What Doctors Don't Know about Cancer Screening and You Should!

A VIEW FROM THE OFFICE

WHAT DOCTORS DON'T KNOW ABOUT CANCER SCREENING 

AND YOU SHOULD!

     Here are a few examples of results from cancer screening studies. See what you think.

#1:  The lung cancer example: "Imagine a group of patients in whom cancer was diagnosed because of symptoms at age 67 years, all of whom die at age 70 years. Each patient survives only 3 years, so the 5-year survival for the group is 0%. Now imagine that the same group undergoes screening. Screening tests by definition lead to earlier diagnosis. Suppose that with screening, cancer is diagnosed in all patients at age 60 years, but they nevertheless die at age 70 years. In this scenario, each patient survives 10 years, so the 5-year survival for the group is 100%." Sounds better, doesn't it? But it's not. "Yet, despite this dramatic improvement in survival rate (from 0% to 100%), nothing has changed about how many people die or when."

#2: The breast cancer example: "[E]ven for mammography screening for breast cancer..., several analyses have demonstrated that the vast majority of women with screen-detected breast cancer have not had their lives saved by screening, but rather have been diagnosed early with no change in outcome or have been overdiagnosed [i.e., diagnosed with a cancer that was never going to do any harm]."

#3: The prostate cancer example: In a survey among practicing physicians, the authors of this report used actual data from prostate cancer screening studies but just referred to the condition as 'Disease X'. They asked the physician respondents to assume that the tests used for screening were noninvasive, free, and detected cases of cancer for which treatment, such as surgery, exists. The effect of the test was described in terms of 5-year survival, and, in another scenario, the effect of the same test for 'Disease Z' was described by showing its effect on the death rate from this cancer.

     The result for the test for disease X was described as showing a 68% survival rate without screening and a 99% survival rate with screening.

     The result for the test for disease Z was described as resulting in 2 deaths per 1000 persons without screening vs. 1.6 deaths per 1000 persons with screening.

     Remember, both of these results apply to prostate cancer. They are just different ways of looking at the same data. Which result appears better to you?

     The key here is that earlier screening will ALWAYS detect more cases, and more early cases, but this fact in and of itself does not imply any improved outcome. Improved outcomes need to be determined by randomized controlled clinical trials.

     In this example, the second way of looking at the result is actually the superior method. It shows that there is a small, but statistically significant difference in mortality, associated with the screening intervention. But what you don't know yet is whether there are any harms from the screening intervention. This is a particularly important question because the mortality benefit is so small (0.4 cases per 1000); any adverse effects might quickly outweigh that benefit. 

     The example in the survey went on to explain that earlier screening for prostate cancer ultimately resulted in an incidence of 46 cases per 1000 persons with screening vs. only 27 cases per 1000 persons without screening.  Since the mortality benefit is only 0.4 deaths per 1000 subjects, these data mean that 19 extra persons will be diagnosed with prostate cancer without receiving any mortality benefit. Thus they will go through biopsies, chemotherapy, surgeries, and complications of surgery including impotence and incontinence. Now think about it. If it was your life, would you want this test? It is precisely because of this problem that the United States Preventive Services Task Force (our national experts) recommended against any screening for prostate cancer with our currently available tests.

     Now let's look a little further at how the physicians in this survey interpreted the data they were given.

1. The primary care physicians demonstrated limited knowledge of what evidence might prove that a cancer screening test saves lives. About one half (47%) incorrectly said that finding more cancer cases in screened as opposed to unscreened populations provided such proof. 

2. Many physicians did not distinguish between irrelevant evidence for screening (e.g., improved survival rates) and relevant evidence (reduced cancer mortality): Nearly as many physician incorrectly believed that survival data proved that screening saves lives (76%) as believed that mortality data provide this proof (81%).

3. 80% of physicians said that the screening test supported by irrelevant evidence (5-year survival increased from 68% to 99%) 'saves lives from cancer,' whereas only 60% said this about the test supported by relevant evidence (cancer mortality reduced from 2 to 1.6 in 1000 persons.

4. Physicians were also three times more likely to say they would 'definitely recommend' the test that improved 5-year survival compared with the one that reduced cancer mortality (69% vs 23%).

5. After seeing the data on the test that improved 5-year survival, physicians were then shown how the screening test increased the proportion of cases of cancer detected at Stage I (from 36% without screening to 54% with screening). This information in fact provides little support for a screening test because even a harmful test--one that increased mortality--could increase detection of early-stage cancer. Nonetheless, 68% of physicians said this information made them 'more' or 'much more' likely to recommend the test. In addition, 57% now expected the screening to save more lives from cancer than they had initially estimated without this additional information.

