Category Archives: aging

Who’s old? Not I

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To someone in their teens or early 20s, anyone over 30 is old. When you’re in your 40s, the 70s seem impossibly ancient. And when you’re 70-something? Well, then it’s the octogenarians who are old.

We think we know what it means to get old, yet our perceptions often are fueled by stereotypes about older adults – and as with most stereotypes, it can end up doing more harm than good.

The down side of pigeonholing older adults was astutely explored in a recent entry at the Covering Health blog. Although it was aimed primarily at reporters, it contains a larger message about what can happen when we categorize older adults as “old” instead of seeing them for what they are: a highly diverse population with diverse needs and in diverse states of health.

For starters, older adults themselves often don’t perceive themselves as old, writes Judith Graham, topic leader on aging for the Association of Health Care Journalists.

She cites a 2009 study by the Pew Research Center that reveals some interesting insights about aging. Here’s one: Of the adults over age 65 who participated in the poll, 60 percent said they felt younger than their actual age, and many said they felt 10 to 20 years younger than they actually were.

Here’s another: There’s a measurable gap between what younger adults expect their lives to be like as they get old – negatives such as memory loss, loneliness, depression – and what older adults report as their own experience.

In other words, despite the stereotypes, aging often isn’t the burden younger adults think it is.

So why do we persist in viewing the elderly as, well, elderly – and, more to the point, what are the consequences of doing so? Some provocative studies have suggested that when older adults internalize the widespread cultural stereotype that to get old means to become frail and diminished, they are more likely to be in poor health and less likely to take care of themselves, Graham writes.

In response, there has been a push to rewrite the script on aging to portray it in more positive terms, she writes. But beware making too many assumptions in this direction, Graham warns:

The danger here is that efforts to create a new narrative focused on the positive aspects of aging – one that centers on activity, wellness, encore careers, volunteering, and having more time to spend with friends, family – risks marginalizing older people who aren’t especially healthy or well off financially.

I’d add that it also risks sending the message that older adults who aren’t as healthy are somehow doing it wrong and are in need of being “corrected.”

To be sure, efforts to create a better, more healthy old age are beneficial, not only to individuals but to the communities they live in as well.The key, points out Graham, is to view older adults as individuals, each with his or her own life story, challenges and desires. When she advises that “there’s no substitute for face-to-face interactions,” she could be talking about the setting of the medical exam room, the hospital room or the skilled nursing facility.

It may take time to encourage older adults to talk about themselves, Graham says. “But I suspect you’ll be surprised by what older people will tell you, if you take the time, suspend judgment and truly listen.”

Is the doctor too old?

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Here’s a dilemma: The doctor is 83 years old and still seeing patients. There’ve been no complaints – so far – about the quality of his care, yet hospital leaders sense it’s only a matter of time before a patient is harmed.

How do you transition an aging physician out of patient care in a way that’s both dignified and safe? Dr. Kenneth H. Cohn recently asked this question on the Hospital Impact blog, triggering an interesting online discussion about the difficult balance between protecting patient safety and respecting an aging doctor’s skills and knowledge.

It’s not an idle question. Americans are getting older and this includes doctors. “This challenge of guiding aging physicians will come up with increasing frequency over the next decade,” Cohn notes.

Look no further than here in Minnesota, where nearly one-third of all the state’s practicing physicians in 2008 were 55 or older. Slightly more than 7 percent were over the age of 65.

A report produced by the Minnesota Department of Health on the physician workforce notes these statistics about older doctors: 19 percent of doctors who were actively practicing in Minnesota in 2008 (this was the most recent year in which workforce information was collected) said they planned to retire in the next five years and more than 40 percent expected to retire within the next 10 years. But of even more note, 10 percent of the doctors older than 65 planned to work for at least another decade.

American society is starting to redefine what it means to retire, and I suspect we’ll be seeing an increasing trend of doctors continuing to practice medicine well into their 70s and possibly even 80s. The recession also has caused many doctors to rethink their retirement plans and decide to work longer.

It’s not unreasonable to wonder whether older doctors can continue to keep up and still provide quality care.

