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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 32. This is the beginning of the thread.
Posted by Phillipa on March 3, 2014, at 11:50:01
This is sad and disheartening to read. I haven't posted any articles in a long time as they seem to be getting closer to almost just saying "die" when it come to people 65 & older. Now no prostrate exams, Mammograms, all the things that were must haves before. And don't feed by tube or supplemental feedings those anorexia. Sad to me. Or is it just me and getting older? Phillipa
Medscape Medical News
Geriatrics Society Releases Second Choosing Wisely List
Larry Hand
February 27, 2014
The American Geriatrics Society (AGS) has released a second list of 5 tests or treatments that physicians and older adult patients or caregivers should question before proceeding with them. Release of the evidence-based recommendations is a continuation of the AGS's participation in the Choosing Wisely initiative, launched in 2012 by the American Board of Internal Medicine Foundation."We are grateful to have had the opportunity to identify these five additional things," Paul Mulhausen, MD, from Iowa City, Iowa, chair of AGS' Choosing Wisely Workgroup, said in a news release. "Because older patients tend to take more medications, and undergo more medical tests and procedures than younger adults, this information is invaluable."
The new list, released online February 27, adds 5 tests or treatments to a previous Choosing Wisely list by AGS that was published in the Journal of the American Geriatric Society in June 2013.
The new recommendations are:
"Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects." If a patient is started on cholinesterase inhibitors and treatment goals are not achieved after a reasonable time such as 12 weeks, medication discontinuation should be considered.
"Don't recommend screening for breast or colorectal cancer, nor prostate cancer (with the [prostate-specific antigen] test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment." Screening for these 3 cancers exposes patients with life expectancies lower than 10 years to potential harms with little benefit potential.
"Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations." No evidence exists that these stimulants and supplements improve quality of life, mood, functional status, or survival
"Don't prescribe a medication without conducting a drug regimen review." A review may reduce medication burdens by exposing unnecessary prescriptions
"Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium." Use physical restraints only as a last resort and discontinue as early as possible
The previous recommendations were:Information from Industry
"Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding."
"Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia."
"Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better."
"Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium."
"Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present."
A national campaign, Choosing Wisely involves more than 50 medical specialty societies identifying common medical tests and treatments that may not be necessary or of benefit to patients."Five Things Physicians and Patients Should Question." AGS
Posted by ed_uk2010 on March 3, 2014, at 13:40:15
In reply to New Recomendations for over 65, testing, Mammo, Me, posted by Phillipa on March 3, 2014, at 11:50:01
> This is sad and disheartening to read.
I actually don't think it is, here's my interpretation...
>"Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects."....
Periodic assessments are vital. It wouldn't be appropriate to Rx cholinesterase inhibitors for dementia without reviewing the response. In many patients, the drugs cause adverse effects or are not effective.
>Don't recommend screening for breast or colorectal cancer, nor prostate cancer (with the [prostate-specific antigen] test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.
If an elderly person has serious illness leading to a short life-expectancy, cancer screening will not be beneficial. Diagnosing cancer in someone with advanced heart failure, for example, will not improve anything for that patient. Cancer screening is useful for people with an otherwise good life expectancy.
>Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations.
High calorie supplements are often expensive and most taste unpleasant. Instead, elderly people need to be provided with support to eat normal healthy food.
>Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.
I cannot see any possible benefit in tube-feeding people with advanced dementia. It is essentially prolonging death, not life. Caregivers should assist feeding by mouth, using liquidised food where appropriate.
>Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.
Attempts to control blood glucose very tightly tends to cause adverse effects in elderly people, and may not be beneficial.
>Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
A lot of elderly people have asymptomatic bacteriuria (not UTI). In the absence of symptoms, treatment provides no benefit but leads to antibiotic resistance.
Posted by baseball55 on March 3, 2014, at 19:22:27
In reply to New Recomendations for over 65, testing, Mammo, Me, posted by Phillipa on March 3, 2014, at 11:50:01
> This is sad and disheartening to read. I haven't posted any articles in a long time as they seem to be getting closer to almost just saying "die" when it come to people 65 & older. Now no prostrate exams, Mammograms, all the things that were must haves before. And don't feed by tube or supplemental feedings those anorexia. Sad to me. Or is it just me and getting older? Phillipa
>
Why is it sad and disheartening? Why do you always read these kind of things as saying - just die. The evidence says that these things don't extend life and make quality of life worse. Why treat a prostate cancer in an elderly male when prostate cancer is a slow-growing cancer that will almost certainly not kill him before he dies of other causes? Why see this as saying, just die?Expenditures on end-of -life care are ridiculous because doctors continue to treat things in people well into their 80s and in otherwise poor health. My mother-in-law's doctors wanted to do open-heart surgery when she was 82 and in poor health, though prognosis after open-heart surgery for someone that age is poor. She refused, didn't want to destroy the quality of her life.