6. After seeing the data on the test that reduced mortality, physicians were shown how the screening test increased cancer incidence (from 27 to 46 per 1000 persons over 5 years). 62% of physicians said the increased incidence made them 'more' or 'much more' likely to recommend the test. In fact, 50% now expected the screening to save even more lives from cancer even thought the increased incidence is irrelevant to mortality. Overall, 11% incorrectly endorsed the explanation that the 'screened group must have had more cancer risk factors.' 42% incorrectly believed that the 'decreased mortality is all the more impressive given the higher incidence' with screening. More than one half (58%) did not endorse the statement that "For every death prevented by screening, some people are diagnosed and treated with cancer Z unnecessarily..."

7. At the end of the scenario about the test that improved survival, physicians were presented with an explanatory note explaining that higher survival (or finding more cases of state I cancer) with screening does not prove that screening saves lives and that such proof can come only from a randomized trial demonstrating lower cancer mortality. Although 76% stated that they found the note helpful, it had an inconsistent effect; 29% said it made them more likely to recommend the screening test, and 21% said it made them less likely.

8. At the end of the scenario about the test that reduced cancer mortality and increased incidence, physicians were presented with an explanatory note that highlighted the possibility of over-diagnosis (that is, to prevent 1 death from cancer, as many as 47 additional people would be diagnosed unnecessarily). 80% found this note helpful, and 40% said it made them less likely to recommend the new test. However, 23% said it made them more likely to recommend the test. 

Now here is the way I like to express the relative effectiveness of cancer screening. I use it as a test for students and residents regularly.  It is simple. Just review the following table for the most commonly recommended screening tests for cancer.

Cancer Type	Relative Risk Reduction	Reduction in All-Cause Mortality
Breast	16% (USPSTF)	0%
Colon	15% (USPSTF)	0%
Cervical	40-60% (USPSTF)	0%
Prostate	unknown (studies inconclusive)	0%
Skin	unknown (studies inconclusive)	0%

     The "relative risk reduction" means that with the screening test for cancer X your risk of dying of cancer X is reduced by this amount; thus breast cancer screening reduces your risk of dying of breast cancer by about 16%. What "Reduction in All-Cause Mortality" means is how many people are still alive at the end of a given period of time. What the number "0" indicates is that, when you consider all possible causes of death, NO ONE appears to be living any longer as a result of cancer screening. 

      Again, what this means is that for all our trouble no one, I mean, No one!, is living any longer when you look at all possible causes of death. Yes, they are having somewhat fewer deaths from breast, colon, and cervical cancer (if they comply with screening recommendations), but they are not living one single day longer. You have just rearranged the desk chairs on the Titanic.

     Most significant from this table, since no single cancer screening strategy reduces all-cause mortality at all, is its clear implication:  IF YOU CAN FIND ANY INTERVENTION THAT LEADS TO EVEN A 1-2% REDUCTION IN ALL-CAUSE MORTALITY, IT WILL DO FAR, FAR MORE GOOD THAN ALL OF THESE CANCER SCREENING INTERVENTIONS PUT TOGETHER!

     Thus, the further question to ask is: Do we have any such interventions that will reduce all-cause mortality?  And I have to say, "Of course, we do." Let's encourage a healthy lifestyle with our Formula for Health. Based on the 14 major observational studies of healthy lifestyle we can impute the following benefits to those who adopt all 5 healthy habits:

       This lifestyle strategy could reduce your overall risk of dying (all-cause morality) by 40-65%. The fact that it leads to 36-64% reductions in ALL cancers plus a 40-65% reduction in all cause mortality means that the adoption or maintenance of a healthy lifestyle is the SINGLE MOST EFFECTIVE THING YOU CAN DO TO REDUCE YOUR PERSONAL RISK OF CANCER.  And it's really pretty easy and inexpensive to promote. Just hand out my pretty little flyers (above) and take a minute or two to talk about it. It beats all the mammograms, FOBTs, sigmoidoscopies, colonoscopies, Pap smears, and colposcopies put together at far, far less cost. What's to think about? This is a no-brainer.

     Do something sensible to prevent cancer today!

Here is your strategy:

ADDENDUM:  I will be at the Portola clinic on Saturday, April 4th. I hope to see some of you there.

References:

1.  Wegwarth O et al. Do physicians understand cancer screening statistics? A national survey of primary care physicians in the United States. Ann Intern Med 2012; 156: 340-9.

2. Editorial: What we don't know can hurt our patients: Physician innumeracy and overuse of screening tests. Ann Intern Med 2012; 156: 392-3.

