Last month at the annual meeting of the American Geriatrics Society, I heard an interesting presentation on the value of reducing a certain class of medications with potential side effects in people with dementia. Most geriatricians, myself included, understand the value of reducing such medications and have significant experience seeing the clinical value in such medication reductions. What was interesting to me is that we don’t have any data on improved cognitive function in relation to such medication reductions. This got me thinking. There are a lot of clinicians who scoff at the benefit of cholinesterase inhibitors, the most commonly used class of medications used in the treatment of Alzheimer’s disease. To many, these medications demonstrate only a “small” though statistically significant improvement in cognitive test results. I realized that we can’t have it both ways. If we can’t even show a statistically significant improvement in cognition with the reduction in medications, how can we undervalue an actual improvement in cognition when we evaluate other medications used to treat Alzheimer’s?
Perhaps we’re looking at all of this the wrong way. Clinical trials are set up to evaluate specific markers, whether they be scores on cognitive function tests, cholesterol levels, or mortality. What about the patient? I’ve had patients with Alzheimer’s disease who’ve begun taking a cholinesterase inhibitor return for follow-up and demonstrate absolutely no improvement on a standardized test, but their family is ecstatic over their dramatic “improvement”! What do I tell them? That there is no improvement? Perhaps I didn’t have a test to measure what they saw. Perhaps the clinical trials didn’t study the right measures. Do I ignore the family’s impression of the “clinical” improvement from their perspective?
When I was a medical student, I realized that the physician taking care of my grandparents was overmedicating them. As a budding geriatrician, he had them on medications that were definitely not recommended nor had any sound basis in the literature. I could never get my grandparents to change doctors, as they loved their doctor. They ultimately lived fairly long lives, and I realized that the love that they had for their doctor might actually have had more to do with their overall clinical condition than the impact of taking the “wrong” medications. There is definitely a placebo effect attached to a patient who believes in their doctor. On the other hand, a very smart doctor who is unable to connect with their patient might very well not achieve the desired outcomes. The marketplace continues to demonstrate the value that patients put on the doctors that they “believe” in. Perhaps we as clinicians need to learn to take this into account.
What’s important to patients? What’s important to families? As physicians, we can get locked into trying to achieve certain numerical goals. Can we get the patient’s blood pressure down to a particular number? Can we reach a certain cholesterol level? What about a score on a mini-mental status exam? Does any of this really matter to the patient or their family? As a young geriatrician, I learned the importance of knowing what mattered to my patients and their families. This information was critical to developing a patient-centered plan of care. It rarely involves specific numerical values. It’s usually about the key tenets of geriatric medicine. Those are function and quality of life. Is my patient able to walk their dog? Can they read a good book? One patient’s priority may mean nothing to another patient. There’s only one way to find out.
I often tell medical students and residents about the importance of getting a good social history from older patients. This means learning about their past. What kind of work did they do? Did they serve in the military? What are their hobbies? What makes them happy? There are multiple reasons for knowing this information. The first is obvious. In order to know what’s important to a patient, one has to get to know that patient. The second is less obvious but just as important. One of the joys of being a geriatrician is getting to know some marvelous people who have accomplished a lot of things. If we are to make a difference in the lives of older people, we have to fully enjoy and appreciate the work that we do.
If you have a loved one who is in the hospital, make sure that the health care providers who care for them get to know them as human beings. If you know that a parent is seeing multiple physicians and receiving various treatments, find a way of going along on some of these doctor visits and make sure that the doctor knows your parent’s priorities. If you have a family member who is going through training in the health care field, send them this article. There is only so much that we can learn in books or journals. In fact, much of the money that is spent on caring for older people is not supported by research or medical literature. We are a long way from reaching a point when this information will be available. Until then, we cannot forget that there is still an art to caring for older patients.