Personally, I plan to avoid at all costs the medical-industrial complex that sucks in most elderly people. I see them whenever I go to the doctor, which I rarely do. Frail elders whose lives revolve around their various medical appointments.
Personally, I want no tests, no doctors visits, no heroics.
Posted by Phillipa on March 3, 2014, at 20:30:14
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by baseball55 on March 3, 2014, at 19:22:27
If age 65 is old then I should just die as about to turn 68 and still ride 6 miles a day on my bike. I shouldn't control blood sugar? Or be given calorie protein fluids if I have a problem that keeps me from eating? Not talking about frail elderly people as I am not one. I am standing up for my rights as a human being and if I chose life over death I have that right. Phillipa
Posted by Phillipa on March 3, 2014, at 20:39:21
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by Phillipa on March 3, 2014, at 20:30:14
And how interesting that 65 is the time when people retire when they have contributed into the system so now that some and not all don't work end their life so the government saves money? Don't you see the changes coming down the road? My husband sure does. Oh and I work from home selling daily. I contribute still to the government. I will continue to get colonoscopies, thyroid testing, see PT for back issues and do the daily PT excercises, mow my lawn, and most of the things those of a younger age do. Daily I watch people contract cancer that are young and have to use insurance now run by the government for costly treatment for stage 4 cancer? And now they can't work too ill? So age shouldn't be the factor the motivation and previous health of the person should be. Phillipa
Posted by Twinleaf on March 3, 2014, at 21:09:59
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by Phillipa on March 3, 2014, at 20:39:21
As I read them, the new guidelines just say to determine whether preventive tests will, if positive, result in treatment which improves length and quality of life. If you are a healthy 80-year old, they would, and they can and should be done if you choose to have them. But it is true that at times, general health is already so impaired that prospective treatments for heart disease, cancer, etc. may not be advisable. I personally have been very fortunate in having excellent physical health and I have always had colonoscopies, mammograms etc. with nothing ever being found.
My mother-in-law, on the other hand, never ever went to a doctor, and lived until 103 -healthy the whole time!
Posted by Phillipa on March 3, 2014, at 22:28:10
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by Twinleaf on March 3, 2014, at 21:09:59
I love to hear the stories of the people in their 90's and l00's that are so healthy. A couple of my facebook friends from high school have the Mothers the same alive and active. Two of them have cancer at the moment. So my concern is that soon the government will just say "well over 65" so why? Phillipa
Posted by corkskru on March 3, 2014, at 22:59:10
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by baseball55 on March 3, 2014, at 19:22:27
I think there should be a case by case determination of the extent and degree of applying these guidelines (the cases above are fairly easy to determine it more harm than good) but does that not allow someone to play as a Higher Power in who may live or not?
What I see is an erosion of benefits for retired people, less gray areas and flexibility and more power given to others at the disadvantage of the patient. I see this as another movement to take away flexibility of the patient/person that no longer contributes to the "system" but I might just be cynical..
Posted by Willful on March 4, 2014, at 1:23:37
In reply to New Recomendations for over 65, testing, Mammo, Me, posted by Phillipa on March 3, 2014, at 11:50:01
You've unfortunately misinterpreted these recommendations.
They are saying, don't do things that are useless and/or make people worse -- mammograms now are not thought to entend survival, because all the recent large scale studies have shown that those who received yearly mammograms do not survive longer than those who do not-- and they often suffer from false positive that lead to frightening, and painful further testing and sometimes treatment of things that turn out not to be cancer, or , like carcinoma in situ, are thought now not to become cancerous.
Don't give people with anorexia high calorie meals because they are determined not to gain weight and will defeat that type of treatment. There may be other types of treatment that will help, which are not discussed.
Physical restraint are barbaric and unnecessary in most cases.
Don't give meds without assessing cognitive or other side effects so as to prevent people taking meds that are disabling them cognitively.
Anti=psychotics often don't help in people with certain types of dementia and are used solely to sedate people-- not to give them treatment. This helps the staff, but deprives the older person of whatever cognitive ability they have left.
For the same reason, don't use xanax or other sedating meds, simply to control people.
As far as I can tell, every one of these recommendations is done to protect from over=medication, danger of false positives without any evidence of increasing survival, and from useless treatments, and to give vulnerable patients greater self control, safety, and comfort, rather than forcing useless and often draconian treatments on them.
