effect.

Pharmacies, Vaccinations and Health Benchmarking

The state legislature in Florida decided it is legal and appropriate for pharmacists and pharmacies to begin administering vaccines against multiple diseases.  Their list of adult vaccines includes seasonal flu shots, pneumovax (pneumonia vaccine) and zostavax (vaccine to prevent shingles).  The rationale of the legislature is that access to doctors to receive these preventive vaccines is limited and difficult.

By refusing to administer vaccines in their office because it is time consuming and not profitable enough, my colleagues in primary care have not made my argument against permitting this any stronger. I thought prevention and administering vaccines was part of the job description in primary care.  I am not asking my colleagues to lose money, but I do believe there is a distinct difference between not making a large profit and losing money.  Isn’t it our professional and ethical responsibility to provide preventive services?

Over the years, the fall season and start of the school year have always provided an opportunity to remind patients that they were due for an annual checkup and to make positive suggestions on what other opportunities were available for them to try and prevent infectious or chronic disease. School-age children have been required to receive immunizations before entering school for obvious public health reasons.  This provides an opportunity to benchmark their growth and age goals and discuss healthy living as well. The visits came towards the end of the calendar year when most individuals had met their annual medical deductible so the out of pocket costs were not great.

As I walk into my local CVS I am confronted by ads for vaccines and same-day clinics. They remind me that physicians have lost this encounter to enhance the doctor/patient relationship and provide sound health advice for the future because administering vaccines isn’t very profitable.  Pharmacies often use vaccinations as a loss-leader to draw you in and get you to purchase other, more profitable, items.

I will continue to provide vaccines in my internal medicine office as I believe it is the professional and responsible thing to do.

How Will Doctors Handle the Flood of Newly Insured Patients?

Albert Fuchs, MD notes in the online journal Medpage that in 2014 thirty million new patients will have health care insurance and will be seeking a doctor.  This will result from the institution of the Affordable Care Act passed in March of 2010.  Dr. Fuchs observes that there is a dramatic shortage of physicians to care for this increased patient load especially in the areas of general internal medicine, family practice and pediatrics.   He cites a study by the medical malpractice insurance company, The Doctors Company, which polled 5,000 physicians about the influx of new patients under the new law.  Sixty percent of the respondents said the large influx would “hurt the level of care they provide.”  Forty-three percent said they will retire in the next five years.   Nine out of 10 respondents said they would not encourage anyone they knew to enter the field of medicine.

Medical Economics published an article in which it said patients should not expect to see a physician. They accurately stated that medical schools cannot possibly produce the number of additional physicians needed in the time allotted.  Nurse practitioners will be elevated in the national healthcare dialogue.   They cited the Massachusetts experience in which many primary care doctors have closed their practices to new patients. An opinion piece in the Wall Street Journal predicted the closing of practices to new patients as well.

It is clear that your next “doctor” may be a nurse.  I have advised my younger family members to find themselves a good primary care physician. I recommend someone who is board certified or eligible in the specialty they are practicing. I also recommend that the physician follows you into the hospital if you require inpatient care, as opposed to turning your care over to a hospital based physician.  If post-hospital care is required, it’s preferred that your doctor will go to your rehab facility to provide care and continuity.  You should also seek a physician who provides same day appointments, when you are ill, and someone who is available and returns phone calls and emails and text messages the same day.

The Wall Street Journal predicted the growth of concierge medicine where patients pay an annual membership fee in exchange for a doctor being accessible.  The cost is about the same as a cup of coffee per day, at most nationally recognized coffee chains, and in many instances is less than one’s monthly cable TV bill.

Let’s face it, your health, which has a direct impact on your quality of life, is a much wiser investment than a daily double chocolate chip frapuccino or 489 cable television channels.

Do Tomatoes Prevent Strokes?

The University of Pennsylvania Department Of Medicine online magazine Medpage Today published a synopsis of an article that appeared in the October 9th issue of the Journal of Neurology. Written by Jouni Karppi, PhD, of the University of Eastern Finland, and colleagues, it discusses how tomatoes and tomato based products may lower the risk of strokes in men. The key ingredient seems to be lycopene. Lycopene is a carotenoid that acts as an antioxidant.

The study looked at 1,031 Finnish men between the ages of 42 and 61 who were followed for 12 plus years. The researchers used statistical techniques to eliminate the influence of variables such as hypertension, tobacco usage, lipid levels and other risk factors of strokes. The research showed that the individuals with the highest levels of lycopene in their serum had the lowest risk of stroke compared to individuals with lower levels. Tomatoes do contain several types of carotenoids such as alpha-carotene, beta-carotene, alpha–tocopherol and retinol, but it is the lycopene that is the difference maker.

Nancy Copperman, MS, RD from the North Shore- Long Island Jewish Health System was quoted as saying, “This study supports the recommendation of eating more servings of fruit and vegetables a day. Foods such as tomatoes, guava, watermelon and grapefruit are good sources of lycopene. When a tomato is cooked, the heat processing actually increases the levels of cis-lycopene – which is easily absorbed by the body.”

This explains why tomato sauce is felt to be such an excellent source of anti-oxidants. Lycopene is believed to have numerous additional health benefits including “reducing inflammation, blocking cholesterol synthesis, boosting immune function, and inhibiting platelet aggregation and thrombosis.”