A VIEW FROM THE OFFICE

HOW DO YOU KNOW IF SOMEONE IS COMPETENT 

TO MAKE A DECISION FOR HEALTH CARE

    The determination of whether someone is competent to make their own decisions is very difficult. Over the last 20 years numerous experts have taken their best shots at designing algorithms or questionnaires to help primary care physicians to make this determination with relatively little success. In this article I am sharing the result of a recent study of the different instruments that have been developed for this.(1) The instrument that has been the best tested and validated is called the "Aid to Capacity Evaluation." A copy of this form is available as a free PDF file online and includes instructions for use.
     My reason for including this information in a consumer blog is because it is often too late to be practical if the family waits for a physician to do the evaluation. These kinds of decisions are best anticipated. Most relatives and friends of someone whose health is deteriorating to the point of being unable to make a quality decision for themselves are aware that in some areas of life the patient should not be left on his/her own. Reviewing this form allows family members to walk through the steps to assess the different areas of capacity/competence. Once family members get to the point of thinking this may be helpful, it is time to formally prepare a document expressing the patient's wishes for end-of-life care or other critical health decisions. Ideally, this can be done before the patient becomes incompetent across the board.
     The legal background for this issue is that all adult patients (over the age of 18) are presumed by law to be competent. Even if a patient has severe chronic disease, even chronic mental illness like schizophrenia, the initial legal presumption is that they are capable of making their own decisions. In general, psychiatric patients cannot be compelled to take their medications. Psychiatric patients are presumed capable of determining whether they want a surgical procedure or not, even if a "reasonable" person of the same age would reach a different conclusion. They are not required to make the "correct" decision (whatever that is). The decision just needs to reflect a minimal understanding of the problem or issue, a clear and consistent preference (whether logical or not), and not be obviously impaired by other illness, particularly depression or delusions. A person with a chronic mental illness such as schizophrenia or dementia can be quite capable of expressing a meaningful decision about a surgical treatment or diagnostic test even when they care clearly incompetent to manage their own finances, hygiene, or usual activities of daily living. So to say a person has dementia, by itself, has no specific implications for their capacity to make medical decisions.
     An individual can be deprived of their right to make their own decisions only by an authorized police official (e.g., for a 5150 Psychiatric hold for 72 hours to perform a formal evaluation of competence and safety) or judicial determination (a competency or custodianship hearing). The police action is only a temporary one. The judicial action obviously requires significant time to go through the steps of finding an advocate, reviewing relevant documents and witnesses, and scheduling a formal hearing on the court docket. As a practical matter, the legal system is simply not capable of responding quickly enough to assist in making decisions about an individual's competency to be helpful when it is needed. That is why it is so important that family members or anyone who takes part in the care or support of a patient proactively address these issues well in advance of acute illness or the need for something like nursing home placement when the patient says s/he does not want to go.
     I believe that the form below is very simple and clear to follow. A lay person can walk through the appropriate evaluation process for someone s/he is concerned about. It is so much better to have this process addressed early in the course of chronic illness, even by a lay person, than it is to wait until the situation is urgent and then try to have a doctor do it. Legally a doctor cannot make the determination that someone is not competent to make a decision. If an advance directive is not in place, then the legal process will have to be invoked.

THE AID TO CAPACITY EVALUATION

[Record observations that support your score in each domain, including exact responses of the patient.  
Indicate your score for each domain with a circle.]


1. Able to understand medical problem 
      (Sample questions: What problem are you having now? What problem is                
        bothering you most? Why are you in the hospital? Do you have (name
        problem)?)            

             YES                   NO                UNSURE
                                                                                            
        Observations:  ______________________________________________  
   
__________________________________________________________

2.  Able to understand proposed treatment 
     (Sample questions:  What is the treatment for [your problem]?
       What else can we do to help you? Can you have [proposed treatment]?

             YES                   NO                UNSURE
         
       Observations: ______________________________________________
        _________________________________________________________

3.  Able to understand alternative to proposed treatment (if any)
     (Sample questions: Are there any other [treatments]? What other
       options do you have? Can you have [alternative treatment]?

             YES                   NO                UNSURE                 UNDISCLOSED


       Observations: ______________________________________________
                                                                                                                                                   
      __________________________________________________________

4. Able to understand option of refusing proposed treatment 
      (including withholding or withdrawing proposed treatment)
       (Sample questions: Can you refuse [proposed treatment]? Can we stop
        [proposed treatment]?

             YES                   NO                UNSURE


        Observations:  _____________________________________________
        _________________________________________________________

5. Able to appreciate reasonably foreseeable consequences of
     accepting proposed treatment
(Sample questions: What could happen to you if you have [proposed
 treatment]? Can [proposed treatment] cause problems/side effects?
 Can [proposed treatment] help you live longer? )

             YES                   NO                UNSURE


       Observations:  _____________________________________________
        _________________________________________________________

6.   Able to appreciate reasonable foreseeable consequences of 
        refusing proposed treatment (including withholding or 
        withdrawing proposed treatment) 
        (Sample questions: What could happen to you if you don't have [proposed
        treatment]? Could you get sicker/die if you don't have [proposed treatment]?
        What could happen if you have [alternative treatment]? (If alternatives are available)

             YES                   NO                UNSURE


       Observations:  _____________________________________________
        _________________________________________________________

(Note: for questions 7a and 7b, a “yes” answer means the person’s decision is affected by depression.)