It nowhere says that if you want nutrition, you will deprived of it. It says if nutrition is rejected, or not wanted or not helpful, do not force it on people, Instead, use treatments that provide greater quality of life and are more effective in helping them.
Posted by ed_uk2010 on March 4, 2014, at 13:47:21
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by Phillipa on March 3, 2014, at 20:30:14
>Or be given calorie protein fluids if I have a problem that keeps me from eating?
The guidelines you posted were about tube feeding pts with advanced dementia. I think you missed the point PJ :)
Posted by Dr. Bob on March 5, 2014, at 1:57:40
In reply to Re: New Recomendations for over 65, testing, Mammo, Me, posted by baseball55 on March 3, 2014, at 19:22:27
> > Now no prostrate exams, Mammograms, all the things that were must haves before. And don't feed by tube or supplemental feedings those anorexia.
> >
> Why is it sad and disheartening? Why do you always read these kind of things as saying - just die.Maybe she read don't do test and don't feed as don't care?
Bob
Posted by ed_uk2010 on March 5, 2014, at 13:00:27
In reply to Re: sad and disheartening, posted by Dr. Bob on March 5, 2014, at 1:57:40
>Maybe she read don't do test and don't feed as don't care?
I think so too, but that's not what the guidelines suggest at all.
(((Phillipa)))
Posted by Twinleaf on March 5, 2014, at 13:10:57
In reply to Re: sad and disheartening, posted by Dr. Bob on March 5, 2014, at 1:57:40
Phillipa clearly did read/feel it as uncaring, but I think Willful's explanation was so clear and helpful for each of the topics, pointing out that good judgement should be involved in each decision to ensure that the possibility for improving quality of life is greater than the possibility of harming or shortening it.
It is in accordance with the Hippocratic Oath - "first, do no harm..." which guides all physicians.
Posted by Phillipa on March 5, 2014, at 20:02:44
In reply to Re: sad and disheartening, posted by Twinleaf on March 5, 2014, at 13:10:57
Times have changed. Do no harm can mean do nothing as to do nothing means not doing a thing. So subject to interpretation. The government medical system is flawed and broken right now and monies must be save. Personally I will pay out of pocket. That is my right. Phillipa
Posted by Twinleaf on March 5, 2014, at 20:48:59
In reply to Re: sad and disheartening » Twinleaf, posted by Phillipa on March 5, 2014, at 20:02:44
No, Phillipa - " do no harm" does not mean to do nothing. In the Hippocratic Oath, it is associated with a promise by the physician to promote and prolong life. This has been so for nearly 2500 years,; current social stresses and trends will not change that.
Several readers, including Dr.Bob, have suggested that you had a negative emotional reaction to the guidelines, feeling that they implied rejection or lack of caring, whereas to others they are just medically reasonable, and designed to promote the best possible care for older patients. As a medical professional yourself, I would hope that you could readily understand this.
We do have serious present stresses on our system of medical care, but this is not one of them.
Posted by Ronnjee on March 6, 2014, at 14:03:13
In reply to Re: sad and disheartening » Phillipa, posted by Twinleaf on March 5, 2014, at 20:48:59
Whenever "modern" medicine realigns itself with reality, I think it's a good thing. Everybody dies, and there's a lot of denial about that simple immutable fact. Science has limitations, physicians have limitations, and many frightened people cannot accept that.
Posted by Phillipa on March 6, 2014, at 17:48:59
In reply to Re: sad and disheartening, posted by Dr. Bob on March 5, 2014, at 1:57:40
Dr Bob more like reading it as if one is now being treated, as example for cancer aggressively as some I know are they will continue to be treated. But now that the system is changed that watch out as it's the beginning of no testing for younger also. Take some other countries where even those at age 40 only are allowed mammograms every three years the trend is leading this way. Do to high costs. Phillipa
Posted by Willful on March 6, 2014, at 22:15:53
In reply to Re: sad and disheartening » Dr. Bob, posted by Phillipa on March 6, 2014, at 17:48:59
but the fact that you seem to not want to hear is that mammograms were recommended once a year because it was originally hoped that that would save lives.
However as science advances, new realizations are arrived at. One is that frequent such as yearly mammograms do not save lives. This has become clearer from some recent large scale studies done. The main effect of yearly exams is to produce more false positive results which lead to people being given more invasive tests, and sometimes unnecessary surgery.--
I know you're capable of understanding this concept phillipa, so I wonder why you don't seem to acknowledge it. Did you even read my the post in which I tried to explain the rationales for the new guidelines that you cited?
