To cut or not to cut - That is the question

We live in a consumer society.

We want everything. And we want it now.

This attitude can become really dangerous when it is applied to your medical care.

Nothing is more alluring than the idea of an "immediate fix".

In and out and done!

Isn't that what we all want?

The pressure is on. You hear it everywhere:

"Call now and get 50% off."
"Only until the end of the month."
"While supplies last."
"This offer expires in one week."
"Offer available for the first 50 customers."
"Decide today."

And on, and on it goes.

High expectations from surgery

By now we got adjusted to this kind of expectation.

We don’t wait, we do, we buy, we get.

Surgery may sometimes seems like the easy and fast solution to a problem (of course, I am NOT talking about life-saving emergency surgery here but rather elective procedures). 

On the one hand, we don’t want to live in pain. On the other, we don’t want to have the hassle of months of physical therapy, changing our diets and taking medications.

Surgery - oh how alluring it is!

On TV medicine is so dramatic. They rush into the operating room and they might even have a cardiac arrest on the table – but of course they come back from it and soon WALK out of the hospital. So, we might start to believe that this was really how it worked.

Any elderly individual undergoing major surgery, especially orthopedic surgery, will require many weeks of post-operative rehabilitation. There you will have to do a lot of physical therapy – and you will likely be in a lot of pain. You will still need to take medications to alleviate the symptoms and you should still change your life-style and diet to prevent future problems. So, now the only difference is that you also had a surgery.

Don’t forget: ANY procedure has its risks.

There is no such thing as a risk-free surgery. What many forget to consider is the following, though: yes, you will likely survive the surgery but you are far from “out of the woods” at that time!

There are many complications that can follow surgery: wound healing problems, serious or minor infections, confusion and delirium, blood clots, stroke, decline of functional status, pain and many more.

I think it is time we faced the reality: there is no such thing as a quick fix.

There are ways to prevent complications of surgery.

One is to very carefully consider the indication of this procedure. 

• Ask your doctor what to expect during and after the surgery:
• How much will you actually benefit from it?
• What does that mean for your everyday life?
• How likely will you suffer post-operative complications?
• How long is the expected rehabilitative phase?
• Will your problem recur after some time?
• How long is that time frame?
• If you were your physician’s mother or father: would they recommend that surgery to you?

And if you are not sure or feel pressured, maybe you should take your time making this decision.

Think about what is important to you.

Consider getting a second opinion.

Speak to people that are important to you and may guide you in this process.

Of course, there are other ways to prevent complications. There is more and more literature and attention to that topic – especially in regards to the elderly surgical patients. 

Surgeons in the OR

A large expert panel has evaluated this topic and has recently (October 2012) come up with guidelines of pre-operative assessment in the elderly. There are no less than 13 (!!!) points that the physicians should address before any surgery in the elderly. I will start a small series talking about these 13 keypoints on this blog – so stay tuned.

Of course, I speak as an internist. My first thought rarely is “surgery”. There are very beneficial procedures available and great surgeons out there. But remember, just because your surgeon is great and the procedure is sophisticated – it doesn’t mean it is for you.

I wish you well in this maze. There is a lot of confusion and it is not an easy decision to make. I just want you to consider to take your time (when you have the luxury of time) and really think it through.

Check out this great article about this topic on the amazing seniorplanet blog.

I wish you wisdom.

Be well,

Dr. B

Aging in America 2013

Everybody is talking about the "Baby Boomers"... the Baby Boomers will soon begin to age.
Are we ready for that? Probably not.. this is an ongoing issue and point of discussion.

The National Council On Aging (NCOA) has published a survey on Aging in America. The NCOA, UnitedHealthcare, and USA TODAY a conducted telephone survey with 4,000 U.S. adults in 2013. Participating cities were Birmingham, Indianapolis, Los Angeles, Orlando, San Antonio. I am quoting from the website NCOA website (see link below).

The goal was to better understand the American seniors’ perspective on aging.

Staying connected means quality of life!

Here the most interesting findings:

What is most important to maintaining a high quality of life in your senior years?

• Top Answer: 40% say: staying connected to friends and family 
• 30% say:  having financial means

Health: 

Being optimistic about aging is connected with setting specific health goals:

Aging in America

"Nearly two-thirds (64%) of optimistic seniors have set one or more specific goals to manage their health in the past 12 months, compared with 47% of the overall senior population."