7a. The person's decision is affected by depression
       (Sample questions: Can you help me understand why you've decided to
        accept/refuse treatment? Do you feel that you're being punished?  Do
        you think you're a bad person? Do you have any hope for the future?
       Do you deserve to be treated? )

             YES                   NO                UNSURE


      Observations:  _____________________________________________
        _________________________________________________________

7b. The person's decision is affected by psychosis
       (Sample questions: Can you help me understand why you've decided to
        accept/refuse treatment? Do you think anyone is trying to hurt/harm
        you? Do you trust your doctor/nurse? )
             YES                   NO                UNSURE


       Observations:  _____________________________________________
        _________________________________________________________


Overall Impression 


Definitely capable     Probably capable     Probably incapable     Definitely incapable 


Comments:
(for example: need for psychiatric assessment, further disclosure and discussion with patient
or consultation with family)

The initial ACE assessment is the first step in the capacity assessment process.  If the ACE is definitely or probably incapable, considerable treatable or reversible causes of incapacity.  Repeat the capacity assessment once these factors have been addressed.  If the ACE result is probably incapable or probably
capable, then take further steps to clarify the situation.  For example, if you are unsure about the person’s ability to understand the proposed treatment, then a further interview which specifically focuses on this area would be helpful.  Similarly, consultation with family, cultural and religious figure and/or psychiatrist,
may clarify some areas of uncertainty.

Never base a finding of incapacity solely on your interpretation of domain 7a and 7b.  Even if you are sure that the decision is based on a delusion or depression, we suggest that you always get an independent
assessment.

Time taken to administer ACE:   ______ minutes
Date:  ______________
Assessor: _______________________________

COMMENT: You will notice that the form records its conclusion in a "fuzzy" way--"probably" vs. "definitely" capable or incapable. This is as good as it gets. If you need to seek more clarity, you seek more input (additional evaluations using the same instrument from other people who know the patient well or other professionals with special expertise in these kinds of assessments. Just remember that no expert is qualified, on his own, to make a determination that a patient is not competent to make a medical decision. In the end, only a court can do this if the patient has not previously appointed a "health care proxy" to make these decisions when s/he should become no longer able.


References:


1. Sessums LL, Zembrzuska H, Jacksoni JL. Does this patient have medical decision-making capacity? JAMA 2011; Jul 27; 306(4): 420-7.

Reliable Quick Answers to Medical Questions on the Web

A VIEW FROM THE OFFICE

RELIABLE QUICK ANSWERS TO MEDICAL QUESTIONS ON THE WEB:

WELCOME TO HEALTHTAP!

     Two weeks ago I read in the Sunday New York Times an article about a web-based consumer information service called "HealthTap." It invites both consumers and physicians to join. Consumers ask the questions. Volunteer physicians provide the answer. HealthTap started its Web site last May. It has signed up more than 9,000 physicians and is adding 100 a day. The site does not carry advertising. "Users can follow particular doctors and topics of interest; new answers related to these are displayed in an “activity feed” shown when users log on to the site. The site offers a peer-based reputation system of its own devising. Next to each answer, users see the number of doctors who agree; with a click, they can see who the approving doctors are, as well as something that HealthTap calls a “reputation level,” which is built by accumulating HealthTap awards, “Agrees” from fellow physicians and other measurable activities at the site."  

Here is a screenshot from the patient side of the website:

Here is a screenshot from my physician side of HealthTap.

      Probably the strongest feature about this site for consumers is the ability to "follow" the opinions of certain physicians who give precise, clear, practical answer. [Some of the answers are indeed too brief to be helpful.] You will be notified of new responses for the physicians that you follow. [You are certainly welcome to follow me.] 
     For the physicians it is an excellent opportunity to reach out to patients outside of the office and to do good for the community (in fact, a very big community--the whole internet!). It can also sharpen physician skills in communication. Trying to be helpful, succinct, and clear in only 400 characters [the limit for each answer] is a good mind-sharpening challenge. I find it an excellent way to both learn something and be useful in the few minutes between patients in the office. It is always informative to see the kinds of things that patients are concerned about but may not bring to the office. Some of the questions are distinctly challenging and send me to do online research so that we can both be educated at the same time. In my opinion, any way that a doctor can make more contact with the community is a good thing. 
     HealthTap offers a very sociable and time-efficient way of getting in touch with a treasure trove of physicians. Try it!


A NOTE TO MY FRIENDS IN PLUMAS COUNTY:  I will be returning to do a Saturday morning clinic on March 3rd at the Portola Clinic. The plan is for me to come back for a clinic session on the first Saturday of each month. I look forward to seeing you there.

Dr. Colin Kopes-Kerr, MD

ARE THE TESTS YOU ARE GETTING WORTHWHILE?

A VIEW FROM THE OFFICE

ARE THE TESTS YOU ARE GETTING WORTHWHILE?

