Trapped in the Hospital Bed

Trapped in the Hospital Bed                                                                 By PAULA SPAN

Assume that Cynthia Brown’s audience, as she addressed the American Geriatrics Society’s annual scientific meeting in Texas this month, already knew that hospitalized older adults spend too much time in bed. Her listeners — geriatricians, nurses, administrators — had probably observed for themselves how quickly elderly patients become deconditioned, how even a few days of “bed rest” causes loss of strength and muscle mass, while the risks of blood clots, bed sores and pneumonia increase.

Dr. Brown, the director of geriatric medicine at the University of Alabama at Birmingham, has been sounding this alarm for a decade. But one number sent a murmur through the auditorium anyway: 43 minutes. That’s the median time a hospitalized elderly patient spends standing or walking daily, Dr. Brown and her colleagues reported in 2009.

Healthy older adults at home are on their feet more than six hours a day. But in this small study, hospitalized patients in their 70s spent 83 percent of their time in bed, according to the accelerometers attached to their thighs and ankles to measure movement. Forty-three minutes. “And this was a population that wasn’t delirious, that didn’t have dementia,” Dr. Brown said when we spoke later. “They were able to walk in the two weeks before they were admitted.” Once they have donned their immodest gowns (another problem), however, “the patient thinks he’s supposed to lie there and no one says, ‘We want you to get up.’ ”

So even when doctors fix whatever problem brought older people to the hospital, prolonged immobility often sends them to rehabilitation (i.e., a nursing home) for weeks or sometimes for good. The less their mobility, Dr. Brown has determined, the greater the decline in patients’ ability to perform “activities of daily living,” like bathing or dressing. Less active patients were also much more likely to be discharged to institutions.

Anyone gets weaker after days spent horizontally, but older people have less of what doctors call physiologic reserve. “If we put you in bed for the typical three- to five-day stay, we might tip you over the edge,” Dr. Brown cautioned. “So you’re not able to recover your previous level of functioning.”

Her Texas talk — she was receiving an award for “outstanding scientific achievement” — encompassed both depressing and heartening findings. One consequence of hospitalization, she reported, is a reduction in something called “life-space mobility,” a scale measuring how often a person leaves the room where he sleeps, leaves his home, moves around his neighborhood or goes “into town.” Patients in their 70s who had surgical hospitalizations — joint replacement, even heart surgery — show sharp declines in such mobility, but they recover fairly quickly.

But patients hospitalized for medical reasons thereafter inhabit a narrower world; they don’t regain their “community mobility” even two years later. “They stay a lot closer to home,” Dr. Brown said. Unless — and here’s the better news — they get up and walk in the hospital. When I last wrote about hospitals and mobility, I mentioned research by Dr. Steven Fisher, of the University of Texas Medical Branch, showing that elderly patients went home two days earlier if they did modest amounts of early walking.

Dr. Brown’s latest experiment involved 100 patients at the VA Medical Center in Birmingham. Those in the mobility group received twice-daily visits from staff members who helped them out of bed and brought them a wheeled walker if they needed one. “They were encouraged to get up and do as much as they could,” to take meals in a chair or walk 15 feet or make a loop around the ward, Dr. Brown said. Their progress was tracked in a folder.

The control group received visits, too. “We’d talk about football or the kids,” Dr. Brown said. “But not encourage them to move.” A month after discharge, the mobility group showed virtually no change in their life-space score, but those who had not walked suffered a significant decline. Their lives had contracted.

To climb out of a hospital bed, after a nurse has warned you not even to take the few steps to the bathroom without ringing for help, can be frightening to an older person who is sick, in pain, afraid of falling. Fear of injuries makes staff members and administrators nervous too, especially because Medicare will not reimburse for additional costs from falls, like surgery.

Even when physicians recognize the hazards of immobility and write orders that include ambulation, overworked staff can’t always find the time. Old people in hospitals walk slowly. But entering a nursing home is an alarming prospect too.

In my own experience, hospital nurses seemed grateful when I asked if I could walk with my father. I brought his walker (it is startling that hospitals don’t typically provide them) and a robe and supportive slippers, wheeled his IV along on a pole and accompanied him up and down the halls several times a day. I’m convinced that helped him recover.