Consider a New York Times article published a year ago that explores this challenge. It outlines the case of a 78-year-old vascular surgeon whose skills were called into question after a patient died. He remained in practice for another four years until a competency assessment was finally ordered, revealing serious cognitive deficits. The surgeon was asked to surrender his license.

The article cites a 2005 study that found doctors who’d been out of medical school for 40 years were more likely to face disciplinary action than doctors practicing for only 10 years.

Just because a doctor is getting old doesn’t mean he or she is no longer fit for medicine, the article notes. “But physicians are hardly immune to dementia, Parkinson’s disease, stroke and other ills of aging. And some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing.”

The generation gap isn’t a new issue in medicine. I blogged awhile back about the differences between old and young doctors. Which is better – youth, energy and the latest knowledge or skills acquired and refined through years of experience? How do you help aging doctors recognize their fallibility without selling them short?

Cohn asks this question on his blog and got some thoughtful responses. One physician wrote: “I consider [m]andatory [r]etirement blatant age discrimination that opens up the possibilities of legal suits and rests on the premise that after a certain age, a different standard is arbitrarily applied in the physician credentialing process.”

Perhaps physicians past a certain age could be required to undergo a cognitive assessment to ensure they’re still able to practice skillfully and safely, someone else suggested – but neurocognitive tests aren’t always reliable, plus there’s the issue of who would pay for it, he wrote.

Another commenter offered a different perspective. He wrote that he has a neighbor who’s a doctor and is about to turn 90. “He volunteers at a nearby free clinic 2-3 days a week. They use his considerable experience effectively and they have a dialogue regarding limitations of practice. It is rewarding for my neighbor and provides a real and needed service to our community.”

Rather than putting older doctors out to pasture, we should find ways to make meaningful use of their skills and experience, urged another commenter. Helping them stay productive would benefit society and allow aging doctors “to ride into their sunsets with graceful dignity and a sense of fulfillment.”

Regardless of age, most doctors want “meaningful work that makes a difference in patients’ lives, a sense of community, and regular and reliable feedback that affirms their value,” Cohn concluded. But as they get older, it’s a good time to think about how they want to be remembered, he suggested. “Legacy becomes increasingly important when the marginal value of seeing one more patient diminishes.”

The next big health story

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What’s going to be the big health story of 2012 – health care reform? The impact of state and federal health spending cuts?

Nope. The next attention-grabbing story could well be about the future of Medicare, the federal program that covers millions of older Americans. This is the assessment of Trudy Lieberman, a contributing editor at the Columbia Journalism Review, who recently blogged about Medicare’s ascendancy as an issue of critical importance.

I’m inclined to agree.

Medicare is headed for a crossroads. Given the size of the federal budget deficit, cuts to the Medicare program are almost inevitable and will likely hit both providers and enrollees – the former in the form of less pay for caring for these patients and the latter in more out-of-pocket costs. The millions of baby boomers poised to become eligible for Medicare over the next couple of decades will only add to the pressure.

Lieberman writes that the outcome of the policy debate about Medicare “will determine whether nearly 50 million older and disabled people will be able to afford health care at all and what kind it will be.”

Most people’s eyes tend to glaze over when the conversation turns to Medicare. It’s not an exciting topic. I’d argue we should make a better effort to pay attention, however, because as with any policy discussion of this magnitude, decisions ultimately will trickle down to the local level.

Imagine, for instance, the hard decisions some doctors might have to make between turning away Medicare patients vs. losing money by continuing to see them.

To be clear, there’s no evidence this will become a widespread trend. But physicians are talking about it and some of them have already taken the step – for instance, a family practice clinic in Raleigh, N.C., that stopped seeing new Medicare patients three years ago. One of the partners told WRAL TV, “Our job is to take care of patients, which is what we love, but if we can’t run our business, we can’t take care of any patients.”

A potentially even larger issue is what might happen if seniors have to start paying more out of pocket for their care.

Lieberman points out, “When you consider that the median income for older women receiving Social Security is only about $15,000 a year and for men about $26,000, you can see why they get upset when there’s talk of cutting benefits or ending the program. Without it, they would get no health care.”

I’d hate to think of this happening to my parents or, for that matter, to any of us as we get older. While it’s true that health decisions made in our younger years can help make or break our health in later years, there’s no escaping the fact that age is an overall risk factor for health issues, period. The social cost of creating an entire future generation of aging adults unable to afford health care hardly even bears thinking about.