Sometimes more treatment and testing is worse treatment and testing--as in the case for mammograms, and many others. The problem of false positive results (results tht suggest, incorrectly that a problem exists) was not recognized at first-- but not doctors see how harmful this can be.
Sedating elderly people is not by any means a good thing-- nor is providing food for those who won't eat, or who won't gain weight even if they do eat it, as with those in some stages of wasting.
Can't you understand that these recommendations actually protect patients from bad treatments or testing?
Why does it have to suggest that those for whom treatment is appropriate will not be treated? Just because it saves money, does not make it a bad thing. Sometimes NOT testing saves money-- but it also protects patients.
Posted by Phillipa on March 7, 2014, at 21:02:14
In reply to Re: sad and disheartening » Phillipa, posted by Willful on March 6, 2014, at 22:15:53
About 8 years ago I had a biopsy from a mammogram. A marker chip was inserted. So now when yearly mammogram is done the docs can see if the calcification has gotten larger or stayed the same. So I'm considered high risk. And because of this I also am given an instant reading on my yearly mammogram. The tech marches the film to the radiologist who gives preliminary reading and then about a week later I receive a letter confirming results. So in my case it's been good. My brother in law as a few days ago after prostrate exam found to have prostrate cancer. This motivated my husband to get him physical done. Digital exam okay, next week the blood work, and then he is being set up for his colonoscopy first he ever had. Prostrate cancer runs in the males in his family. His Father also had it and his father as well. His Mother had colon cancer. Without testing an early diagnosis would not be possible. Right now trying to set up the Di Vinci robotic surgery for his Brother rather than old school surgery. Less risky, less complications, less hospital & recovery time, and less risk of cutting the nerve which controls ED. So what's the problem? Phillipa
Posted by Twinleaf on March 7, 2014, at 21:54:01
In reply to Re: sad and disheartening » Willful, posted by Phillipa on March 7, 2014, at 21:02:14
There's no problem, Phillipa. These are all the right choices for you and your family. The guidelines would not suggest anything different for you, but they might suggest different approaches for older patients who have serious pre-existing conditions - that's all the guidelines are saying. Everything is not necessarily related to you.
An even better option for prostate cancer is IMRT or proton beam radiation. No erectile difficulties and higher cure rates. Men in my family have had each kind of radiation, with excellent results for both kinds.
Posted by Phillipa on March 7, 2014, at 22:33:03
In reply to Re: sad and disheartening » Phillipa, posted by Twinleaf on March 7, 2014, at 21:54:01
Twinleaf not for his 58 year old brother. The whole gland must be removed as 6 0f l0 biopsies in gland are positive and prostrate lymph nodes. So now his Brother wrote the doc says traditional prostrate surgery. Makes no sense to me but since he was recently diagnosed with high blood pressure the urologist doesn't want him under anesthesia for long. If the tumor was just part of the gland the radiation would be possible but it's more extensive also due to young age. Phillipa
Posted by Twinleaf on March 7, 2014, at 22:52:35
In reply to Re: sad and disheartening » Twinleaf, posted by Phillipa on March 7, 2014, at 22:33:03
Not an expert at all, but think these new types of radiation would be more curative if the disease has spread beyond the gland. One of the men I mentioned had early spread and IMRT was curative - or at least he's fine 10 years later
Posted by Ronnjee on March 8, 2014, at 15:08:43
In reply to Re: sad and disheartening » Twinleaf, posted by Phillipa on March 7, 2014, at 22:33:03
> Twinleaf not for his 58 year old brother. The whole gland must be removed as 6 0f l0 biopsies in gland are positive and prostrate lymph nodes. So now his Brother wrote the doc says traditional prostrate surgery. Makes no sense to me but since he was recently diagnosed with high blood pressure the urologist doesn't want him under anesthesia for long. If the tumor was just part of the gland the radiation would be possible but it's more extensive also due to young age. Phillipa
"prostrate"?
Posted by Phillipa on March 8, 2014, at 19:23:37
In reply to Re: sad and disheartening, posted by Ronnjee on March 8, 2014, at 15:08:43
Yes & it was ll of 12 sectional biopsies of prostrate positive and the lymph nodes surrounding it. From the further research I have done and talking today to his Brother. He seems pretty convinced that the open approach is what his doc wants. I did see that if the Da Vinci is used and nodes come back positive then the prostrate will not be moved and treatment changes to radiation and possibly chemo? Phillipa
Posted by 10derheart on March 8, 2014, at 19:30:51
In reply to Re: sad and disheartening, posted by Ronnjee on March 8, 2014, at 15:08:43
I know what she means. I'll bet you do, too.
It's a common mistake or misspelling.
No worries, Phillipa.
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