Tips Of All Sorts

The coming tsunami of baby boomers means physicians are destined to see an increase in the number of elderly patients in their offices. Preparing to do well by them could require a change in attitude as well as office furniture.

It won't be business as usual, according to the Institute of Medicine's 2008 report "Retooling for an Aging America: Building the Health Care Workforce."

Only about 7,000 physicians in the nation are certified geriatricians, but 36,000 will be needed to provide care for the aging population by 2030, according to the report. The consensus is -- that's not going to happen.

Instead, what will occur is that more and more elderly people will turn to internists and family physicians for care, and the best course of action for these physicians is to prepare for and embrace the inevitable, say a number of geriatricians who offer a variety of pointers.

For starters, "you need to get a sense from them as to what their goals are," said Rosanne Leipzig, MD, PhD, professor of geriatrics and adult development at Mount Sinai School of Medicine in New York City. She also is an adviser to the American Medical Association on aging issues.

Dr. Leipzig works to help her patients live the life they want . She said this mind-set can lead to approaches that vary widely, because older people are a heterogeneous group. "When you've seen one, you've seen one."

Taking the time upfront to consider level of care will save time in the long run. "Is this someone you are going to think about as a robust elder, or someone who is frail, or someone who is in the last stages of life?" Dr. Leipzig asked.

"Some 85-year-olds you would treat as aggressively as you would a 65-year-old," said Jerome Epplin, MD, a family physician who cares for predominantly older patients in Litchfield, Ill.

David Mehr, MD, a professor of family and community medicine at the University of Missouri School of Medicine, in Columbia, noted that "with an 80-year-old you can have a competing athlete or someone with significant disabilities."

Regardless of the patient's level of ability, the treatment goal remains the same: "Keep them functioning independently and having a good quality of life," said Judah Ronch, PhD, professor at the University of Maryland's Erickson School in Baltimore. The school focuses on improving services for older people.

Rewards and attitudes

Caring for this population is a rewarding way to spend the day, said several physicians who do just that. "Geriatrics is going to be the fastest-growing segment of primary care practice, and this is good, because taking care of older people is one of the most thrilling experiences in medicine," said Bill Thomas, MD, also a professor at the Erickson School.

M. Mayes DuBose, MD, a geriatrician who established the first geriatrics-only medical practice in Sumter, S.C., also revels in his work. "I think I got into it for the right reasons. Otherwise I think I'd be burned out." And the right reasons? "The desire to provide high-quality care to America's older adults. And the desire comes from the recognition that they are such a vulnerable population," Dr. DuBose said.

Only about 7,000 U.S. physicians are certified geriatricians.

Caring for older people is "one area of medicine where you can practice the true art of medicine," Dr. Epplin said. The goal is maintaining a proper balance between treating enough to make a difference without overtreating, he said.

Plus, "you have to have an interest in it," Dr. Epplin said. Developing that interest may require an attitude adjustment. Some physicians may see patients older than 70 and assume they are on a downhill course, he said. A conversation may include: "Your knee hurts? You're old, what do you expect?" The biggest complaint Dr. Epplin hears from his patients is that other physicians dismiss their concerns. "Remember that these are very viable people who have a future as well as a past. Then you look at it in a more positive way."

At the same time, legitimate concerns surround the time commitment necessary to care for these complex patients. The primary care physician who is going to care for a significant number of America's elderly has to be willing to change his or her standard of practice, Dr. DuBose said. "There has to be more time taken, and it has to be a slower process than the typical office visit."

Sharpening communication skills is one way to use limited time effectively, several doctors said. Poor communication can cause the entire medical encounter to fall apart, noted John C. Houchins, MD, assistant professor in the Dept. of Family and Preventive Medicine at the University of Utah School of Medicine, and others in a 2006 article in Family Practice Management.

Their communication tips include avoiding distractions, sitting face-to-face with a patient, maintaining eye contact, listening and sticking to one topic at a time.

Patients also may be unable to hear well, whether because of a hearing loss or the loss of the ability to hear higher frequencies. Women doctors may have to enlist the help of male colleagues with lower-frequency voices to improve a patient's ability to hear them, Dr. Leipzig said.

But Dr. Thomas cautions that not all older patients are hearing-impaired, and physicians shouldn't assume they are. "I like to first speak in a normal voice to all older people."

