NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # INNOVATION: PCORI APP Challenge

Dementia

Dementia is a chronic disease of aging that robs people of cognitive function, leaving them unable to tend to even the most basic activities of living. But demented persons can live for many years, incurring long-term care bills that can leave surviving spouses impoverished and estates depleted.

In a study published recently in the New England Journal of Medicine, my colleagues and I reported that the total costs of paying for care for seniors with dementia in the United States are expected to more than double by 2040. Medicaid pays these costs for the poor, and some people have private insurance. But for large numbers of elderly Americans, dementia brings not only human suffering but financial ruin as well.

Designing and building a program to protect Americans from the cost of dementia care is a daunting and expensive task, one that probably cannot be accomplished without the help of the federal government. The federal government has broad experience in creating health safety nets and has been expressing concern over the state of the nation’s long-term care systems for some time now. If Congress and the administration need a reason to act, our numbers on costs can provide it.

Currently, some 15 percent of Americans 71 or older have dementia. That is about 3.8 million people; a large number to be sure, but one that will pale by comparison to the 9.1 million expected to be suffering from the disease by 2040.

Our report, The Monetary Costs of Dementia in the United States, estimated that in 2010 Americans spent $109 billion for dementia care purchased in the market place, like nursing home stays. Factoring in the costs of informal care—provided by family members or others outside of institutional settings—the total cost of caring for dementia patients grew to between $159 billion and $215 billion.

Continue reading “The Cost of Dementia: Who Will Pay?”

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Do they need a PET scan to confirm the presence or absence of amyloid plaque?

More importantly, would doing such PET scans make meaningful impacts on patients’ health?

Those are the questions that a Medicare expert panel recently considered, and their impression, after carefully reviewing lots of high-quality research, is that we don’t yet have evidence supporting the benefit of using the PET scans. Unsurprisingly, some experts disagree, including a working group convened by the Alzheimer’s Association. This group of experts reviewed the evidence and common clinical scenarios, and concluded that in certain select situations, use of the PET scan would be appropriate. (See their guidelines here.)

As someone who evaluates many memory complaints, I’m certainly interested in Medicare’s inquiry, and in whether they’ll decide to cover the scan. (The NYT’s New Old Age Blog has a nice summary of the debate; a good read if you haven’t seen it yet, esp the comments.)

Also, I blogged last fall about how I thought the new scan could and wouldn’t help clinicians like myself evaluating cognitive complaints, especially in those who likely have early dementia. In particular, I commented on the difficult period of uncertainty that we often go through, as we wait to see if subtle problems progress or not.

Would the PET scan meaningfully help with that period of uncertainty? Hard to say, and it hasn’t yet been tested. I myself think that this period of uncertainty can be pretty hard on families, but measuring this burden is tricky. (Much easier to measure hospitalizations and utilization!)

I also suspect that it’ll be hard to prove benefit from “knowing earlier,” in large part because our healthcare system is currently so poorly equipped to meaningfully help people with a new dementia diagnosis.

Which brings me to the part of this story that has me annoyed.

Continue reading “The Four Things You Should Absolutely, Positively Do For Somebody at Risk of Developing Alzheimer’s”

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There are 900,000 people in the United States who reside in assisted living settings, at an average age of nearly 87. On average, these individuals pay privately between $3,000-$6,000 per month for services that often include room and board, medication delivery and pill box set-up, supervision, and assistance with activities of daily living. Assisted living facilities are an integral part of the health care delivery system for many of our nation’s frailest older adults.  Despite the high quality care that is often provided, the assisted living environment can often leave healthcare providers scratching their heads about what they can and cannot order for their patients.  My recent experience with such a facility involving a patient with possible influenza illustrates the complex middle ground these facilities occupy.

A phone call from an assisted living facility in town interrupted me from my afternoon schedule. The facility’s nurse introduced herself and began to give me a report about my 85-year-old patient with dementia.

“Mr. Smith has a fever to 102 and is coughing up some ugly looking sputum.  I’d like to order some labs and perhaps a chest X-ray. We might also want to consider an antibiotic.”

I asked the nurse a series of questions. Was my patient’s blood pressure unstable? Was he short of breath? Was he confused or disoriented?”

In each case, she told me, “no.”

“He is sitting quite comfortably watching a talk show on television. His only complaint is the occasional cough.”

