THCB

“You Doctors These Days Just Want Us To Go off and Die …”

A recent case taught me a lot about how people perceive their medicines.

I was trying to help a 92-year-old man get off some of his medicine. I can’t go into the details, but suffice to say, there was much opportunity to trim a long list of drugs, many of which were threatening his existence and impairing his quality of life.

As I was discussing stopping many of the meds, the patient said (with a quite sincere tone):

“You doctors these days just want us old people to go off and die.”

That was a zinger, a real punch in the gut. I was trying to do the opposite–allow him to live a longer and better life–but the patient perceived me as a mini-death panel.

I’ve been thinking a lot about this case. Why was this man “attached” to his meds? Why had he associated his longevity with chemicals that now threatened his existence?

The answer, I believe, is a knowledge gap. He, like many people, doctors included, fell into the trap of association and causation. He associated his health with his medicines; he overestimated their benefits. He thought the pills were keeping him alive. They were not. He lived despite his medicines.

What I tried to explain to this patient was that benefits from medicines do not continue indefinitely. Things change in the elderly, and, what is for younger patients may not be in the aged.

Take the case of preventing stroke in the elderly. Simple drugs, such as high blood pressure medicines and statins, may no longer offer a net benefit to the patient over the age of 80. Really. It is true.

Let me tell you about a recent commentary in the journal Evidence Based Medicine (from BMJ).

Dr Kit Byatt is a doctor in the UK who specializes in Geriatric Medicine. He wrote this refreshingly concise summaryoutlining four reasons why the medical community should reconsider its overenthusiastic views of stroke reduction in patients over the age of 80. In the title, Dr. Byatt asks whether we are being disingenuous to ourselves and to our elderly patients.

The answer is yes.

Dr Byatt makes four arguments:

First, he points out that population studies (like Framingham) of the elderly show that high blood pressure ceases to be a significant risk factor for stroke in patients over the age 80. In fact, in this study of 4000 veterans, mortality was higher in those with lower blood pressure. Likewise, the utility of cholesterol as a predictor of stroke in the elderly is dubious. Researchers put together this systematic review involving 900,000 patients and found no independent positive association of cholesterol levels with stroke mortality, especially at older ages or higher blood pressures.

Second, Dr. Byatt goes onto refute the evidence that treating high blood pressure in the elderly effectively reduces the risk of stroke. Here, he reviews the actual data from the 2008 HYVET trial (NEJM), which was a comparison of blood pressure medicine v. placebo in 3845 elderly patients followed for 2 years. The primary outcome was the combination of any stroke (nonfatal plus fatal.) Unlike the authors of the paper, Dr. Byatt emphasizes the actual not relative results: for the reduction of stroke in the elderly, treatment and placebo performed 99% the same. (and this did not reach statistical significance.)

Third, Dr. Byatt moves on to the use of statins in the elderly. He uses thePROSPER trial, which looked at 6000 high-risk patients (age 72-80) who took either pravastatin or placebo over 3 years. Although the composite endpoint (all fatal or non-fatal strokes or cardiac events) was statistically lower with statins, the absolute difference was just 1.7%. This means statins and placebo performed 98.3% the same. What’s more, when one looks at Table 2 from that Lancet paper, there were no differences in non-fatal or fatal strokes.

Finally, Dr Byatt asks doctors to consider the goals of care of the elder person. He points out that patients’ values and preferences relating to stroke vary a lot, and, importantly, differ from physicians. He says, “deciding what to focus on in frail older patients with multiple pathology is much more challenging than these ‘single problem’ cases, and a complex interaction of factors influence these decisions.” That’s an understatement.

My summary:

This is really important stuff. The elderly are different. They develop other diseases and take other drugs. The human body gets worse with age, not just our bones and muscles, but also our ability to clear drugs from our system. It is always important to treat the person rather than his or her diseases, but never more so than in the elderly.

Dr. Byatt reminds us that even “simple” drugs, such as anti-hypertensives and statins, have marginal benefits in the elderly. His essay is persuasive because he uses the actual data from major trials. This view of science often leads to a more truthful outlook on things.