     An important new article in the Annals of Internal Medicine urges physicians (and ultimately their patients) to limit a lot of common testing based on the value to the patient (Will the test actually improve the patient's outcome?) and the cost to the system, which in the end we all pay.

     They have selected 34 tests as appropriate targets for reduced use. Here I will comment on the tests that I have seen most often used in Plumas County with little or no benefit to either the physician or the patient.

     

1. Bone Mineral Density Testing: The national guideline from the United States Preventive Services Task Force does not call for routine DEXA scanning of average risk women until age 65. As I have explained in a recent post here, new evidence shows that for average risk women with normal DEXA scans at age 65, they do not need another one for 15 years! I have seen many women who have been coming in for one every year or every other year.

    Even for women at high-risk or who have abnormal scans at baseline, there is little evidence to suggest any benefit to repeating the scans in less than 5 years. 

2. Lipid panel testing. Many people come in for a lipid panel every year or sometimes even more often. The recommendation for asymptomatic health persons is to have this done every 5 years starting at age 30. If you're not on any treatment, there is no need to repeat more often than this. Even if you are on treatment, a British Study (The British Heart Study) has shown that once you select the treatment and just continue the medication, as long as there are no side  effects, you don't need to recheck the lipid panel or adjust the dose (ever). You can still get exactly the same 33% reduction of all-cause mortality and cardiac events that you do when you get all the extra tests and medication adjustments. Why go through all that extra trouble and expense?

3. Pre-operative testing: Many surgeons, almost all, in fact, want patients to get an elaborate set of blood tests, urinalysis, chest x-rays, and ECGs before they have any kind of elective surgery. I recently had occasion to undergo an upper GI endoscopy twice. When I had it done here, the Portola hospital did not require any specific testing, but when I need to have the endoscopy repeated at Saint Mary's they routinely threw in a requirement for blood counts, chemistry panel, coagulation tests, urinalysis, chest x-ray, and ECG. This was more than a little irksome since they did not inform me of this in advance, and because I knew it was ultimately pointless. All tests were in fact normal, and I lost both time and money. This report strongly advises against all forms of routine preoperative testing for average risk adults before any general elective surgery.

      COMMENT: Of course, this is usually not a decision you make yourself. Your surgeon makes it. But you can, and should, ask why. And don't be afraid to bring them a copy of this article and the reference supplied below to encourage them to think twice about ordering unnecessary tests.

4. Colon cancer screening: This group also takes a strong stand against any routine colon cancer screening after the age of 75. You can get it, if you really want it, but there is no evidence of systematic benefit at this age.

5. Cervical cancer screening: There is no reason that a healthy 65 year old woman needs additional Pap smears as long as she has had regular screening up to age 65 (every 3 years) and they have all been negative over the last 10 years.

6. Prostate cancer screening: This group takes only the position that men over age 75 should not be screening for prostate cancer with the PSA test. I encourage the more straight forward recommendation of the United States Preventive Services Task Force--that no man, at any age, should be routinely screened for prostate cancer with a PSA test.

     Here I describe only a handful of the 34 tests covered in the report. But these are the most common ones. If we learn to use these tests correctly, we will solve a lot of the problem. A patient should: "Think not what these tests can do for the physician, but what these tests can really do for you!"

REFERENCE: Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine 2012; 156:147-9.

Who Knows What Their Blood Pressure Is?

A VIEW FROM THE OFFICE

WHO KNOWS WHAT THEIR BLOOD PRESSURE IS?

     Everyone knows that blood pressure is one of the most important variables in health. Uncontrolled blood pressure leads over many years to strokes, heart attacks, peripheral vascular disease, aneurysms, and heart failure. 

     Most people know that the recommended level of blood pressure is to have the upper number (systolic pressure) be less than 140 mm Hg, and to have the lower number (diastolic pressure) less than 90 mm Hg.  The systolic number is the level of pressure achieved in the arteries when the heart contracts, and the diastolic number is the level of pressure in the arteries when the heart relaxes in between beats. Of these two numbers the upper systolic pressure number is the more important.

     So, what's your blood pressure? How would one know? Most people know (if they can remember it) their blood pressure from a visit to the doctor's office. But is the number you get from the doctor's office the correct number? A large number of new studies suggests that it is not. 

     First, there is the factor of "white coat hypertension," which by now most of my patients seem to know about; this is when your blood pressure is transiently elevated because one may feel somewhat nervous or anxious about going to the doctor. Pain is another factor that will elevate the blood pressure in a doctor's office. 

     A second factor is that in the busy flow of doctors' office practice, the correct technique for measurement may not be employed. According to the experts, the proper way of measuring blood pressure is to check it after at least 5 minutes of quiet sitting waiting for the doctor. In most practices, the nurse checks it as soon as or right before leading a patient into the exam room, which is not optimal. Usual practice, however, is for the doctor to re-measure any high readings after 5 minutes has passed. If the patient has been waiting for 45 minutes to an hour for the doctor, however, the blood pressure may be elevated just due to aggravation.