What’s the solution for Medicare? I wish I knew. In the meantime, I plan to stay tuned to the debate.

The case for geriatricians

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If ever there was a case to be made for the importance of gerontology as a medical specialty, it can be found at the GeriPal geriatrics and palliative care blog, where several recent entries focused on the special needs and dynamics surrounding health care for older adults.

One entry explored what’s known as “hospital disability syndrome,” or the downward spiral that can occur among older adults for whom a hospital stay might result in higher risk of falls, delirium, poor nutrition and functional decline.

Another entry raised important issues about the growing use of standard, one-size-fits-all indicators to measure quality of care. While rigorous control of blood pressure and blood sugar is beneficial for the majority of adults, it can result in more medication, a higher risk of side effects and a higher risk of harm for older patients, blogger Ken Covinsky wrote. “A key issue is that quality indicators almost always promote more medical intervention and more medical is not always better. This is especially the case for frail older persons, where the risk of treatments often exceeds the benefits.”

Finally, an entry titled “Too Much of a Good Thing” analyzed a recent study in the New England Journal of Medicine about emergency hospitalizations among older adults due to adverse drug events, and drew two conclusions: First, many of the older patients in the study got into trouble because they were receiving too much of a prescription medication – for instance, too much insulin. Second, many of the less obvious adverse drug events among the elderly, such as drug-induced delirium, can be difficult to recognize in the emergency room and indeed might not be identified at all.

Geriatrics is defined as “the branch of medicine concerned with the diagnosis, treatment and prevention of disease in older people and the problems specific to aging.”

It’s not a specialty that carries much allure. Doctors who specialize in geriatrics tend to earn some of the lowest salaries in medicine. Moreover, in America’s youth-obsessed culture, caring for aging patients with multiple health issues often holds little appeal.

It’s not surprising, then, that the U.S. health care system is woefully short of geriatricians, even as the number of older adults has been rising dramatically. According to the Geriatrics Workforce Policy Studies Center of the American
Geriatrics Society, only 86 students who graduated from medical schools in the U.S. in 2009 chose geriatrics as a specialty. That’s fewer than 1 percent of family medicine and internal medicine grads. And it’s not for lack of training slots, because about half of the fellowships available in gerontology were left unfilled.

The Geriatrics Workforce Policy Studies Center estimates there’s currently one geriatrician for every 2,620 Americans over the age of 75. By 2030, this ratio is projected to fall to one geriatrician per 3,798 older adults.

You could argue that we don’t really need specialists in geriatrics. Why can’t the care of aging adults be managed just as well by internists or family medicine physicians? There’s in fact a fair amount of debate on this point, helped along by confusion on the part of many patients and families about what, exactly, a geriatrician does.

To be sure, many internists and family medicine doctors are skilled and knowledgeable in caring for the elderly. And not everyone who’s old necessarily needs to have a geriatrician, particularly if they’re relatively healthy.

But let’s not underestimate what geriatricians bring to the table. In “The Way We Age Now,” a lengthy article that appeared in 2007 in The New Yorker, Dr. Atul Gawande takes readers into the world of aging, what it means in the medical sense to age, and what it takes to help older adults remain healthy and functional.

Gawande makes many important observations about care of the elderly, one of them being this: “Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline.”

And this: “People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable, and to avert at least some of the worst effects.”

Although primary care doctors can certainly fulfill this role, it’s perhaps unrealistic to think they’ll be able to keep up with the new research being added almost daily to what we know about aging. Moreover, it takes both expertise and experience to understand the nuances surrounding geriatric health – to recognize, for instance, that when we talk about rigorous cut-off points for blood sugar levels, it can be harmful to older adults whose bodies don’t function the same way as younger adults and who have much more to lose from side effects such as dizziness leading to falls.

If we can’t buy into geriatrics from the standpoint of enhancing the quality of life for older adults, maybe we’ll be swayed by the economics of what it’s likely to cost if we don’t become better at meeting the health needs that come with aging.

Photo: Wikimedia Commons

Pill City

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You know your life is changing when the number of prescription medications you take each day begins to inch its way up.