Who do seniors believe to be responsible for their needs:

• 71% of seniors feel the community they live in is responsive to their needs
• 49% believe their community is doing enough to prepare for the future needs of the growing senior population

Don't Worry! Be Happy!

Positive Outlook on aging 

• 57% of seniors state that overall, the past year of their life has been “normal”
• 51% of seniors expect their quality of life to stay about the same during the next 5 to 10 years
• 21% expect it to get much or somewhat better

Seniors and Technology

• 34% of seniors cite “I don’t understand how to use it” as a barrier preventing them from using more technology
• 47% of low-income seniors quote financial reasons for not using technology

Check out their fact sheet for more information. 

In summary, what remains the most important for a high quality of life is the sense of connectedness to others.

Life is all about relationships and this does not change with aging.

If anything, the need to be connected to others increases.

Many elderly are isolated (see previous post) and suffer from this tremendously. 

Technology may be one way to stay connected to others. With computers, tablets and smart phones people don't even have to leave their living rooms in order to see their loved ones. It may not be the exact same as in person but it is a pretty good substitute!

Now, we only have to figure out how to overcome the barriers to technology for the elderly.

The vast majority of surveyed seniors believe that their communities are responsible for their needs and at the same time only half of the surveyed think that the communities are doing enough in that regard.

This is a great challenge. Especially with the expected rise in older population. Generation Baby Boom is on the rise... they are beginning to age. Slowly but surely.

How can communities prepare?

Where is the money going to come from?

What is the solution?

I believe that people should really think things through and plan ahead.

Yes, surely, communities and our society should do their parts, however, so should the individual.

First steps in planning for aging

Start planning while you are still "young old" and while you can voice your concerns and questions. Discuss with your loved ones early on what is important to you and what expectations you have.

• Think about what options you have.
• Consider a consult with a social worker. Social workers can be amazing resources.
• Consider seeing a Geriatrician who may point out things you did not consider (check my post).
• Consider developing a relationship with a private pay / long-term insurance paid home health aide / personal care aide to learn the system with its limitations and understand your options.

There is Hope!

Overall, most seniors maintain a positive outlook on life and are expecting to do well.

And isn't that wonderful? I think it is. In the end of the day, this is a great quote:

"Don't worry! Be happy!" 

I wish you all the best!

Be well,

Dr. B

Coming Up – Screening For Lung Cancer

What is screening? 

What is cancer screening?

Simply put, screening is a test that is looking for early stages of a disease in people WITHOUT any symptoms.

In order for screening to “make sense” on the larger scale it has to look for a disease that can be cured or treated if found early.

When is screening recommended?

There are a lot of factors that need to be considered in regards to whether or not to screen for something and also whom to screen.

Not all screening is appropriate for everybody.

There is potential harm involved such as extensive follow up testing in false positive cases.

Additionally, there may be anxiety from the positive test results.

Sometimes, we might find a cancer that would normally have been progressing so slowly that the person would have died from other causes before even reaching end-stages of this cancer.

Screening is a big topic and I will talk more about it as we go along.

Today I want to mention something that is coming up!

And since we spoke about smoking yesterday it is right up the alley:

Screening for lung cancer!

Screening for lung cancer in smokers! 

Up until now there has been no screening method that has been proven to be successful when looking for early stages of lung cancer.

The US Preventive Services Task Force (USPSTF) has just released a draft recommendation (it is not finalized yet) for lung cancer screening in smokers.

You may check out the draft of this recommendation on their website by clicking here. The draft will be accessible until August 26, 2013 only.

Here some of their main points:

• Lung cancer is leading cause of cancer death in the USA
• 90% of people diagnosed with lung cancer will die from it as it is found too late
• the biggest risk factor for lung cancer is SMOKING
• 85% of lung cancer are caused by smoking
• the most important means to reduce your risk of developing lung cancer is to stop smoking and to avoid any exposure to tobacco

Screening for lung cancer in smokers: 

Low-dose CT scan for screening of lung cancer

How?

CT-scan (“CAT scan”) with lower dose of radiation

(low-dose CT, also LDCT) of the lung

Who is a candidate?

A person who is

• Between 55-79 years of age
• WITH a history of heavy smoking



Don't gamble with your health!

• AND is still a smoker or has stopped smoking within 15 years 

How often?

Once a year

What is defined as “heavy smoking”?

30 “pack years” and above is considered heavy

What is a “pack year”?