     The expert recommendations also call for the blood pressure to be taken while the patient is sitting upright in a chair with his/her back supported and the feet flat on the floor. Checking the patients' blood pressure while they are sitting on the exam table with their backs unsupported and their feet dangling in the air is not consistent with these standards, but it is, in fact, the most common way blood pressure is measured in the office. 

     Other problems that occur in doctors' office are the use of an incorrect cuff size (cuffs that are too small tend to elevated the pressure readings) due to an inexperienced staff person. Also, the blood pressure devices themselves can get banged up, dropped, or just old and no longer give accurate readings.

     For all of these reasons and some others a single blood pressure measurement in a doctor's office is simply not a reliable indicator of the true blood pressure.  A new study in the Annals of Internal Medicine* concludes that: "Physicians who want to have 80% or more certainty that they are correctly classifying patients' BP control should use the average of several measurements. Hypertension quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients." The data from this study show clearly that patients could not be classified as having BP that was in or out of control with 80% certainty on the basis of a single clinic systolic blood pressure measurement anywhere in the range from 120 mm Hg to 157 mm Hg. The investigators recommend obtaining an average of several measurements and feel that the optimal number of readings to average is 5 to 6.

     Based on several other studies it now appears that the optimal way to measure and manage patients' blood pressure is for the patients to monitor their blood pressure at home with the increasingly accurate and inexpensive automatic measuring devices that are now available. This is actually better than using the numbers obtained in the doctor's office, even if the doctor does go through the trouble to average 5-6 readings. (Most don't!)

     I advise patients not to be obsessive about it. (This tends to raise your blood pressure.) There is no point in checking it several times a day; nor is there any need really to check it more than twice a week. I tell most patients that once a week is fine. Ideal management calls for patients to bring into their doctor a list or log of at least 5-6 recent measurements so that a reliable average blood pressure may be obtained. In the near future, I expect that the makers of the blood pressure devices will computerize and memorize hundreds of measurements so that a continuous average is reported automatically. Until then we'll just have to obtain an average the old fashioned way--add up all the numbers and divide by the number of readings. The improvement that should come soon to doctors' offices is that electronic medical record system will begin to automatically calculate the average of multiple physician readings.

     It is certainly clear to me in my practice that blood pressures vary quite erratically for many patients, and I only make my decisions on blood pressure medication adjustment based on an average blood pressure. I recommend that all patients who have been told that they have high blood pressure get themselves a home blood pressure measuring device (now available for less than $50). If they can bring in at least 5-6 readings from home every 4 months we will really be able to do a great job of managing hypertension.

* References: (Powers BJ et al, "Measuring blood pressure for decision making and quality reporting: Where and how many measures?" 2011; 154: 781-788; editorial by Appel LJ et al., "Improving the measurement of flood pressure: Is it time for regulated standards?" 154: 836-7) 

STUDY CALLS FOR REDUCED USED OF BONE MINERAL DENSITY TESTING

THE VIEW FROM THE OFFICE

STUDY CALLS FOR REDUCED BONE MINERAL DENSITY TESTING FOR OSTEOPOROSIS

     It is a long-standing problem that there has been little or no hard evidence to guide the decision on how to screen for and prevent osteoporosis. The United States Preventive Services Task Force has gone ahead and endorsed it despite the lack of evidence. The recent "Welcome to Medicare" guidelines will pay for it every 2 years. I have long been opposed to this test because it is expensive and because no one is sure how to use it. The vast majority of its value lies in the first screening with a bone density test technique, and, simply stated, none of the numerous experts has any real idea of if and when to repeat the test for patients who are normal, for patients who have osteopenia, and/or for patients who have actual osteoporosis.  My recommendation has been for everyone simply to exercise regularly and take the recommended amount of daily calcium (1000 mg/day) and vitamin D (800 IU/day).

     Until now, that is. A study just published today in the New England Journal of Medicine (Gourlay ML et al. NEJM 2012; 366: 225-33) answered the question. They studied a group of 4957 women, 67 years of age or older, who had normal initial bone density or had only mild osteopenia on initial testing; these women had no history of fracture of the wrist, hip, or spine and were not taking medications like Fosamax for osteoporosis. They analyzed their bone density at 2 years, 6 years, 8 years, 10 years, and 16 years. They divided their subjects into 3 subgroups:  a group with normal bone density and a group with osteopenia (mild, moderate, and severe) and analyzed the time until progression to frank osteoporosis. 

     The estimated time for women with normal bone density to progress to osteoporosis was 16.8 years. The estimated time for women with mild osteopenia to progress to osteoporosis was 17.3 years, for women with moderate osteopenia, 4.7 years; and for women with severe osteopenia, 1.1 years.