It’s a fact that Americans pop a lot of pills. I recently spent a few minutes researching this issue online and made some rather eye-opening discoveries. A report issued last year by the Kaiser Family Foundation estimated U.S. spending on prescription drugs at $234.1 billion in 2008. According to the report, the number of prescriptions increased 39 percent – from 2.8 billion to 3.9 billion – during the decade between 1999 and 2009.

Here’s the statistic that was really surprising: In 1999 the average number of retail prescriptions was 10.1 per capita. By 2009, this had risen to 12.6 per capita.

Some of these undoubtedly were one-time medications, such as a course of antibiotics, rather than pills being taken 365 days a year. But when you consider that some people get by with one or two prescriptions a year (or perhaps none at all), it’s clear from the math that plenty of others are probably making up for it, and then some, with significant quantities of prescription medications.

A couple more tidbits from the Kaiser Family Foundation report: About 62 percent of American households have at least some prescription drug expenses annually. The likelihood of spending money on prescription medications goes up with age; 58 percent of Americans under age 65 had at least one prescription in 2007, but for those older than 65, it was 90 percent.

Is this a bad thing? Not necessarily. When correctly prescribed and taken, medication undoubtedly helps people manage asthma, allergies, depression, diabetes, high blood pressure, pain and more, allowing them to function and possibly sparing them – or at least reducing their risk – of more serious problems down the road.

But there’s a dark side to all of this. The prevalence of prescription drug use in the U.S. has given rise to polypharmacy, or multiple prescriptions that can increase the risk of unwanted side effects and potentially dangerous drug interactions, especially among the elderly. There’s also “prescribing cascade,” which happens when a prescription medication produces side effects, the doctor prescribes another medication to combat the side effects, which results in yet more side effects, yet another medication and on and on.

Adherence can become an issue as well. It gets complicated when someone takes a dozen prescription medications daily – some once a day, others twice a day, some with food, some without, some that can be taken together, others that can’t. It can be challenging to even remember a regimen like this, let alone stick to it day after day.

For all of the apparent emphasis on pills, many people don’t like taking them. In a study conducted a few years ago, researchers queried older adults about their prescription medication habits and found multiple reasons why these individuals didn’t always take their pills. At the top of the list was cost – but people also often cited concerns about side effects and drug interactions, or didn’t really believe the drug was necessary.

There were some rather strong reactions to a CNN story earlier this year that asked, “Are you taking too many meds?” One person’s comment: “Big pharma is one of the greatest contributors to the wreck and ruination of America.” (I noticed that very few of the commenters addressed the opposite question: Are you not taking meds that would truly benefit your health?)

The truth probably lies somewhere in a gray zone. In recent years there seems to be a trend toward being more thoughtful when prescribing drugs. There’s growing awareness, for instance, that statins to lower cholesterol may not be all that helpful to individuals who have no previous history of heart attack. More recently, the effectiveness of multivitamins for middle-aged women has been called into question. Evidence-based guidelines are forcing more consideration of when a drug is genuinely appropriate.

Most of us are unlikely to get through life without needing a few prescription medications along the way. It’s smart to ask questions to make sure a prescription drug is truly necessary, and smart to take it if the honest answer is yes.

Photo: Wikimedia Commons

The memory gap

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This blog entry is about… wait, the word is on the tip of my tongue… it’s… um, ummm… no, that’s not it… wait, I’ll think of it in just a few seconds… what was I saying?

Once we hit middle age, it becomes an increasingly familiar scenario: Words – and especially names – are more elusive. Retrieving a factoid from the databanks of the brain, a task that we used to accomplish in a millisecond, takes longer. It’s harder for us to concentrate. We forget stuff.

Does this mean we should start worrying about the onset of dementia? Or is this just part of the normal aging process?

A study that appears in the latest issue of Science sheds some interesting new light on how the brain remembers. Working with monkeys, researchers at the University of New York were able to identify the parts of the brain involved in remembering the sequence of events within an episode.

Two main areas of the medial temporal lobe – the hippocampus and the perirhinal cortex – appear to play the main role in integrating “what” and “when”.