Smoking 1 pack of cigarettes per day (PPD) for 1 year = 1 “pack year”

So, 30 pack years are equivalent to the following:

• 1 pack per day for 30 years
• 2 packs per day for 15 years
• 3 packs per day for 10 years

What are some of the harms of screening?

• Radiation exposure
• False positive test results that may lead to
• More testing
• Anxiety
• worry

As I mentioned this is currently still a draft but probably coming up as an official USPSTF recommendation soon.

If you fulfill the criteria for screening, discuss it with your doctor whether or not you are a candidate and whether or not you want to go forward with this.

Stop smoking TODAY!

If you still smoke: STOP (check yesterday’s post)!

Nothing good comes from smoking! 

Do I HAVE to go for the screening, if I don't want to?

Nobody can force you to do anything. You can make your decision. Just think through all the options and discuss them with your doctor and people you trust.

If you have many medical problems and already feel burdened by all the medical treatment that you are undergoing you may want to think about what the consequence of a positive test result would be for you. 

Would you want treatment?

Would you consider further testing, surgery, or chemotherapy?

If not, you may not want to do the screening test to begin with.

Sometimes it is better not to know.

Have a wonderful rest of your day.

Be well,

Dr. B

PS: This is based on a systematic review published in the Annals if Internal Medicine on July 30, 2013. Click here for link to article.

Smoking - Is Bad For You. Period.

Smoking is your enemy!

By now we have all heard it:
Smoking is really bad for you!

You are basically inhaling hundreds of toxic substances. 

I want to emphasize this today: 

Smoking does so much damage to your health and well-being that it is NEVER too late to quit.

What smoking does: 

• puts you at higher risk for many cancers (e.g. lung, throat, kidney, pancreas - to name a few)
• increases your risk for a heart attack or a stroke (check out yesterday's post on stroke risk)
• damages your lungs and may likely lead to COPD / emphysema or asthma
• puts you at higher risk for pneumonia and other infections
• may give you erectile dysfunction



Smoking is ugly! Not cool!

• stains your teeth and gives bad breath

Be aware that second hand smoking is harmful as well!

And consider also that ALL tobacco products are hazardous, no matter what form they come in.

Essentially, smoking is the number one cause for premature, preventable death in the United States!

Stop smoking TODAY!

The best and most important thing you can do for your health today, no matter how old you are, is to STOP smoking!!! 

It is never too late to stop smoking!

The good news are that the overall percentage of smokers among older Americans has decreased over the last decades.

There are plenty of immediate and longterm benefits of quitting smoking, no matter your age. But of course, the earlier the better!!

Nicotine is an addictive substance and it may not be easy to do this alone. Ask your physician for guidance, help and possibly medications. Also, check this cancer website for more info.

Check out this book by Allen Carr: Easy Way to Stop Smoking. I know people who swear by this book (although I personally have not read it).

Value your body and health!

Value your body and your health! Take responsibility!

Make the best of it!

Be well,

Dr. B

Will I Get A Stroke? Stroke Risk Awareness

A stroke can be a very devastating event; it can even lead to death. What most people are afraid of is not necessarily dying but rather surviving with severe disability. Whereas some people may recover fully after a stroke others might suffer from the effects for the rest of their lives. They might become bed-bound, unable to swallow, unable to speak and with severe damage to their cognition (vascular dementia).

Strokes are "brain attacks"

What is a stroke? 

Simply put a stroke is a “brain attack”. There is either lack of blood flow to areas of the brain (called ischemic stroke) or a sudden brain bleed (hemorrhagic stroke).

What are some of the symptoms of a stroke?

As per the National Stroke Association (NSA) these are the symptoms of stroke:

• Sudden numbness or weakness of face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

Other important but less common symptoms include:

• Sudden nausea, and vomiting - different from a viral illness because of how fast it begins (minutes or hours vs. several days)
• Brief loss of consciousness or a period of decreased consciousness (fainting, confusion, convulsions or coma)

If you have any of these symptoms or see them in someone else, call 911!

Treatment can be more effective if given quickly. 

Every minute counts!

What is a TIA or a mini-stroke?

TIA stands for transient ischemic attack and it basically means that stroke-like symptoms appear and then spontaneously resolve without causing an actual infarction of the brain (Easton et al in Stroke 2009).

Up until recently the definition included the time window of 24 hours: if your neurological findings resolved within 24 hours this was considered a TIA.