Doctors also should be aware that their oldest patients may not be forthcoming with information because they don't want to cause the doctor any problems, Ronch said. "They might not be comfortable communicating issues that are important for the physician to know about."

Caution also should be taken to ensure that patients can read the materials they are provided. Use large font sizes and high contrast, so the letters are black and the paper is white and nonglare, Dr. Leipzig said.

The top priorities

Some concerns loom as exceptionally important when caring for older patients, and among them is the elimination of medication errors.

Geriatricians agree that all patients should bring a bag of their medications to each visit. Included should be prescription and over-the-counter items, vitamins and herbal products.

Eliminating medical errors is a top priority when caring for older patients.

Dr. DuBose likes to have patients bring the bottles, rather than a list of medications, so he can write on the bottles if a change is required. "Medication errors are very common," he said. "So a doctor or a nurse needs to make a dedicated effort to review all their medications."

Having a good, online resource to check for dosing information and drug interactions is also invaluable, a number of physicians said.

Another top priority is the ability to diagnose dementia and differentiate between dementia and delirium.

Dementia isn't always obvious at earlier stages, Dr. DuBose said. But once it is diagnosed, doctors can prescribe medications to slow its progress. Financial and health safeguards can be put in place for patients' protection.

A primary care physician doesn't need to be able to deal with every complicated patient with dementia, but they should have a good basic approach to follow if a family member expresses concern about an individual or if a patient comes in and says they are concerned about their memory, Dr. Mehr said.

Preventing falls is another area of importance. "One of the most devastating things you can help prevent is falls and resulting hip fractures," Dr. Leipzig said. An evaluation of gait, balance, vision and use of psychotropic medications is necessary.

A "get up and go test" is a fairly simple way to determine an individual's capability, Dr. Mehr said. "Ask a person to get up from their chair, walk across the room and walk back. You want to see if they use their hands to get up."

Doctors also should be sensitive to incontinence, he said, which is common in older women.

Caring for this population is a team effort. Physicians often enlist office staff to carry out many evaluations, and they should also be aware of community resources so they can help connect their patients with services such as visiting nurses, senior centers and entitlement programs. "You don't need to be a social worker, but you need to refer," Dr. Leipzig said.

Changes to the office layout also can make a difference to older patients. Ease of entry is a help to patients of all ages, Dr. Thomas noted. "People living with disabilities will thank you, as will younger people who have torn their Achilles tendons and are on crutches.

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Two physician groups are urging the federal government to update policies related to HIV infections, charging that the policies were drafted years ago when infection with the virus equaled a death sentence.

Now, with appropriate treatment, people infected with HIV can live a near-normal life span, noted Michael Saag, MD, chair-elect of the Infectious Diseases Society of America's HIV Medicine Assn. He spoke during an April 17 press briefing to introduce a joint position paper of the American College of Physicians and the HIVMA. The paper was released online April 16 and is to be published in the May 15 Clinical Infectious Diseases.

In their paper, the groups call for earlier identification of those infected with the virus, expanded access to treatment and stronger national leadership to respond to HIV's spread in the United States and abroad.

Gains on HIV diagnosis and treatment have made it more important to identify people carrying the virus as early as possible, the position paper said. Yet recent estimates by the Centers for Disease Control and Prevention say that of the 1.1 million people in the U.S. infected, one in five is unaware of his or her status.

Because of near-universal testing and implementation of effective treatments for infected mothers-to-be, transmission to infants has basically stopped, Dr. Saag said. "Now this same concept needs to be applied to the entire population."

1 in 5 of the 1.1 million people in the U.S. with HIV is unaware he or she has it.

Another reason for rapid identification and treatment is a recent finding that the AIDS virus is now more virulent, and damage to patients' immune systems is occurring earlier.

A paper published May 1 in Clinical Infectious Diseases found that 25% of patients diagnosed with HIV in recent years already had CD4 cell counts of less than 350, which is the threshold for implementing antiretroviral therapy, compared with only 12% of patients in the late 1980s.

"Unfortunately, it may no longer be true that there is a time period of several years between diagnosis and the need for treatment -- instead, this time span is shortening," said study author Nancy Crum-Cianflone, MD, MPH, an infectious diseases specialist at San Diego Naval Medical Center.

Broad screening urged

Although the CDC put out a call in 2006 urging widespread HIV screening, the response has been spotty from the nation's hospitals, clinics and physicians' offices. The AMA also recommends that physicians routinely test adult patients.