     The investigators conclude that the appropriate re-screening interval in which to repeat any type of bone density testing was 15 years for either normal women or women with mild osteopenia. For women with moderate osteopenia, rescreening should take place in 5 years, and for women with advanced osteopenia, rescreening should take place every years.

     This recommendation is clear and firmly evidence-based. A majority of the currently carried out rescreening with bone density tests, usually on an annual or biannual basis, should cease. Live a healthy lifestyle, exercise, take your calcium and vitamin D, and say your prayers--"Lord, may I live another 15 years."  Then you can get your repeat bone density test and derive some benefit from it. The rest is waste for women with normal bone density or only mild osteopenia.

Why Am I Reading This?

THE VIEW FROM THE OFFICE

WHY AM I READING THIS?

            Before we answer that question, I want to you to read and remember these 4 words.

APPLE            MR. JOHNSON        CHARITY                  TUNNEL

            Moving on. Now your second task, before I let you go is to:  DRAW A CLOCK THAT SAYS 11:15 am.

            The question I would like to discuss in this essay is:  When is poor and declining memory significant?  As we each experience it, do we also need to worry about Alzheimer’s disease? Fortunately, the answer is mostly NOT. But let me explain.

            We’ll start with consideration of a case that was recently described in the New England Journal of Medicine (1):  A 77-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep tract of appointments and recent telephone calls. The process has been insidious. She lives independently in the community and drives a car. She pays her own bills and maintains good hygiene and an attractive appearance.

            This case is an example of what is called “mild cognitive impairment.” To put this into perspective it is worth noting that only 1% of all elderly patients will be fortunate enough to experience NO cognitive decline. For the rest of us, we have to expect some. In fact, 10-20% of us who are over the age of 65 will experience this same condition—mild cognitive impairment.  The good news is that, of this 10-20%, only 10% will go on to develop Alzheimer’s disease.  As we get even older, among persons aged 70-89, 11%  will experience mild cognitive impairment; 4.9% will develop Alzheimer’s disease.

            A more recent New England Journal of Medicine published another case, one that I feel can lift some our anxieties if we are among the unfortunate few who develop Alzheimer’s disease.(2) Here is Michael Donohue’s story.

            "At the age of 69, a year after retiring from his practice as a Minneapolis trial lawyer, Mike Donohue noticed his driving skills deteriorating. His wife persuaded him to undergo a simulated driving examination. 'I flunked it miserably,' he recalls. Donohue consulted his physician, underwent tests, and learned that he had early Alzheimer's disease. His doctor told him, 'Take this medication, call me in a year, and call the Alzheimer's Association.'"

    Try to imagine for a moment your reaction to both this information and this manner of care.

    Fortunately, this patient did not resign himself to such implied pessimism. He called the Alzheimer's Association's local office. He volunteered there, where he met other people with early-stage disease, helped to launch some programs for them, and now, 5 years later, serves on an advisory committee about services for people with newly diagnosed Alzheimer's disease and their family. Recently, he and several friends with the condition entered a new program where they’ll serve as mentors for others with a new Alzheimer's diagnosis.

    'There's a great loneliness out there, Donohue says. 'It comes from the stereotype that we’re all drooling in a corner,' even though most people living with the diseases are in community settings rather than nursing homes. 'My cognition remains good, and until recently my memory remained reasonably good. These friendships are so important to me.' 

One of  the pieces of major good news amid the spreading epidemic of Alzheimer’s disease is that we are having larger numbers of people survive and function well with a meaningful social life. The modern Alzheimer’s disease is not the end of the road. This is a more important fact than that research so far has failed to identify any medications that truly make a big difference for persons with Alzheimer’s.

Let’s return to our original point. There is mild cognitive impairment and there is Alzheimer’s disease. Where in this spectrum , for the 99% of us not destined to have no cognitive impairment at all, do we fit in with our ordinary failings of memory. What do you forget?  Here are some typical examples.

•         Difficulty with word finding (we all do this)

•         Difficulty with recalling names (most of us do this at least some of the time)

•         Forgetting why you went into a room (we all do this)

•         Forgetting where you put something (we all do this)

•         Forgetting appointments (this is a little bit more severe forgetfulness)

•         Forgetting telephone calls (this is a little bit more severe forgetfulness)

•         Forgetting recent events that you participated in (this is quite severe forgetfulness)

So assume you or I are doing at least the first four items a lot. What does it mean? Are they going to take us away in the morning? Fortunately not. The lesson here is that this is the new normal. When 99% of the population repeatedly encounter this kind of experience, on a statistical basis, it is clearly normal behavior.

So, when should I worry?

There are some simple cues.