We now recognize that even 2 hours of neurological symptoms may lead to actual damages in your brain.

Additionally, a TIA is a serious warning sign that a larger stroke may occur within the next 24-72 hours!

You may need brain imaging when stroke is suspected.

Can I do anything to prevent having a stroke? 

Yes, you most definitively can!

The majority of strokes are potentially preventable!

How do I prevent a stroke?

Know your risk factors and adjust your lifestyle!

Some Risk factors for stroke that you have no control over:

• Your age (the older you are the higher your risk)
• Your gender (more women have strokes than men per year, partly because women live longer)
• Your race (African Americans have highest risk)
• Family or own history of stroke / TIA

STOP smoking!

Risk factors for stroke that you can control or treat: 

• Smoking
• Drinking too much alcohol
• Obesity
• High Blood Pressure
• Diabetes
• High Cholesterol
• Atrial Fibrillation
• Atherosclerosis

Click here to access the Stroke Risk Scorecard of the National Stroke Association. 

If you think you may have any of these risk factors, speak to your physician about it and then work with your physician to reduce your stroke risk.

• STOP smoking, if you smoke (it is recommendable for many reasons!)
• Start exercising (even if it only 30 min of brisk walking 3 times a week)
• Open a conversation about your wishes at severe illness or end of life (check blog post on documentation at end-of-life on Health Care Proxy for more info).

Make the best of the life you have!

Make the best out of the life you have! 

Be well,

Dr. B

PS: For more info check out NSA website. 

Aggression– A Difficult Behavioral Disturbance In Demented Persons

If you have a loved one who has dementia then you know how many everyday things become problems.

Tasks and abilities that we take for granted gradually and surely turn into difficult challenges.

Dementia is a vast topic and there are many points that can be made about it. There will be several other posts which will address other facets of dementia.

Aggression in Dementia

Today I want to talk about aggressive behavior that may be seen in patients with dementia. 

When I say aggressive behavior, I mean shouting, yelling, throwing things, being very agitated, maybe even punching someone.

Let’s first consider the following: a hot tempered person who has been easily agitated and borderline violent all his or her life will not all of a sudden turn into this calm persona when demented (at least not typically). When people have normal cognition they are usually inhibited to some degree and will not allow their aggressive impulses to reign freely. Demented persons on the other hand often lose their inhibitions. They speak their minds freely and they don’t necessarily “pull themselves together” in order to act “socially appropriate”. There are no medications that can treat how a person is.

This is not easy to accept. We often wish there were easy solutions but unfortunately, there are not.

When there are new behaviors of violence or aggression in a demented person we have to stop and analyze: What is going on? A demented person cannot clearly articulate and express what bothers or hurt them.

The first question to answer is this: What were the circumstances of the event? What has led to it? Who were the people involved? What was the environment like? Was there some kind of provocation?

Possible triggers may be: 

There are many reasons for aggressions

• Change in environment
• Change in care taker
• fear
• A loud noise
• Temperature too hot or too cold (in room or water when washing)
• Aggressive care giver with little patience
• Rough care taking without soothing explanations

The best way to figure this one out is to put yourself into the person’s position. If someone came to you and treated you that particular way would that agitate you?

When there is a change from someone’s regular behavior it is always something to worry about and should trigger evaluation by a nurse, or a physician.

Causes for these behaviors may be: 

• Pain
• Hunger, Thirst
• Infection
• Constipation
• Soiled diapers



Aggression can be ugly

• Side effects from medications

Aggressive behavior in people with dementia is one of the most common reason for institutionalization. It really poses a huge problem. You should not face it alone. Seek help from physicians, home care services, nurses and support groups.

Remember also that these behaviors are not really “against” you. They need to be interpreted in context and often are rudimentary expressions of a person who can no longer express accurately.

Here is a wonderful resource from the website of National Institute of Aging: click here.

Stay calm, don’t argue, de-escalate, and get help! You are not alone!

I really hope you find the support that you need. 

Don't lose hope!

Be well,

Dr. B

Prognostication – Do Physicians Have The Magic Ball?

As per dictionary.com the definition of “to prognosticate” is as follows:

Do physicians have a magic ball?

prog·nos·ti·cate 

1. to forecast or predict (something future) from present indications or signs; prophesy

2. to foretoken; presage: birds prognosticating spring

3. to make a forecast; prophesy

Is it only me, or does this sound very sobering? In other words, to prognosticate means to foretell the future. And who can really do that?