This study was carried out with monkeys, so its application to the human brain is limited. It adds some insight, however, to the complex mechanics of memory and which parts of the brain might be involved in memory-related disorders such as Alzheimer’s disease.

There are many reasons, of course, why people find it hard to remember things, and dementia isn’t invariably the main culprit. Stress and distraction can cause people to lose their train of thought. Conditions such as hypothyroidism, depression or fibromyalgia have been linked to so-called brain fog, or difficulty with concentration and memory. Ditto for cancer-related cognitive dysfunction, aka chemo brain, which is reported by many people who are undergoing or have completed cancer treatment and can cause problems with word retrieval and mental multi-tasking.

In an article a few years ago, Time magazine went so far as to call forgetting “the new normal.” The main point: Some degree of memory decline happens to everyone as they get older.

The good news, according to the article, is that “science is as interested in what’s going on as you are.”

With better scanning equipment and knowledge of brain structure and chemistry, investigators are steadily improving their understanding of how memory works, what makes it fail, how the problems can be fixed – and when they can’t.

For most people, all this will mean reassurance as worrisome symptoms turn out to be nothing at all. “Normal is the new frontier,” says Mony de Leon, director of the Center for Brain Health at New York University Tisch Hospital. And for those who do drift beyond that frontier, the same research may offer new hope for treatments and even cures.

How can we tell the difference between what’s normal forgetfulness and what isn’t? This online quiz can help distinguish typical memory problems from those that might signal something more serious.

Most people, as they age, will occasionally forget names or appointments only to remember them later, the Alzheimer’s Association says. What’s not normal is to experience memory loss that interferes with daily life, or to forget something and to be unable to recall later that you’ve forgotten.

A helpful rule of thumb from the brain and memory experts: If you’re worried that you’re losing your memory, your awareness of the problem is most likely a sign that your capabilities are still normal.

Ageless artists

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When a team with the Research Center for Arts and Culture at Columbia University was gathering information for a study on aging artists, their subjects had plenty of observations to share, from the thoughtful to the matter-of-fact.

“My job is a verb – constantly learning,” an 87-year-old actor from New York City declared. A former Rockette dancer, age 68, confided, “It’s the jumping that’s hard. I can still kick.”

The report, aptly titled “Still Kicking,” was released Thursday. (An executive summary is here; the full report is here.) Although the topic – the well-being of aging professional performers in New York City and Los Angeles – may seem rarefied, the lessons are not.

The researchers found that most of the artists they interviewed were still working, engaged with their art and their audiences and highly satisfied with their lives. As the baby boom generation reaches retirement and America wrestles with thorny social and policy questions about aging, perhaps we should turn to performing artists as an example of how to rescript the story of our lives and grow older with grace and resilience, the authors suggest. “This is one case where artists can show the way.”

The findings in “Still Kicking” are based on interviews with 219 professional performing artists in New York City and 51 in Los Angeles. The artists ranged in age from 62 to 97 and included actors, musicians, dancers, choreographers and singers.

One of the clearest things that emerged is that older performing artists enjoy fulfilling lives. They are satisfied with their lifetime performing career and most would choose the same career all over again. They take more artistic risks than when they were younger and have a deeper creative experience.

Although the majority of those who were interviewed lived alone, they communicated daily or weekly with other artists. More than half continued to be working artists and didn’t plan to retire until they were 90. A professional singer told the interviewers, “Singers don’t have retirement plans; I have to sing until I die.”

On the practical side, most of the artists who were surveyed had health insurance. Ninety-two percent had a will. The majority also had a designated health proxy and power of attorney.

The study found that performing artists face challenges as they age. Physical limitations were one of the barriers, especially for dancers. Many of the artists said they would stop working if injuries or declining health made it too difficult for them to continue. For some, the report noted, “retirement is both a financial and an emotional impossibility.”

Ageism was another barrier. The study recounts the experience of one actress:

One fit, attractive, brown-haired 75-year-old actress whom we interviewed, was called to audition for the role of a 75-year-old. She had to go out and buy a white wig and borrow a cane to emulate what the casting director thought 75 looked like.

The number of performing artists who work sporadically or who are freelancers also means that many fall outside the safety net of health and retirement benefits for a significant portion of their career.

