The Older Patient

Early detection of disease is a good thing, but we should not forget about our older patients. Older patients are particularly likely to benefit from interventions to reduce heart attacks and stroke. These include controlling blood pressure and lowering cholesterol as well as weight reduction. Weight loss produces favorable changes in elevated cholesterol, elevated blood sugar and elevated blood pressure. Control of obesity also encourages a more active lifestyle.  

The symptoms of coronary artery disease may be more subtle over the age of 80; patients should be sure to report even what they consider to be trivial complaints. A pain in the calf while walking could indicate a critical blockage in a coronary artery.  

It is never too late to stop smoking! Within five years of smoking cessation the risk of smoke declines to that of people who never smoked. Approximately 15 percent of adults over age 65 years experience health problems related to the complications of alcohol consumption in combination with medication or chronic conditions. Risk factors for alcohol abuse among older adults include bereavement, depression, anxiety, pain, disability, and a prior history of alcohol use. 

All older adults, including the very old, those with multiple medical problems, or those who are in chronic care facilities, can benefit from physical activity. Participation in any amount of physical activity will result in some health benefit.  

It’s never too late to improve your health. Small investments can have big pay-offs.

The High Cost of Medications

Every day I am shocked by the price of medications. Many patients think it’s a little silly when their $10 co-pay receipt states that they ‘saved’ $163 dollars; what they don’t realize is that patients without insurance actually need to pay the full freight of $173. The very high price might be appropriate for a new medication since the pharmaceutical company should be able to recoup that research and development costs. However, due to changes in the health care law many of the old medications that used to be cheaper than Tylenol now carry breath-taking price tags.

I spoke to a pharmacist about this. His belief is that since everyone will soon need to carry insurance that covers medication, the manufacturers are increasing prices. Unfortunately, patients who carry the new high deductible health insurance plans will be paying the inflated costs out of pocket. A round of antibiotics that a couple of years ago cost less than $25 can now sent one back by more than $250.  An excellent arthritis gel that is available over the counter for less than 10 euros in France is $150 per tube here.

One of my patients is not sure that she will have her cataract operation. Medicare will pay for the procedure but on her fixed income she doesn’t have several hundred dollars for the necessary eyedrops. I suggested that she ask her children for an early Christmas gift. This might solve her problem this time. But what about the next time?

Smart Patients

The smartest patients come to the doctor’s appointment prepared. Now that more patients are paying a greater portion of their medical bills, it’s important to make the best use of your time and money.

The first step is to stay on top of your medical information. If your cholesterol was checked last month at a health fair, unless there is a problem it’s unlikely that it will need to be checked again soon. You can cut down the number of imaging studies in your future if you tell your new doctor that you have an extra blood vessel in your liver. Immunizations are important, but it’s silly to get shots that you don’t need because you forgot that you already had it.

 Unless you are having crushing chest pain or actively bleeding, there is probably time to get a second opinion. Get a second point of view before making a major medical decision. I don't recommend consulting with Dr. Google or his colleague, Dr. Wickipedia.

Keep track of your medications – all of them, from every doctor. Don’t forget over the counter products, herbs, supplements and vitamins. Be honest about your alcohol intake. Don’t fib about recreational drug use.

 

There can never be enough time to answer all questions. Decide before the visit what is most important to you and tell the doctor at the start of the visit. The doctor may have another agenda but will be better able to manage the visit. And – if you run out of time, schedule your next visit before leaving the office. You will have the full attention of the scheduler and won’t have to wend your way through a telephone tree.

 A smart patient will be a healthier patient.

Too Strict?

The Wall Street Journal featured an article about tough teachers and how they achieve results: a traditional educator with strict discipline and unyielding demands has successful students. I wonder if some of these concepts should be introduced to the physician-patient encounter.

Strict is better than nice. Rather than leading students through discussions and collaborative learning, teachers who provide explicit instructions and lectures achieve the best results.