Visiting family members cannot give their elders injections or change their IVs, but walking is something that — with staff permission — we can take on. “If families can be there to be cheerleaders and to help, it can make a huge difference in the health of an older person,” Dr. Brown said. “We want people to say, ‘We need Mama to get up.’ ”

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

http://newsletters.chartmeds.com/Newsletters/ViewArticle.aspx?Aid=269&uid=48387

Dementia Tops Cancer and Heart Disease in Cost

Dementia Tops Cancer and Heart Disease in Cost

By Marilynn Marchione, Associated Press

Cancer and heart disease are bigger killers, but Alzheimer's is the most expensive malady in the U.S., costing families and society $157 billion to $215 billion a year, according to a new study that looked at this in unprecedented detail. The biggest cost of Alzheimer's and other types of dementia isn't drugs or other medical treatments, but the care that's needed just to get mentally impaired people through daily life, the nonprofit RAND Corp.'s study found.

It also gives what experts say is the most reliable estimate for how many Americans have dementia — around 4.1 million. That's less than the widely cited 5.2 million estimate from the Alzheimer's Association, which comes from a study that included people with less severe impairment.

"The bottom line here is the same: Dementia is among the most costly diseases to society, and we need to address this if we're going to come to terms with the cost to the Medicare and Medicaid system," said Matthew Baumgart, senior director of public policy at the Alzheimer's Association.

Dementia's direct costs, from medicines to nursing homes, are $109 billion a year in 2010 dollars, the new RAND report found. That compares to $102 billion for heart disease and $77 billion for cancer. Informal care by family members and others pushes dementia's total even higher, depending on how that care and lost wages are valued.

"The informal care costs are substantially higher for dementia than for cancer or heart conditions," said Michael Hurd, a RAND economist who led the study. It was sponsored by the government's National Institute on Aging and will be published in Thursday's New England Journal of Medicine.

Alzheimer's is the most common form of dementia and the sixth leading cause of death in the United States. Dementia also can result from a stroke or other diseases. It is rapidly growing in prevalence as the population ages. Current treatments only temporarily ease symptoms and don't slow the disease. Patients live four to eight years on average after an Alzheimer's diagnosis, but some live 20 years. By age 80, about 75 percent of people with Alzheimer's will be in a nursing home compared with only 4 percent of the general population, the Alzheimer's group says.

"Most people have understood the enormous toll in terms of human suffering and cost," but the new comparisons to heart disease and cancer may surprise some, said Dr. Richard Hodes, director of the Institute on Aging. "Alzheimer's disease has a burden that exceeds many of these other illnesses," especially because of how long people live with it and need care, he said.

For the new study, researchers started with about 11,000 people in a long-running government health survey of a nationally representative sample of the population. They gave 856 of these people extensive tests to determine how many had dementia, and projected that to the larger group to determine a prevalence rate — nearly 15 percent of people over age 70.

Using Medicare and other records, they tallied the cost of purchased care — nursing homes, medicines, other treatments — including out-of-pocket expenses for dementia in 2010. Next, they subtracted spending for other health conditions such as high blood pressure, diabetes or depression so they could isolate the true cost of dementia alone.

"This is an important difference" from other studies that could not determine how much health care cost was attributable just to dementia, said Dr. Kenneth Langa, a University of Michigan researcher who helped lead the work. Even with that adjustment, dementia topped heart disease and cancer in cost, according to data on spending for those conditions from the federal Agency for Healthcare Research and Quality.

Finally, researchers factored in unpaid care using two different ways to estimate its value — foregone wages for caregivers and what the care would have cost if bought from a provider such as a home health aide. That gave a total annual cost of $41,000 to $56,000 per year for each dementia case, depending on which valuation method was used.

"They did a very careful job," and the new estimate that dementia affects about 4.1 million Americans seems the most solidly based than any before, Hodes said. The government doesn't have an official estimate but more recently has been saying "up to 5 million" cases, he said.

The most worrisome part of the report is the trend it portends, with an aging population and fewer younger people "able to take on the informal caregiving role," Hodes said. "The best hope to change this apparent future is to find a way to intervene" and prevent Alzheimer's or change its course once it develops, he said.

http://newsletters.chartmeds.com/Newsletters/ViewArticle.aspx?Aid=268&uid=48387

'Death With Dignity' Claims Another Victim

'Death With Dignity' Claims Another Victim              by Paul McHugh

May 24, 2013 edition of The Wall Street Journal

Now Vermont has joined the misguided movement toward physician-assisted suicide. Nearly 30 years ago, Arnold Schwarzenegger's "Terminator" character made famous the phrase "I'll be back," the implacable cyborg assassin's response to a setback. Today, similarly relentless terminators are among us, also with a deadly mission: to move America toward acceptance of physician-assisted suicide.