Some observations from the report:

- As Americans live longer and the proportion of older Americans continues to grow, an emphasis has emerged on “creative aging” and the role the arts can play in promoting better health among older adults.

- Older artists can serve as a model for more flexible approaches to work, semi-retirement and access to health insurance.

- Older adults can feel fulfilled and supported in their later years when they have meaningful work and are engaged with their community.

This is believed to be the first study that has examined the needs of performing artists as they age. It seems to point the way toward models that other aging adults can follow. “A greater understanding of aging artists’ survival mechanisms, their relationship to their work, to each other, and to the social systems which make their work possible can provide a beacon for a lifetime of meaning, often self-motivated and self-generated,” the study’s authors wrote. “This meaning is something to pass on to future generations and as part of their early and continuing education. It is a guide to what is most central in our lives, and to our individual legacies.”

Photos, from top: Jazz musician Ellis Marsalis Jr., age 77; actor/director Clint Eastwood, age 81, on the set of “Gran Torino” in 2008; actress Patricia Neal, age 85. Courtesy of Wikimedia Commons

Tools for caregivers

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If one of my parents were to suddenly be hospitalized, I would probably know some details of their medical history and current medications, but would this be enough to prepare me for dealing with the situation?

The results from a recent online survey, conducted by The Boomer Project on behalf of Home Instead Senior Care, suggest that many midlife adults are in the same boat when it comes to their readiness to be caregivers.

Only about one in 10 of the survey participants believed they could be thrust into the caregiving role at any moment. Just under half said they were knowledgeable about their parents’ medical conditions. Nearly half couldn’t name any of the medications taken by their parents, and 40 percent didn’t know who their parents’ primary physician was or if their parents even had a primary physician.

When you talk to professionals who provide services for older adults, they often speak of the family crisis that can ensue when an aging parent falls and breaks a hip, becomes seriously ill or faces some other kind of health challenge that requires decisions to be made.

While there may be no way to make these situations less emotionally difficult, it can help when adult children of older parents are at least somewhat prepared to take on the role of caregiver. The problem for many of us, quite frankly, is where to start. That’s why I took notice when Home Instead Senior Care gave me a heads up recently on a new project they’ve initiated, the Senior Emergency Kit.

Developed in collaboration with Humana Points of Caregiving, the kit “is designed to help family caregivers gather details about a senior’s doctors, pharmacy and insurance company, medications and dosages, as well as allergies, power of attorney and other important information,” Home Instead explains on its website.

If you check it out, you’ll see that it contains worksheets and checklists of all the important information that should be collected in one place – things like names and phone numbers for key contacts, a medication tracker, a worksheet to help get the most out of doctor appointments, and even an emergency wallet card. There’s also a guide to help adult children navigate the challenges of understanding their parents’ medical coverage.

There can be a fine line between assisting one’s aging parents and respecting their autonomy vs. dictating how they should live their lives, between sharing vital medical information vs. invading a parent’s privacy. Home Instead offers the “70/40″ Rule: If parents are 70 and their adult children are 40, it’s time to start having some meaningful conversations about the future – preferably before there’s a crisis.

The 70/40 Rule and its suggestions for implementing discussion on sensitive topics are based on research indicating that many communication difficulties between parents and their adult children stem from the persistence of the parent-child dynamic. How well do you think you communicate with your older parents? This quick online assessment will give you some idea, and perhaps help identify areas that might need attention.

When something happens to an older parent, families can’t assume the health care system will take care of all their parent’s needs. Although the professionals are there to help, there’s no real substitute for adult children who are engaged, informed and prepared.

Photo: Wikimedia Commons

Framing the osteoporosis discussion

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Some of the latest clinically relevant findings in preventing, diagnosing and treating osteoporosis will be presented this week as the National Osteoporosis Foundation holds its ninth international symposium in Las Vegas.

It looks as if the agenda will cover a wide range of topics: drug therapy, nutrition, communicating with patients about drug side effects, and the emerging science on clinical practice and therapeutic issues related to osteoporosis. The week will wind up with a session co-sponsored by the American Society for Bone and Mineral Research on what’s new in bone research.