As a physician who deals with a lot of seriously ill people I have faced this problem many times: how can I estimate someone’s prognosis?

Why is this important? Does it really matter?

Time is running out.

I think it does. I believe that prognostication gives a framework to patients, their families and physicians. It makes a big difference whether someone expects to go on living for several more years or whether he has a high likelihood of dying within the next few weeks. There may be things to take care of, amends to be made, trips to be had. Making peace with the idea of the impeding departure from life on this planet may lead to appreciation of the time left and the chance to resolve open issues.

As we already discovered, prognostication is not an easy task, if not borderline impossible. Who can predict the future? None of us, really! 

How do we address prognostication scientifically then?

There are different tools that attempt to aide physicians with this problem.

How to predict somebody's life expectancy?

Ultimately, it comes down to looking at the patient as a whole:

• How old are they?
• How many illnesses do they have? 
• How well controlled are their illnesses?
• Do they have any terminal disease?
• At what stage is that disease?
• What is their functional status? (see previous blog post on that topic: click here)
• How rapidly did they decline? (e.g. compared to how they were doing 6 months ago)

Statistics provide framework

In June 2001 Dr. Walter and Dr. Covinsky published an article in JAMA titled: Cancer Screening in Elderly Patients in which they pointed out that more than just age alone a person’s overall life expectancy should be crucial to whether or not certain screening tests should be performed (more about these issues of cancer screening in future blog posts, click here for link to their article). They used statistics published by the CDC called “United States Life Tables” to categorize life expectancies (click here for an example of such a report).

They put these statistics into tables divided by genders and stratified by age groups. Then they looked at the life expectancy of the average person (50^th percentile) of an age group as well as the life exptectancies of people healthier (top 25^th percentile) or sicker (lowest 25^th percentile) than the average group.

Therefore, when a physician is trying to estimate someone’s general life expectancy he/ she is looking at whether the person is about average in health status or sicker versus healthier than average.

In oncology there is a commonly used term “median survival”. Dr. Eldridge explains this well on about.com (click here for link):

“Median survival is defined as the time after which 50% of people with a particular condition are still living, and 50% have died. For example, a median survival of 6 months would indicate that after 6 months, 50% of people with that condition would be alive, and 50% would have passed away.”

This concept may be difficult to grasp when it affects you. Ask your doctor how to apply this to your life.

Some tools frequently used are called ECOG Performance Scale (click here) and “Karnofsky Performance Status Scale” (click here for link) which help physicians estimate how functionally impaired a person is from the disease burden. The ECOG is often used in palliative care or oncology. As a matter of fact, the ECOG is one of the most important factors that oncologists take into consideration when assessing whether someone is a candidate for treatment or not.

I want you to keep something in mind: physicians are normal humans, not prophets that know the future. We are striving to learn more and more about the subject of prognostication and we are trying to do a good job. In the end of the day it remains an estimation based on a multitude of factors. We also don’t like to give “bad news” and often shy away from facing how ill a person is. Many times this does not get communicated to patients and their families.

Also, consider that physicians consistently overestimate prognosis. A very simplistic tool is the "surprise question": Moss et al. published an article in the Journal of Palliative Medicine in July 2010 (abstract here). Oncologists were posed with 853 patients and had to ask themselves: "Would I be surprised if this patient died in the next year?" There was a correlation between this question and the 1 year mortality of the patients. In a way this "surprise question" evokes a gut answer by the physician and as the study showed, sometimes a gut answer is not so far off.

Time is fleeting.

Don’t accept concrete numbers, though. Nobody can say “you will die in 2.5 months”, the only thing that can be said is “there is a high likelihood of her dying within the next few weeks to few months” (or hours to days, days to weeks, months to years… I think you see what I mean). 

The search for the perfect tools to prognosticate goes on. There are many potential benefits in knowing and accepting the limitation of time.

In the end of the day, nobody knows the future. It is wise to plan ahead with the right documentation (see my previous blog posts on Health Care Proxy and MOLST form) and the discussion about the topic with your loved ones.

No matter how you look at it. Life is short and full of surprises.

Make the best of today. Be prepared for the future but don’t allow anxiety and fear to dominate your present.

Make today count.

Make peace with others.

Forgive who has done you wrong and don’t hold grudges. 

Make today count.

I wish you well,

Dr. B