Among the changes requested by the ACP and the HIVMA are those allowing reimbursement for the screening of all patients in federal health programs. "Although the Centers for Medicare & Medicaid Services are considering reimbursing the cost for testing high-risk patients, we would recommend they expand this policy to cover all Medicare beneficiaries," said Jeffrey Harris, MD, ACP's immediate past president.

The federal government does not support needle-exchange programs.

The cost of treatment increases dramatically in later stages of infection, he noted. With early treatment, the cost is less than $14,000 per year, but that figure increases to more than $36,000 annually, he said.

The groups also request the expansion of proven prevention strategies. "It's time to support evidence-based transmission prevention efforts such as needle-exchange programs and comprehensive sexual education," said Kathleen Squires, MD, HIVMA vice chair. Despite studies showing the effectiveness of needle-exchange programs, the federal government does not support them, she said.

J. Fred Ralston, MD, president-elect of the ACP said work force issues also must be addressed.

Screening is going to be done by primary care physicians, and that network is "in critical condition as we speak," he said. "It has been shown that the collapse of primary care is going to lead to higher costs, lower quality, diminished access and decreased patient satisfaction, which is certainly not the direction in which we want to head."

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Tight control of blood glucose levels, the bedrock of diabetes care for some time, may not be the best option for all patients with the type 2 form of the disease. The burden of complex treatment regimens, risk of low blood glucose, possible weight gain and expense of reaching these goals may not always be worth it. In addition, hemoglobin A1c targets should be individualized, according to a review of recent studies in the June 2 Annals of Internal Medicine.

"It's time to look at the patient with diabetes as an individual who has more issues than just blood sugar," said Victor Montori, MD, lead author and professor of medicine at the Mayo Clinic in Rochester, Minn. "It's key that we change the emphasis from blood sugar to well-being, adequate preventive care and adequate cardiovascular risk reduction."

Researchers pooled several large randomized trials comparing effects of working toward various glycemic targets. Tight control made no impact on all-cause mortality, cardiovascular death, stroke, amputations or microvascular complications. This diabetes care strategy also increased the risk of hypoglycemia and weight gain.

Aiming for ever-lower blood glucose levels has been the emphasis of diabetes care from several organizations because of evidence indicating the approach reduces the risk of long-term complications. Most urge that the majority of patients achieve hemoglobin A1c numbers around 7% or lower.

This paper is the latest to suggest this strategy may not always be proper. Results of projects released in the past year, such as the Action to Control Cardiovascular Risk in Diabetes, the Veterans Affairs Diabetes Trial, and Action in Diabetes and Vascular Disease -- Preterax and Diamicron Modified Release Controlled Evaluation, noted that efforts to tightly control blood glucose levels may not mean lower risk of cardiovascular disease. They may even increase the risk of death for some.

"Hypoglycemia can be very dangerous in the older population, particularly for older patients who have co-existing illness and are on numerous medications," said William Duckworth, MD, director of diabetes research at the Phoenix Veterans Affairs Health Care Center and VADT's principal investigator.

In response, the American College of Cardiology, the American Diabetes Assn. and the American Heart Assn. published a statement in their respective journals last year saying most patients should still aim for an A1c of 7%. Those with a history of severe hypoglycemia, short life expectancy and advanced complications may not need such intense glycemic control. A commentary in the April 15 Journal of the American Medical Association also suggested that younger patients who have not had the disease long and do not have many cardiovascular risk factors are most likely to benefit from tight control. "The goal for the majority of people is a hemoglobin A1c as close to normal as possible," said Bruce Bode, MD, a spokesman for the Endocrine Society and associate professor at Emory University School of Medicine in Atlanta.

Response to this more recent paper varied. Some praised it for bringing attention to the fact that tight control may not be best for everyone.

"We are treating people, not numbers," said Rodney Hayward, MD, co-director of the VA Health Services Research and Development Center of Excellence in Ann Arbor, Mich. "People have different goals in their life. For them to check their blood sugar multiple times a day may come at a huge cost and may not really be valuable. It may even be dangerous."

But the findings also drew criticism. Some experts questioned the conclusions because researchers lumped together several trials focusing on very different populations. Many also expressed concern that worries about the patient burden of getting to low numbers may have been overblown.

