Aging Well/WSJ

[Guest guest]

Aging Well

Older patients may have to fight to get the right care

By KELLY GREENE

Staff Reporter of THE WALL STREET JOURNAL

June 20, 2005; Page R5

When 66-year-old Rowe was diagnosed with leukemia five years ago,

he started researching cures -- and hitting brick walls.

First, Mr. Rowe's oncologist told him that the death rate was too high

for people over 50 to attempt a bone-marrow transplant. Next, he was

told that he shouldn't take Interferon, a proven cancer treatment that

could lead to remission, because it would make him feel like he had a

perpetual case of the flu.

Finally, when he pressed the oncologist about a clinical trial for

Gleevec, which at the time was still an experimental cancer drug,

" this young doctor looked me in the eye and said, 'Look, Mr. Rowe, you

don't understand. That drug is in short supply, there's high demand,

and they aren't going to waste it on you.' "

So, on his own, Mr. Rowe, a Census Bureau retiree, snared the last

spot in a clinical trial for Gleevec in nearby Baltimore, and in one

year was in remission. Today, he's still cancer-free. " Age isn't just

chronological, " he says. " Attitude has a lot to do with it. "

The evidence is piling up that many doctors share the age bias that

Mr. Rowe experienced -- despite the fact that many older patients with

serious illnesses respond well to treatment. Research shows that older

patients aren't being steered toward the medical screening and

preventive care they should get, even though Medicare would pay for

much of it. And detected illnesses often go untreated.

To make matters worse, research also suggests that many older patients

share their doctors' bias, believing that aches and pains are an

irreversible part of aging.

" There is a lot of withholding of aggressive medical treatment for

people, based not on the evidence of whether they will benefit or not

but by the perception of the physician that they're too old to

benefit, " says , executive director of the Alliance for

Aging Research, an advocacy group in Washington.

Adds Studenski, a geriatrician and professor at the

University of Pittsburgh: " Chronological age is a poor reflection of

life expectancy and ability to tolerate treatments. There are

85-year-olds who might seriously consider aggressive treatment and

there are 65-year-olds who might not. But we know there's a widespread

relationship between age and whether someone is offered these options. "

Going Undetected

Nine of every 10 adults over age 65 go without appropriate screenings

and immunizations, according to the Centers for Disease Control and

Prevention in Atlanta, and one in three older adults don't get flu

shots. Even fewer get pneumonia vaccines.

At least one in four people who are 65 or older have enough of a

hearing impairment to affect their ability to work or drive -- but the

majority of older people aren't assessed for hearing loss, according

to a 2003 study led by Seattle researchers.

And a study four years ago of 200,000 women age 50 or older found that

40% had osteopina, 11% had suffered from fractures since age 45, and

7% had full-blown osteoporosis -- but none of them knew it because

their doctors hadn't identified the problems.

But getting a health problem diagnosed doesn't guarantee it will be

get treated. Heart disease is the No. 1 killer of people who are 65

and older. Still, more than a third of doctors consider high blood

pressure to be a normal part of aging, according to a 2002 study by

University of South Carolina. Other researchers have found that nearly

half of Americans age 50 and older don't realize they have

hypertension, and that half of the hospitalizations of Medicare

beneficiaries with chronic heart failure are preventable.

Less than half of people 50 or older have received one of the two most

common types of colorectal screenings, despite the fact that colon

cancer is second only to lung cancer as a cause of cancer-related

deaths, according to the American Cancer Society. And just over half

of 4,768 colon-cancer patients in the 65-plus age group, diagnosed

between 1992 and 1996, received chemotherapy -- despite the fact that

it was " significantly associated with reduced mortality in older

patients, " according to a 2002 study by Columbia University researchers.

Similarly, a study released in March found that older and younger

breast-cancer patients showed similar reductions in cancer recurrence,

and death, from chemotherapy -- even though chemotherapy is

" frequently not offered " to otherwise healthy older women. Of the 146

ovarian-cancer patients studied at the Memorial Sloan-Kettering Cancer

Center in New York, only 17% over age 65 received aggressive

treatment, compared with 46% of their younger counterparts.

Little has been done to recognize or treat older patients with chronic

depression as well. Older people are disproportionately likely to die

by suicide, with white men age 85 and older the most likely to do so,

according to the American Association for Geriatric Psychiatry. Mr.

of the Alliance for Aging Research says that nearly 40% of older

adults who commit suicide do so within a week of seeing their

physicians, showing that doctors aren't recognizing depression in

these patients.

Sometimes a doctor's reluctance to medicate an older patient is simply

based on a lack of evidence that it will work. From 1991 to 2000, 40%

of clinical trials excluded people over age 75, according to the

International Longevity Center in New York. And a study of nearly

29,000 cancer patients in drug trials from 1995 to 2002 found that

only 36% were 65 or older -- compared with 60% of cancer patients overall.

Many doctors also lack the geriatric training that might help them

better weigh whether a patient should undergo treatment. Only about

10% of U.S. medical schools require course work or rotations in

geriatric medicine, according to the Alliance for Aging Research.

Taking Control

But there are some strategies for older patients who want their health

problems treated more aggressively.

Robin Kornhaber, senior vice president of patient services for the

Leukemia and Lymphoma Society in White Plains, N.Y., suggests two

tactics that patients with any illness could employ:

First, get a comprehensive geriatric assessment, preferably by a

geriatrician, to help your specialist assess the sort of treatment you

could withstand and ways you could shore up your body to help. For

example, " if nutrition is the issue, you could get meals brought in, "

she says.

Second, " it's really important to have a partner in your care, " to

help you ask doctors questions and understand the answers, she says.

" You need someone there who can clearly hear what's going on, take

notes and talk through these things with you and other members of the

family. " (You can get the society's " Toolkit for Older Adults with

Cancer and Their Caregivers " by calling 800-955-4572.)

What if you are the partner, and you're frustrated that your loved one

is refusing treatment? " It's important to try to keep that

conversation going and draw out what it is that's concerning that

older adult, " says Dr. Studenski, the geriatrician. " Maybe they tried

a blood-pressure pill and felt very dizzy on it. Or maybe their

diuretic made them have to rush to the bathroom, or kept them up at

night. " With those real-life concerns out in the open, she says, the

doctor can try to find a more comfortable alternative.

--Ms. Greene is a staff reporter in The Wall Street Journal Atlanta

bureau.

Write to Greene at kelly.greene@...