Breast Cancer Screening DOES SAVE LIVES

Eugenio Paci, MD, of the ISPO Cancer Prevention and Research Unit in Florence, Italy working with a European breast cancer screening group, published data in the Journal of Medical Screening that clearly showed that screening mammograms save lives. The study was necessitated because of recent controversial data presented by the US Preventive Services Task Force (“USPSTF”) calling for women to wait until age 50 to begin mammograms and having them every other year rather than annually. The USPSTF recommendations were based on the belief that too many false positive tests led to too many unnecessary and expensive follow-up tests.

The European researchers found that for every 1,000 women screened from age 50 to 51, and followed to age 79, an estimated 7 to 9 lives would be saved and; an additional four cases of cancer would be diagnosed early. The screening resulted in 170 women having to have a repeat non-invasive test to rule out cancer (such as a repeat mammogram and or ultrasound of the breast) and 30 women would have to undergo an invasive test such as a biopsy.

The researchers looked at a 10 year period in Europe and expected 30 deaths per 1,000 women from breast cancer of which 19 could be prevented by screening. Their figures showed that 14 women need to be screened to diagnose one case of breast cancer and 111 to 143 need to be screened to save one life.

I will continue to recommend that patients learn how to perform a breast self exam and perform it regularly. We will begin screening our high risk patients at age 40 and others at age 50.

A thorough annual breast exam by the patient’s doctor is advised. A decision on annual mammograms versus every other year should be decided by the patient’s risk factors, family and personal health history, current examination and past mammogram findings.

How Long Do Prescription Drugs Last?

In a letter to the Archives of Internal Medicine, Lee Cantrell, PharmD of the California Poison Control System in San Diego, discussed his research that showed that many prescription medications and their main ingredients retain their effectiveness and potency 40 years after the expiration date. He and his group specifically looked at aspirin, butalbital, phenacetin, caffeine, phenobarbital, homatropine, chlorpheniramine and acetaminophen. Of the 14 compounds analyzed, 12 retained the generally recognized minimal acceptable potency of 90% of the labeled amount almost 40 years after they had reached the expiration date. Out of the 14 compounds, Aspirin and amphetamine were the only 2 that didn’t retain their effectiveness some 336 months beyond the expiration date.

The authors did not advocate relying on outdated and expired pharmaceuticals. They did see a cost savings in re-defining how long a product will last and remain effective when stored appropriately. This could save consumers thousands of dollars each year if they store their prescription drugs in the correct environment.

I will certainly not advise my patients to use significantly outdated and expired prescriptions. The study shows that, under emergency conditions, these specific outdated compounds still maintain their efficacy.

Their research did not answer questions about the multitude of newer drugs that have been developed over the last 40 years and how long they will last.  Nor did not address the question of whether over time any new chemicals developed within the 40 year old products that may be harmful. The research certainly did raise the question of why we need to look at the traditional expiration dates and reassess the length of time a product still is safe and of value to the consumer.

Infectious Disease Society of America Updates Guidelines for Strep Throat

The Infectious Disease Society of America updated its 2002 guidelines for the diagnosis and treatment of Group A streptococcal sore throat.  In adults with a sore throat, only 5 – 15% actually have Group A streptococcal sore throat and require an antibiotic to treat the illness. Adults in that group usually have been in the proximity of young children or adolescents who have strep throat.  In 85 – 95% of the cases, the adults have a viral illness that is causing their sore throat and viruses do not respond to the use of antibiotics.    For patients at risk for Group A streptococcal sore throat, usually presenting with fever, swollen neck lymph glands and an exudative pharyngitis; it is recommended that a rapid antigen detection test be performed to confirm the diagnosis and appropriately start the patient on antibiotics.

According to Stanford Shulman, MD of Northwestern University’s Feinberg School of Medicine in Chicago, once the rapid antigen detection test is positive no confirmatory formal throat culture is necessary.  If the test is negative in a child or adolescent only, they recommend performing a formal throat culture to rule out the bacterial infection. This is not necessary for adults because there is a low risk of them having this type of infection and very low risk of complications like rheumatic fever.

Once strep throat is diagnosed, the treatment of choice remains penicillin or amoxicillin taken for 10 full days. If the patient is penicillin allergic, alternative choices of antibiotics including cephalosporins, clindamycin or clarithromycin are warranted.  Acetaminophen and non steroidal anti-inflammatory medications are acceptable to reduce discomfort and symptoms.

Distinguishing between a viral sore throat and bacterial Group A streptococcal sore throat is very difficult using symptoms alone since the bacteria have changed their presentation as an adaptive survival mechanism. Most clinicians however feel confident that if the patient has a runny nose (rhinorrhea), hoarseness, mouth ulcers and cough it is probably viral and does not require antibiotics.

This guideline change comes on the heels of a report in the Archives of Internal Medicine pointing out that antibiotic use by senior citizens in the southern United States is more frequent in January through March than in other parts of the country. The study talks about the inappropriate use of oral antibiotics during the cold and flu season leading to bacteria becoming resistant to simple and inexpensive antibiotics.  In addition to a resistance to antibiotics, we are observing an increased number of complications of antibiotic use such as antibiotic related colitis (clostridium difficile).

This information is presented as an educational effort especially for patients who demand an antibiotic inappropriately when they catch a cold (viral illness) or who demand an antibiotic when they travel “just in case I catch a cold”.