"I agree that glucose targets need to be individualized. I don't necessarily think it's appropriate to combine all of these studies together," said Irl B. Hirsch, MD, professor of metabolism, endocrinology and nutrition at the University of Washington School of Medicine in Seattle. "I disagree with some of the conclusions about the burden of care on the patient."

The authors say tight blood glucose control is a good option for some patients but, because it is not for all, advocate that A1c numbers not be used for pay-for-performance and other quality measures.

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Weight-loss surgery may help those with less-severe obesity shed pounds, but questions remain about long-term outcomes and whether some versions of the procedure are better than others. The conclusion was the result of a data review by researchers at the University of Southampton in England. Their findings were published April 15 in The Cochrane Library.

"[This paper] is not saying that we should be doing surgery for those with a BMI between 30 and 35. It's saying that, yes, surgery results in a greater weight loss, but is it worth it? We don't know," said Caroline Apovian, MD, director of the Nutrition and Weight Management Center at Boston Medical Center. She was not affiliated with the Cochrane review.

A National Institutes of Health 1991 consensus paper stated that bariatric surgery was appropriate for those with a body mass index higher than 40. It also noted those with a BMI between 35 and 40 who had serious weight-related illnesses could be considered. But the significant number of people who carry excess pounds combined with the development of safer, less-invasive procedures is leading some physicians to ask whether these recommendations should be adjusted.

"Eighteen years ago, procedures had a higher complication rate. The [gastric] band and sleeve didn't even exist. This should be studied," said Scott Shikora, MD, president of the American Society for Metabolic and Bariatric Surgery and director of the Weight and Wellness Center at Tufts Medical Center in Boston.

A 2004 consensus statement from the ASMBS suggested that bariatric surgery for patients with a BMI between 30 and 35 who have weight-related medical conditions may be indicated and needs study. A few research projects investigating the option as a treatment for people who have diabetes and a BMI as low as 30, including one project by Dr. Shikora, are either under way or being planned.

Bariatric surgery is more effective than medical management for weight loss.

Some doctors say bariatric surgery for these patients could lower their chances of experiencing more severe weight-related adverse events.

"It means we're going to get to people earlier in the disease process," said Nick Nicholson, MD, medical director of the weight-loss surgery program at Baylor University Medical Center in Dallas and the Baylor Regional Medical Center in Plano, Texas. "[Surgery] is technically easier when they're at lower weights." On rare occasions, he has operated on patients with BMIs as low as 32 who had severe obesity-related complications.

But other physicians say unanswered questions remain on the longer-term effects. Some also feel the medical management used as a comparison in the reviewed studies was not as intensive as it could be -- giving the outcome advantage to surgery. And although the review found that surgery was more effective than medical management for weight loss, many would like to see analyses looking at differences in other factors, such as cost and adverse events.

"Surgery looks terribly promising, and I know it will play an important role. I don't think we know what the role is right now," said Tim Church, MD, MPH, PhD, director of preventive medicine research at Pennington Biomedical Research Center in Baton Rouge, La., who researches nonsurgical weight loss. "We spend 25 or 50 grand on bariatric surgery. We would never dream of committing even half that to a good behavioral intervention. Give me half that fee, and I will change someone's behavior and keep it changed."

Physicians who specialize in nonsurgical weight-loss strategies also say it is possible to lose large amounts of weight without an operation and expressed concern about patients having these kinds of procedures before exhausting other options.

"We can reverse many of the complications of obesity almost as effectively as bariatric surgery with a minimal rate of complications and cost," said Allen Rader, MD, secretary/treasurer of the American Society of Bariatric Physicians and the founder of Idaho Weight Loss in Boise. "We believe the treatment paradigm for obesity should be primary care physicians first, then referral to a bariatrician, then referral to the bariatric surgeon."

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Washington -- With each new insight about asthma, it becomes increasingly clear how much remains unknown. That message was one of the themes at the American Academy of Allergy, Asthma & Immunology's annual meeting.

"Asthma is a diverse, complicated disease with many presentations, outcomes and variability in responses to treatment. It's not just one disease," said William Busse, MD, chair of the Dept. of Medicine at the University of Wisconsin's School of Medicine and Public Health. He was speaking at a news briefing during the meeting held in Washington, D.C., March 13-17.

Coughing, wheezing and shortness of breath are all common factors, but the interplay of allergens and responses to medications varies dramatically. With triggers including cats, cockroaches, stress and obesity, treatments often must be tailored for each patient.

