‘Cookbook Medicine’ Won’t Do for Elderly

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‘Cookbook Medicine’ Won’t Do for Elderly

http://www.nytimes.com/2008/12/30/health/30brod.html?nl=8hlth & emc=hlth

By JANE E. BRODY

Published: December 29, 2008

The Martha Center for Living at Mount Sinai Medical Center in

New York is like no medical clinic I’ve ever seen. It is brightly

lighted and quiet — there is no television blasting. It has wide

corridors and plenty of comfortable chairs with sturdy arms, and yet few

people wait more than 10 minutes to see a doctor or nurse practitioner.

The center, which opened in 2007, was designed especially for primary

care of older adults, many of whom have complex chronic medical problems

like diabetes, heart disease and hypertension as well as debilitating

conditions like arthritis and osteoporosis.

Just as a child is not a small adult and requires specialized care,

adults over the age of, say, 65, are not just old adults and should not

be treated like patients half their age.

The population of aging Americans is expected to mushroom in the years

ahead. Geriatricians, the experts in elder care, are already in short

supply, and their numbers will continue to shrink. But knowing the kind

of care that these specialists provide may help older people and those

who look after them learn to seek it out wherever they go.

“Cookbook medicine may be appropriate for younger people but is not

always appropriate for older people,” Dr. Mark Lachs, a geriatrician at

Weill-Cornell Medical Center in New York, said in an interview. He sees

two dangers in how older adults are treated: overtreatment and

undertreatment.

“If a high-functioning 80- or 90-year-old develops angina, aggressive

treatment would be appropriate,” Dr. Lachs said. “Care should not be

withheld solely on the basis of age.”

On the other hand, overtesting and overtreating older patients can

result in debilitating side effects. Before deciding on tests and

treatment, he said, “the doctor must take into account the whole picture

of the patient, the patient’s family and life situation.”

Screening for Lifestyle

Dr. R. on is one of the geriatricians at Mount Sinai. “The

overall goal is to help older adults achieve the best quality of life

possible, given the limits of medical technology and knowledge,” he said.

When I asked how he would approach a new patient of 85, Dr. on

said he would start with a series of questions: “Tell me about yourself.

What do you like to do? What are the things you would like to do that

you cannot do anymore? What is your medical history? What medications do

you currently take? What brings you here today?”

The geriatric exam itself would depend on the patient’s answers. “If the

patient is a healthy 75-year-old who plays golf and tennis and has no

functional limitations,” Dr. on said, “the focus would be on

preventive screening and advance care planning.

“But if the patient has functional limitations, the focus would be to

restore and improve what can be restored and improved, such as reducing

the risk of falls, addressing any acute medical conditions, and

streamlining medications for chronic health problems so that the right

drugs are taken for the right conditions.”

“You want a doctor who asks more than just about your medical

conditions,” he added. The doctor should ask about the effect of medical

conditions on quality of life, and then should explore what improvements

are possible. “The focus of care should be on quality of life,” he said.

“Too often, doctors lose sight of this goal when the focus is on

treating specific diseases.”

The doctor should address a patient’s most serious health threats, of

course, but also the patient’s most serious concerns. Is the patient

troubled by problems like fatigue, pain or shortness of breath, or

having problems with medications?

For example, he said, if a patient has serious arthritis and

hypertension and cannot go to places without a readily accessible

bathroom on the first floor because she takes a diuretic for high blood

pressure, perhaps the blood pressure medication should be changed. The

patient may prefer a different drug that carries a slightly greater risk

of stroke if it means a better quality of life.

The Exam

“When going to a new doctor, an older patient should receive a

comprehensive assessment, not just a physical exam,” Dr. Chad Boult, a

geriatrician at the s Hopkins School of Public Health, said in an

interview. “The patient should be asked, What is important to you about

your health now? What is your life like — your exercise habits, diet,

use of alcohol and tobacco? Is your environment safe and convenient?”

There are three areas that should be explored during a geriatric exam

that are often missed if the doctor focuses on a specific illness, Dr.

on said:

¶Dementia. He asks the patient: “Are you having trouble with your

memory? Is it O.K. if I check with a family member about this?” He said

there were often treatable causes for memory problems, like thyroid

disease, medication side effects or depression.

¶Risk of falls. Checking balance, gait and strength is easy, he said. “I

would meet you in the waiting room, watch how you stand up from a chair

and walk to the exam room. I’d throw a pen on the floor and ask you to

pick it up. I’d ask you to sit in a chair and stand up three times as

quickly as you can. Can you get up and down without using the arms of

the chair? If the patient uses a cane, how is it used and is it the

right height?”

¶Incontinence. “There’s a tremendous social stigma associated with

incontinence even when there are medical reasons for it,” Dr. on

said. It is as common as hypertension and diabetes among the elderly,

but patients rarely discuss it with their doctors unless asked about it,

he said.

Dr. Boult said that patients’ feet were often overlooked, leading to

problems that can become life-limiting. Many older people cannot reach

their feet to clean them and cut their toenails, and they develop

painful sores.

Other Considerations

Dr. on said that before recommending screening tests like

mammograms for breast cancer and PSA tests for prostate cancer, the

question to ask is, “What are we going to do with the test results? If

we’re not going to act on them, screening should be stopped.” If a

patient has chronic conditions that limit life expectancy, he said,

there is no point in screening for most cancers.

On the other hand, he said, two medical procedures can greatly improve

the quality of life for older adults: joint replacement and cataract

surgery. Too often, patients think such surgeries aren’t worth the

bother because they won’t be around much longer. He described a woman

who at 82 was having trouble walking but chose not to have a knee

replacement. Now 102, the patient told him, “I should have listened to

you years ago.”

Like this woman at 82, many older people are quite healthy, Dr. Boult said.

But about one-quarter of the older population has multiple chronic

conditions and spends 80 percent of Medicare dollars, he added. “These

patients need coordinated care, a system of regular monitoring, and

regular access to a primary care doctor who can detect problems early

before they require expensive, dramatic treatments.”

--

ne Holden, MS, RD

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