I asked a few more questions and was reassured that he was otherwise fine. I told her that her initial request for blood work and a chest X-ray sounded like a good idea. We would wait on the antibiotic until the results came back.

“I’ll call you later today with the results,” she said.

Continue reading “When is a Health Care Facility not a Health Care Facility?”

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I found out this past weekend that the VA will be making clinician progress notes available for patients to view on the MyHealtheVet portal. In other words, the VA is going OpenNotes. (Note: I was a primary care provider in geriatrics clinic at the San Francisco VA from 2006-2010.)

My first reaction was to be impressed by this bold progressive move.

My next reaction was to feel mildly relieved that I’m no longer a PCP there.

Now, it’s not because I’m against transparency in healthcare, or am suspicious of patient engagement, or feel that patients shouldn’t see their health information without the assistance/gatekeeping/interference of a clinician. Far from it.

It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.

So whew, I find myself relieved that I don’t have to figure out how to document (or not document?) these concerns.

Instead, I’ll get to see how my friends at the VA handle these issues.

Wondering what they are? Ok, I will tell you but shh … don’t tell my elderly patients that I may be considering these topics as I care for them.

Six awkward concerns in geriatric primary care practice

· Possible dementia. As a geriatrician, I focus on an age group that has a high incidence of dementia. Which means that when someone starts to tell me odd stories (concerns related to poison are a popular theme, as well as reports that someone is stealing things repeatedly), I start wondering about possible dementia. Ditto if he or she starts floundering with the medications, or starts having other difficulties with IADLs.

Why it’s awkward: Patients and families really hate it when I bring up the possibility that there might be dementia. Many find the possibility of a disease such as Alzheimer’s truly terrifying, both because it’s perceived as a terrible disease, and because they worry about having to leave their homes or otherwise losing their independence. Note that if I’m considering the possibility of dementia, I usually let the patient know during the visit.

Continue reading “Six Awkward Concerns in My OpenNotes”

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Few diseases invoke more fear in patients and families than dementia (e.g., Alzheimer’s Disease (AD), progressive multiple sclerosis, Pick’s Disease). Surveys have shown the fear of dementia—especially AD—far outweighs concerns of a diagnosis of cancer, stroke, or cardiovascular disease.

Perhaps this fear arises from two concerns: (1) dementia robs us of what makes us human—memory, reasoning, emotions, language—and (2) in most cases there are no effective treatments to cure or palliate the disease. While diagnostics for certain forms of dementia are progressing—allowing us to sort out the reversible causes of dementia, such as hydrocephalus, electrolyte or blood sugar imbalances, brain tumors, and brain injuries—once the diagnosis of AD or Pick’s disease is made, there is little we can do aside from manage the comfort and safety of the patient and family.

What if we could prevent or delay dementia?

In the mid-1960s, the incidence of heart attacks and stroke were increasing at an alarming rate. Great strides were made in treating existing cardiovascular disease, followed by programs at preventing the disease in the first place. These prevention methods included exercise, diet, and the tracking of key incidence indicators such as blood pressure, body mass index, and cholesterol levels to maintain a quantifiable physical health.

Could we use similar prevention methods for preventing or delaying dementia?

Continue reading “Can We Stop Dementia Before It Starts?”

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“Would I let my son play football?”

It’s a question that more and more parents are asking themselves these days. There are some people out there who say, “No way!”

Football is way too violent and should be abolished as a sport. Even some NFL players admit that they would not let their own sons play football. Then there are others, fierce advocates who think football is a wonderful game with tremendous benefits to its participants and think all of the media hype about injuries are just overrated scare tactics and headline grabbers.

But the majority of us are probably somewhere in the middle and aren’t quite sure what to think. So why don’t we spend a little time sifting through all the facts and emotions and see if we can make some logical decisions about the subject. I have an interesting perspective in that I am a sports medicine physician who is a true fan of the game, has played the game, has sustained injuries and has a son of my own.

Thus I can see the argument from all sides. Let’s start with the physician side. My job is taking care of injured athletes. I see patients with fractures, sprains, strains, overuse injuries, head injuries, concussions, trauma, you name it. During the months of August, September, October and November, I probably see more patients than I do for the entire remainder of the year. Why? Football season.

Continue reading “Would I Let My Son Play Football?”

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