The message here is simple: Doctors should “rethink our priorities and beliefs about stroke prevention, and actively inform and involve the views of the key person, the patient.”

Hear-hear.

John Mandrola, MD (@drjohnm) is a cardiac electrophysiologist in Louisville, KY. He contributes regularly to theHeart.org. This originally appeared on his personal blog.

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4 replies »

  1. Thanks, Carcher1.

    The problem with posts like mine above is that any one person’s medical story is long and boring. Who wants to hear about someone’s aches ‘n pains? And if it’s chronic pain and drugs, well then you’re an addict, etc etc etc.

    It’s really frustrating, and it’s been quite the eye opener for me to watch how my partner is treated. One pain clinic he goes to has a slogan printed on the wall about how they don’t want pain itself to be a disabling condition. But they refuse to treat my partner’s pain, and outright lie to him about it.

    Sometimes I want to strangle the doctor at that place. Oh yeah, it’s a pain clinic alright.

  2. Not real happy: wow, very well said. You added another dimension to how I perceive this new found “puritanical fad ” of withholding the drugs that have worked for so long. I feel bad for you and your partner who has to live with that kind of pain. I’m not a dr or anything, just another person who is disillusioned with the medical profession in general. Fortunately I have never needed any type of pain management, but it must b very difficult. Good luck.

  3. Let me give you a different view. I’ll try to be as brief as possible, but don’t know how successful I’ll be.

    I am the partner of someone who’s been in two serious motorcycle accidents. He is held together with a titanium plate and his own determination. For the past decade, he was doing fine on 40 mg a day of hydrocodone, along with a long list of other drugs including some valium and a “benzo” of some kind to help him sleep.

    This was all an outrgrowth of the brief medical fad of compassion, in which pain management was a matter of helping keep people “ahead of the pain.” Then, as of last year, a new fad took hold. “Opiods” were declared evil because the usual suspects were diverting to the street and people were dying.

    So, this country being junior high school, the people who needed their medicine were punished. It didn’t help matters that, prior to his accidents, he’d been abusing alcohol and painkillers — which he stopped doing before the serious accidents, and had long since abstained from alcohol and used his painkillers responsibly.

    All last year, and up until last week, I sat in the offices of doctors and watched him be labeled a “drug seeker” (as if there’s something wrong with that when you get up in the middle of the night writhing in pain), a “doctor shopper” and an addict, all for wanting to continue his access to the medicine he needs.

    He is going to have a surgical procedure in a couple of weeks, and the doctor cautioned that it’ll (in the doctor’s words — I was there) “hurt like hell for a couple weeks after.” But his access to pain medication is controlled by the medical center’s pain management clinic. I was in that meeting, during which the doctor advised him to (her words) “use an ice pack,” and told him that 40 mg of hydrocodone, steadily, could kill him. By itself, not in combination with anything else.

    Oh, and she advised that he take an antidepressant, Effexor, and implied that it would reduce his pain. Effexor’s side effects are just horrendous, and there’s no evidence whatsoever that it will reduce the kind of pain that afflicts my partner.

    So, given that the medical establishment has decided that they’d just as soon he suffer, my partner’s turning to medical marijuana. This is something he resisted for a long time, fearing that he’d be on a slippery slope back to his pre-alcohol and drug abuse treatment days. He could handle the hydrocodone, etc., because it really was about the pain, but marijuana has other associations and he wanted to stay away from it.

    But this is what he’s got to do, because the medical establishment is off on a puritanical fad, and the politicians have imposed collective punishment. I really hope the marijuana will help; there are so-called “CBD” strains out there that aren’t as psychoactive, and that’s what we’ll be looking for.

    The next stop past that is hard drugs on the street. And those WILL kill you. Not that the doctors care about that either. These days, the medical “profession” would just as soon that he go off and die. I have watched someone struggle hard to stay within the lines; to comply with the prescriptions; to tell the truth; to look for solutions. I have seen him so thoroughly disrespected, humiliated and ignored that I come home and want to yell and cry at the same time.

    To actually have medicine that everyone knows will work, and which has worked for a decade, and not give it to him because suddenly the fad has shifted? It’s unconscionable.

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