On Monday, the terminators gained a victory when Vermont Gov. Peter Shumlin signed into law the "Patient Choice and Control at End of Life Act." The bill had been passed by the state legislature the week before without consulting the electorate, possibly because the lawmakers had seen what happened last fall next door in Massachusetts, where voters rejected a similar initiative. Now Vermont doctors will be able to prescribe lethal medication to patients as the state joins Oregon, Washington and Montana in supporting the practice.

So the terminators are back. The reasons for opposing them and opposing physician-assisted suicide never went away. The reasons have been with us since ancient Greek doctors wrote in the Hippocratic oath that "I will neither give a deadly drug to anybody if asked for it nor will I make a suggestion to that effect." The oath is a central tenet in the profession of medicine, and it has remained so for centuries.

Dr. Leon Kass, in a brilliant essay on the Hippocratic oath in his 1985 book "Toward a More Natural Science," explains why this has been true. Medicine and surgery, he says, are not simply biological procedures but expressions, in action, of a profession given to helping nature in perpetuating and enhancing human life. "The doctor is the cooperative ally of nature," Dr. Kass writes, "not its master." It shouldn't need saying, but the exercises of healing people and killing people are opposed to one another.

Traditionally the public rests its trust in doctors on this understanding of medicine. Doctors occasionally remind the public of it when they explain why they do not participate in capital punishment or bear arms in military service. But the terminators who champion physician-assisted suicide propose that, as seen in intensive-care units, contemporary medicine prolongs unnecessary suffering.

As a psychiatrist, I work with doctors on such units, and I can testify that all of them realize that human life itself is limited in duration and scope. These doctors regularly consider just how far they should go in sustaining a hope for recovery—cooperating with nature's resilience in treating advancing disease. They also consider when prolonging a futile effort should be replaced by comforting the person as his life naturally comes to an end. The judgment is delicate, though, and most families are justified in leaving it to skilled physicians.

Another argument for physician-assisted suicide is that many patients with cancer live too long in pain. The suffering could be reduced if their legitimate wish for death were fulfilled. These are the arguments pressed by Dr. Timothy Quill and many in the Oregon "death with dignity" group.

But scientific publications from oncologists such as Kathleen Foley, who studies patients with painful cancers, reveal that, quite to the contrary, most cancer patients want help with the pain so they can continue to live. Suicide is mentioned only by those patients with serious but treatable depressive illness, or by those who are overwhelmed by confusion about matters such as their burden on loved ones and their therapeutic options. These patients are relieved when their doctors attend to the sources of their psychological distress and correct them.

In the nearly two decades that Oregon has permitted physician-assisted suicide, I became suspicious that just such depressed and confused patients number large among those who ask for and take life-ending poisons. Why suspicious? Because the law does not demand a psychiatric assessment before they take the fatal step. Yet all efforts by psychiatrists anxious to read the medical charts of these patients after their deaths have been thwarted by the champions of their suicides, who have shrouded the patients' mental states in secrecy by raising the "privacy privilege." I believe that these doctors are killing patients of the sort that I help every day.

And then there is this talk about "death with dignity," as the Oregon and Washington laws are titled. Surely what we want is "life with dignity." Seeking life, we're ready to endure much in order to keep it going. Think of the life-saving and life-preserving colonoscopy—all dignity drops with your trousers.

The advance of the hospice movement has made a shambles of the terminators' insistence that medicine prolongs suffering and denies dignity. The doctors, nurses and social workers committed to hospice care demonstrate how an alliance with nature at life's end plays out in just the way that the medical profession intends. As hospice ways become more familiar, the public can overcome the fears that the terminators used to win over the Vermont legislature.

For you see, the terminators ultimately are not merely interested in killing people who are suffering the throes of a final illness. They have even others in mind, as history tells us. The drive to allow doctors to "assist" in suicide is not recent. Its roots are in the Progressive era of the early 20th century, when many Americans placed utter confidence in reform and in technocratic elites. Then the enthusiasts for euthanasia lined up with those clamoring for government intervention in the name of eugenics and population control.