First of all, if you’re aware enough to be concerned about how memory may be interfering with your overall function, you probably don’t have Alzheimer’s. It is characteristic of the global cognitive defects in Alzheimer’s that the patient is not explicitly aware of the number and nature of the defects and the degree of impairment. Patient’s with Alzheimer’s don’t go on their own to the doctor to ask about their memory. Friends or family members bring them and the friends or family members ask the questions about memory and provide the behavioral details. On the other hand, patients with mild cognitive impairment frequently go to the doctor to express their concern about their slow decline from their peak mental performance. The question they ask the doctor is, “Is this anything to worry about, Doc?”  If the patient is asking this question, then the doctor can generally be very comfortable in say, “Nope. This is just part of the new you (and me, I might add).”

Remember the little tasks I asked you to do right at the beginning of this essay. This would be a good time to take a look at the clock you drew. If you drew a clock with a full closed circle, 2 hands, one longer than the other, centered in the middle of the clock, 12 digits, each at least in the appropriate quadrant, and had the hands at the right time, you’re good. You don’t have Alzheimer’s disease.                                                         

 

Figures 1 and 2: This clock passes the test. All the other clocks below do not.

Why can we say this? It is because Alzheimer’s disease affects more than simple memory. One of its prominent effects is impairment or destruction of our sense of space, which is what, is tested with the clock test. The inability to pass this test is one of the earliest signs of Alzheimer’s disease. It’s one you can use yourself for someone about whom you may be concerned. (Just ask them to draw a clock that shows 11:15 a.m.) Generally, as long as all the little cognitive defects are only in the area of memory, and not in the realm of visuospatial sense, motor skills, or coordination, that the worst we are talking about is mild cognitive impairment, which all your friends have too. So don’t feel so bad.

Another way to recognize whether it is more than just mild cognitive impairment is to think about how you function in your life. Can you adequately do all your routine daily tasks? People with mild cognitive impairment can, no matter how irritated they may be at forgetting some of the details. People with Alzheimer’s can’t. They just can’t.
Here are some of the tasks that patients with Alzheimer’s often cannot do:

1.      Write checks, pay bills, keep financial records

2.      Put together tax records, business records, or personal papers

3.      Shop alone for clothes, household necessities, or groceries

4.      Play a game of skill or work on a hobby

5.      Heat water, make a cup of coffee, or remember to turn off the stove

6.      Keep track of current events

7.      Pay attention to a TV program, book, or magazine and report the story

8.      Remember appointments, special family events, holidays, or medications

9.      Drive out of the neighborhood safely in a car, or plan how to use a bus system.

So, if you’re currently doing all these functions OK, you have nothing to worry about at this time. You still, however, will forget things.

OK. So now you’re at the point of accepting that you have some memory lapses and probably have mild cognitive impairment. What do you do about it? First, don’t worry so much about it. Second, become proactive. There’s a lot you can do.

The first proactive step is to get active. Exercise prevents cognitive impairment and a host of other problems too. "Recent epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining cognitive health. This was studied in more than 2800 female health professionals over the age of 65 with at least 3 vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile.  A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit." (3)

      My recommendation, following the US national exercise recommendation, is to engage in at least 150 minutes of exercise, at least brisk walking, each week—broken up in any way you want to do it.

Second, do mental exercises regularly. In a recent comprehensive review of all studies of various kinds of mental exercises “The data showed statistically significant improvements at the end of training on 44% of objective measures of memory and statistically significant improvements after treatment were obtained on 49% of subjective measures of memory, quality of life, or mood.” (4)

And, of course, I am going to recommend eating healthy—5 servings of fruits and vegetables a day, lots of grains, small (4 oz) portions of red meat, and a regular multiple vitamin with calcium and vitamin D.  All this is with a view to keep your BMI (body mass index) below 30.
            Of course, you’re not going to smoke because smoking leads to narrowed blood vessels, and, if you care about your memory, you want your precious little brain cells to get every ounce of circulation they can.
            Finally, carry out a plan for some time spent relaxing every day. Relaxing can be going for a quiet walk, time with a pet, reading, dancing, reading the Bible, watching a good movie  (no sex, no violence, no commercials), of doing something creative—gardening, painting, writing, interior design, refurbishing an old car, whatever gets you in your groove. Memory cells like it when you relax and turn off all the other chatter and clutter of your daily life.
Actually, this advice is rather simple. You’ve heard it before. It’s no more than the Formula for Health. Give it a try!

By the way, if you can still remember     APPLE           MR. JOHNSON        CHARITY

TUNNEL, you’re doing pretty good.

Colin Kopes-Kerr, MD
December 1, 2011

References:
1. Petersen RC. Mild Cognitive Impairment. New England Journal of Medicine 2011; 364: 2227-34.
2. Okie S. Confronting Alzheimer’s Disease. New England Journal of Medicine 2011; 365: 12: 1069-72.

3. Middleton LE et al. Activity energy expenditure and incident cognitive impairment in older adults. Archives of Internal Medicine 2011; 171(14): 1251-7.

4. Jean L et al. Cognitive intervention programs for individuals with mild cognitive impairment: Systematic review of the literature. American Journal of Geriatric Psychiatry 2010; 1