I always sort of assumed that most adult Americans know at least a little bit about osteoporosis, or thinning of the bones, a condition that’s often age-related and can increase the risk of fractures. After all, ads for prescription drugs to stave off osteoporosis seem to be everywhere these days. So I was a little surprised when a recent survey, conducted by the National Osteoporosis Foundation and Harris Interactive, found that 34 percent of the respondents had never heard of the condition.

Although 70 percent of the survey participants believed osteoporosis can be prevented, half didn’t know that exercise can make a difference, and almost three-fourths were unaware of the role nutrition can play. (Since I’ve been unable to find any information on how the survey was conducted or how many people participated, take these findings with a slight grain of salt.)

Poor bone health can be a big deal. Individuals with osteoporosis are more vulnerable to breaking a bone, leading to pain, disability, medical expenses and, in the most serious cases, loss of independence and/or shortened lifespan. Some people never truly recover. It’s thought that as many as two out of every 10 older adults who break a hip die within a year, due to problems either associated with the injury itself or the surgery to fix it.

Figuring out the best screening and prevention strategies hasn’t been easy, though. Do we screen everyone past a certain age? How do we identify other at-risk populations? What are the important risk factors? How often should people be screened? How aggressive should we be about prescribing medication to prevent osteoporosis? Which people are the best candidates for medication and how long should they take a drug?

The U.S. Preventive Services Task Force, the main body for developing evidence-based screening guidelines for clinical practice, issued new recommendations back in January on screening for osteoporosis. The gist of the task force’s recommendations: Women who are over age 65 and women who are younger but have the same or higher fracture risk as a white woman over age 65 should be screened.

The panel concluded there was “convincing evidence” that bone density measurement with DXA, or dual-energy X-ray absorptiometry, can effectively predict the short-term risk of a fracture and appears to be more reliable than questionnaire forms of screening. Overall, the USPSTF concluded that for these two populations of women, “there is moderate certainty that the net benefit of screening for osteoporosis by using DXA is at least moderate.”

So what about drug therapy to lower the risk of osteoporosis? Here the evidence becomes rather murky. In a guest essay published online last week at Kevin MD, Dr. Juliet K. Mavromatis notes that she sees many women who “are left on these drugs for years and years,” despite limited clinical knowledge about the long-term safety.

It’s an area that’s ill-defined, she wrote:

Many questions remain about how to approach the treatment of aging bones to prevent the debilitating outcome of bone fracture. Seasoned clinicians have seen the problems that may occur in some cases with treating large populations of well patients for normal life processes (postmenopausal estrogen replacement therapy). Let’s hope that future research will address the question of when to treat with medication and for how long with further precision. Until then let’s use appropriate caution when prescribing medicine for normal senior bones.

The USPSTF recommendations do in fact call for more research on several issues: how often women should be screened for osteoporosis, the extent to which screening truly has an impact on long-term health outcomes, and the impact of osteoporosis on women of color. More studies also need to be designed for men, who can get osteoporosis too although their risk is lower than that of women.

Given the swelling numbers of Americans who are getting older and the likely rise in the number of people with osteoporosis, this seems to be an area of study that calls for some serious attention.

Image: Wikimedia Commons

Don’t forget – live guest-blogging tomorrow with the Willmar Ambulance Service!

Confronting dementia: When ignorance isn’t bliss

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If the findings from a recent Harris poll are any indication, many American adults worry their post-retirement years will be darkened by the shadow of Alzheimer’s disease and related dementias. Yet despite this fact, the majority have made few, if any, preparations.

The poll, conducted by Harris Interactive for the MetLife Foundation, contains some rather eye-opening observations:

- Of the 1,007 respondents, 31 percent said Alzheimer’s is the disease they fear most. Age-related dementia was second only to cancer, which was listed as the most feared disease by 41 percent of those who took part in the survey.

- Although nearly one-fourth of the survey participants were extremely or very concerned they would some day have to provide care for a loved one with Alzheimer’s, fewer than one in five have made any plans for the possibility of some day developing Alzheimer’s disease.

- Fewer than half said they’ve talked to their families about Alzheimer’s.

- 33 percent have considered the care options for Alzheimer’s disease and 44 percent have designated who their caregiver will be.

- Slightly more than one in five of the respondents said they had made financial arrangements for the possibility of Alzheimer’s.