Across the decades, Americans have fought off such dire temptations with reasoned arguments about the nature of medicine. Despite Vermont's unfortunate decision, Americans elsewhere likely will continue to defeat physician-assisted suicide at the ballot box and in the statehouse. But the enemies of life are terminators—they'll be back.

Dr. McHugh, former psychiatrist in chief at Johns Hopkins Hospital, is the author of "Try to Remember: Psychiatry's Clash Over Meaning, Memory, and Mind" (Dana Press, 2008).

http://online.wsj.com/article/SB10001424127887323475304578499774161574386.html

Active Lifestyle Boosts Brain Structure in Older Adults

By: PATRICE WENDLING

02/07/13

CHICAGO – An active lifestyle positively influences brain volume in older adults with or without Alzheimer’s disease, a magnetic resonance imaging study revealed.

Among 876 individuals, the average gray matter volume was 663 mL in those with an active lifestyle, compared with 628 mL in those with an inactive lifestyle. That equates to a significant 5% difference (P value less than .05).

“That is a large number difference when you consider the tremendous biologic forces that have to be at work for gray matter volume to decrease,” lead author Dr. Cyrus Raji said in a press briefing at the annual meeting of the Radiological Society of North America.

Prior research has looked at the influence of individual lifestyle factors such as obesity or walking on brain structure, but not a variety of activities, as was done in the current study. Improving lifestyle could reduce the risk for Alzheimer’s disease by 50%, resulting in 1.1 million fewer cases in the United States, said Dr. Raji, a radiology resident at the University of California, Los Angeles.

“In the United States, the lack of physical activity is the No. 1 most powerful lifestyle factor, contributing to 21% of cases of Alzheimer’s disease,” he said. “Worldwide, it is the third most powerful risk factor after low educational attainment and smoking.”

To determine how lifestyle influences brain structure, the investigators used MRI scans and clinical data collected over 20 years from 876 individuals enrolled at four sites in the Cardiovascular Health Study. The Minnesota Leisure Time Physical Activity Questionnaire was used to assess caloric expenditure during 15 different aerobic activities: swimming, hiking, aerobics, jogging, tennis, racquetball, walking, gardening, mowing, raking, golfing, bicycling, dancing, calisthenics, and riding an exercise bike. A technique called voxel-based morphology was used to quantify the amount of brain matter in the MRI scans.

The participants expended an average of 1,093 kcal/week. Overall, 42% were men, 88% were white, and about 25% had been diagnosed with Alzheimer’s disease or mild cognitive impairment (MCI). The cohort was largely overweight, with an average body mass index of 27 kg/m. Their average age was 78 years.

The analysis controlled for head size; age; gender; body mass index, which has been related to brain structure and atrophy; small vessel ischemic disease, which reflects processes like diabetes and hypertension that can affect the brain; Alzheimer’s or mild cognitive impairment (MCI) status; and study site.

The most active participants burned an average of 3,434 kcal/week, compared with 348 kcal/week in the least active participants.

There was larger bilateral gray matter volume in the cingulate gyrus, hippocampus, and temporal lobes – areas responsible for memory and learning – among individuals who burned the most calories per week, compared with those who burned the fewest, Dr. Raji said.

“That means the areas of the brain that are benefiting the most from this active lifestyle are also the areas affected in Alzheimer’s disease and are also responsible for cognition,” he explained.

The same findings were observed in participants with Alzheimer’s disease or MCI. “People with Alzheimer’s who were more physically active in our study weren’t cured, but they had less deterioration in their brain matter volume, compared with the sedentary individuals,” said Dr. Raji, who described the study as one of the largest voxel-based imaging studies of humans ever done.

Press briefing moderator Dr. Candice A. Johnstone of the Medical College of Wisconsin in Milwaukee said in an interview that what’s unique about the study is that it shows that physical activity actually changes brain volume and that this benefit can be obtained through a variety of activities. This is especially important when counseling patients who may have difficulty walking.

What the study fails to address, however, is whether an active lifestyle will have an impact on the symptoms of Alzheimer’s or MCI. “Whether physical activity can significantly alter the course remains to be seen,” she said. “It may be that people with changes in brain volume may be more likely to have [fewer] symptoms because their brain’s actively working to enhance those areas, but that’s the subject of future research. We do not know that.”