Optimism can be taught. Teachers who believed that their students would improve had better academic gains, since the students came to believe that they would improve.

Praise makes you weak. Don’t applaud the outcome, encourage the process. Things worth achieving are hard work.

Failure is an option. Trying again is part of the learning process. Get up, dust yourself off and take another shot.

Stress makes you strong. Dealing with negative events builds resilience. Things are tough and always will be – so move on.

The bottom line: the belief in the student’s ability to do better. 

Flu Shots

Flu season usually starts in November, making October the ideal time to get the flu shot. It’s widely available now and there is plenty of supply. Travelers should remember that the Southern hemisphere may be ahead of the Northern hemisphere and that many new types of flu originate in the far East.

Because the prevailing flu virus mutates, it is necessary to get a new flu vaccine every year. People who get the flu vaccine have a lower chance of getting the flu and a lower chance of dying from the flu as compared to people who don’t get immunized. Flu shots cannot cause the flu since the virus is inactivated. The inactivated virus will allow the body to make protective antibodies. It takes about two weeks to form the protective antibodies.

The typical flu vaccine is formulated to protect against what is predicted to be the three most common varieties of influenza. The more expensive quadrivalent vaccine adds another B virus. The CDC doesn’t recommend one type over the other.

More information from Centers for Disease Control and Prevention.

What Size?

I needed to replace the lightbulbs in a bathroom fixture. As I stood at the vast lightbulb display, holding the old bulb in my hand, I realized that my choice was limited to two. Nothing else would fit. A couple of years ago I needed to replace the refrigerator in my kitchen. With that purchase I had only one option; I bought the model that fit into the space.

We face much of the same dilemma in clinical medicine. Pharmaceuticals come in defined doses and we need to choose from what is available. Sophisticated delivery systems (sustained release, enteric coating) mean that cutting pills to achieve an in-between dose will affect how a medication is metabolized. Only rarely should capsules be opened.

The good news is that a limited number of dosing options will meet almost every need. Even though patients come in all sizes, healthy kidneys and livers are remarkably uniform in size and function. Lean body mass, which is most often how we determine the amount of medication to use, doesn’t vary too much across the population.

When I bought my lightbulbs, I was confident that the size of the socket was not going to change while I was at the store. Nor is the size likely to change one year from now. It doesn’t matter how often I flip the light switch. Human behavior is not as predictable. Choosing a medication dose for a patient assumes that the medication will be taken the same time every day under the same conditions (with or without food). Additional medications or certain foods can alter drug metabolism. The underlying disease might change. What would appear to be the perfect calculated dose might not work out. This is why lightbulbs are over the counter and most medications need a prescription. 

A Regular Routine

The kids are back to school: time to resume the schedule. While it’s fun to laze about a bit during the summer, we as human beings really do better with a set routine. Just as a two year old is less terrible with a set naptime, adults benefit from eating and sleeping in a predicable pattern.

The time that we awaken sets the biological clock for the day. Getting up at the same time every day allows our hormones to assume a diurnal pattern leading to better mood, digestion and cognition. Since we need at least eight hours of sleep, we should plan on going to bed about eight and a half hours before we plan to start the day. Wind down at the end of the day and turn off all screens.

It is recommended that we don’t eat for at least two hours before going to bed: this will help determine the best time for dinner. Sit down and enjoy the meal. Since the overnight fast will be at least ten hours, chances are that we will be hungry for breakfast. Consider some non-traditional foods to start the day, rather than the carbohydrate heavy regulars. Therefore, awakening the same time every day will help determine what time to eat both breakfast and lunch. Most people will want a meal at midday. Brown-bagging will help make wise choices and save a lot of money.

Exercise should be part of the daily routine. Midday is an excellent time for this since it will help provide energy for the afternoon tasks. Think back to grade school – wasn’t running around after lunch the best part of the school day?

Having a predicable sleep/wake/eating pattern might be mundane, but it really works to maintain health. Try to maintain the pattern on the weekends as well.