More than five million Americans currently have Alzheimer’s disease. Once the baby boom generation reaches age 65 and beyond, their ranks are expected to swell substantially, accompanied by considerable personal and financial cost.

Given these facts, it’s both baffling and concerning that so many people seem unprepared – or perhaps they simply prefer not to think about it. To muddy the waters further, an ethical debate appears to be brewing over new tests that make it possible to diagnose Alzheimer’s in its early stages. Should people be told, or is it better not to burden them with the knowledge of a disease with no known cure or prevention? It puts doctors in a quandary, Lisa Suennen of the Psilos Group writes on The Health Care Blog:

If they tell their patients the bad news, it may have a profound negative effect on their psyche and lead to debilitating depression; if they don’t tell, they are withholding information that might enable a person to prepare their life more effectively to deal with the oncoming challenges.

In a recent guest post on Kevin, MD, Dr. George Lundberg is blunt about the value of the florbetapir-assisted PET scan of the brain, which can detect early Alzheimer’s disease with a certainty previously available only upon autopsy. Calling it “a diagnostic bridge to nowhere,” Lundberg asks:

Doctor, do you really want to know if your patient has a chronic, slowly progressive, fatal, debilitating disease for which you have no effective intervention?

Patient, do you really want to know if you have a chronic, slowly progressive, fatal, debilitating disease for which medicine has no effective intervention?

If you put it that way, the answer would probably be no. The more important question, though, isn’t whether we want to know; it’s whether we should know so we can begin planning for the inevitable decline.

“Diagnosis is an end in itself,” wrote one of the commenters to Dr. Lundberg’s guest post. “Patients who want to know their condition should have access to a test that can tell them what their medical condition is and/or is likely to become, even if this test is self-pay. Patients can anticipate what is to come, and for [A]lzheimer’s patients in particular it enables choices before the power of choice is gone for the individual.”

A commenter on The Health Care Blog also brought up the importance of helping families prepare:

If you know your older relative will probably end up with Alzheimer’s, it completely changes the family’s ability to cope with the challenge. They suddenly have the option of realistically planning for it. This is in contrast to the panic that sets in when you’re in a situation where you are watching the elderly person deteriorate and trying to figure out what’s going on – or worse, fighting through the elderly person’s total denial of their situation.

If you expect your mother will have Alzheimer’s, maybe you adjust your life so you don’tmove away for that new job. Maybe you go so far as to have one kid fewer. Maybe you organize a neighborhood babysitting share so that when you do have one more kid, if mom is starting to deteriorate, three days a week you can take care of mom. Maybe you put money in some kind of special caregiving account – and if you’re really savvy and well connected, you start lobbying to make such an account tax-free! Maybe you get co-signing rights to checks or rights to oversight of all of dad’s financial accounts while he’s still compos mentis, so that you can monitor them and take them over when dad gets to the point where he can’t make good decisions and people start trying to rip him off. Maybe mom makes you or a friend she trusts eligible to share her medical records, so that her caregivers can plan with you and freely share her information with you.

I’m not sure there are any easy or obvious answers here, other than that none of us can assume we won’t ever be faced with dementia in a loved one or in ourselves.

For starters, though, if you live anywhere near west central Minnesota, consider attending a free community education program in Willmar next week, sponsored by the West Central Dementia Awareness Network. It’s at Bethel Lutheran Church at 5 p.m. Tuesday, April 12. Guest speakers Marcia Berry, education manager of the Alzheimer’s Association of Minnesota and North Dakota, and Willmar attorney Brad Schmidt of the Johnson, Moody, Schmidt and Kleinhuizen law firm will talk about early identification of Alzheimer’s and legal planning. The event is free and will include exhibits, educational materials and a barbecue supper.

When you talk to people who have dealt with Alzheimer’s disease in a parent, spouse or sibling, a common theme tends to emerge: Families can take refuge in denial and end up delaying appropriate care and services for too long. Then there’s a crisis and decisions must be made when people’s backs are against the wall. Ignorance isn’t necessarily bliss; too often it only seems that way until reality intrudes to shatter the illusion.

Photo by Rob Farrow, from the Geograph Project collection.

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