The difficulties doctors and patients face in striking this chord are demonstrated by statistics. For instance, asthma continues to be one of the most common reasons for hospital admission and emergency department care even though most asthma cases can be managed on an outpatient basis, according to research presented by scientists from the federal Agency for Healthcare Research and Quality, and others.

From 2000 to 2005, the number of adults hospitalized with asthma as a secondary condition increased by 113%, the scientists said. From 1997 to 2006, the number of pediatric hospitalizations with asthma noted as a secondary reason rose by about 54%.

Asthma is among the most common reasons for hospital admission and ED care.

Many treatment challenges begin long before a patient lands in an acute situation. Sometimes they start with the illnesses' varying forms of presentation. Although asthma is most commonly recognized in children, it also can begin in adulthood. And asthma among the elderly may be an entirely different disease, as well as one that is hard to diagnose. Its presence among 60-, 70- and 80-year-olds may be mistaken for something else, Dr. Busse said. He also headed the panel that developed the 2007 federal "Guidelines for the Diagnosis and Management of Asthma," which the AMA encourages physicians to follow.

Science continues to offer additional possible underlying causes. Dr. Busse noted that a new, type C rhinovirus, identified about a year ago, seems to play a role in triggering about two-thirds of the asthma attributable to cold viruses. But it's too early in the research to know why.

"Are these new cold viruses more virulent and more likely to cause disease? Or, maybe they have characteristics that lead to airway changes?" he asked.

Steps toward disease control

Although the disease is far from conquered, research presented at the meeting shows progress, said Stanley Szefler, MD, head of pediatric clinical pharmacology at the National Jewish Health hospital system in Denver.

For one thing, asthma mortality has dropped, he noted, and the number of patients incapacitated by medication-induced hypertension, osteoporosis or cataracts has declined.

The number of adults hospitalized with asthma as a secondary condition more than doubled from 2000 to 2005.

But in a less promising finding, researchers at National Jewish Health determined that even families with health insurance and a regular source of care for children often come to emergency departments when they have flare-ups.

Conventional wisdom holds that adequate insurance with access to physicians should lead to successful outpatient asthma control. That was not the case for many of the 153 asthmatic students who completed questionnaires. Fifty-eight percent reported getting care from a physician or other health care professional but said they used emergency department care for treatment regardless.

Dr. Szefler also described research on promising ways to educate children and teens about asthma control. "That's a new opportunity that we have in the schools."

In one effort, Pittsburgh physicians linked basketball camp to asthma education in a pilot study of 21 children age 6 to 12 who all had asthma. A comparison between pre- and post-camp behavior revealed a significant decrease in emergency department visits and physician contacts after the study.

In another pilot study, Chicago physicians sent text messages to teens reminding them to take their medications. At the conclusion of this small, four-student initiative, researchers noted increased adherence to medications.

During a symposium, Peter J. Gergen, MD, MPH, medical officer at the National Institute of Allergy and Infectious Diseases, examined research on children and teens in urban environments and elsewhere.

Cockroaches are the most prevalent allergy source in cities while cats are in the suburbs.

"Asthma morbidity and mortality remain high in the inner city, but biologically the asthma in the city is the same disease we are seeing across the United States," Dr. Gergen said. It also is just as responsive to treatment.

Differences in risk factors play a role, though. For example, cockroaches are the most prevalent inner-city allergens, according to most research, while cats prompt the most allergies in the suburbs, Dr. Gergen said.

The obesity trigger is an even bigger problem in cities where more children are overweight. The psychosocial burden, including stressful life events, also is much higher.

All of these factors affect treatment, Dr. Gergen said, and interventions must be tailored accordingly.

Physicians and their patients soon should hear much more about asthma and its treatment as plans are being developed to better utilize the 2007 guidelines, said Gary Rachelefsky, MD, professor of Allergy and Immunology at the University of California, Los Angeles, Geffen School of Medicine.

The guidelines include several messages: Inhaled corticosteroids are the most effective anti-inflammatory medications for long-term asthma management, and all patients with asthma should have a written action plan. In addition, reviews of disease control should be made at follow-up visits, and subsequent visits should be scheduled regularly to be proactive. Lastly, every patient should have a plan to reduce exposure to allergens at home, school, day care or work.

This content was published online only.