By PAULA SPAN
Philippe Huguen/Agence France-Presse — Getty Images
Medical groups have developed separate clinical guidelines for most of these diseases, but when doctors simply follow those recommendations, treating one disease can worsen another.
Drugs interact in unpredictable ways.
Side effects make patients miserable, even if their lab results look better.
The drugs an endocrinologist might prescribe to strictly control a diabetic patient’s blood sugar (and very low blood sugar doesn’t benefit the older patient) can cause problems for people who also have kidney disease, for example.
Opioids to control arthritis pain can impair cognition.
The examples are probably infinite.
“There’s not a good understanding of how to manage all these problems simultaneously,” said Dr. Matthew McNabney, a Johns Hopkins geriatrician and the American Geriatrics Society’s chairman of clinical practice. “Not only is it difficult and complicated, but it’s often harmful.”
Dr. McNabney led a panel of 11 geriatrics experts — including an ethicist, a nurse practitioner and a pharmacologist — who began meeting more than a year ago to come up with a better approach to treating “multimorbidity” (medspeak for having several chronic illnesses) in older adults.
Initially, the group focused on reorienting other doctors, who often have “a single-disease focus,” Dr. McNabney said.
The resulting 25-page document, “Guiding Principles for the Care of Older Adults With Multimorbidity,” appeared in The Journal of the American Geriatrics Society last week, and panel members have been presenting their findings at professional meetings around the country.
But not long into their discussions, the group also recognized the need to bring older adults themselves — their experiences, values and priorities — into these decisions.
They’re the ones living with all these conditions, after all, and trying to follow all of the sometimes competing advice about what to do, what to test for, what to take.
“You can sense, talking with your patients, how overwhelming and confusing it all is,” Dr. McNabney said.
So the group also drafted a tip sheet for patients and caregivers, “Living With Multiple Health Problems: What Older Adults Should Know.”
You can find it on the Web site of the society’s Foundation for Health in Aging; you may also spot it at doctors’ offices and clinics in coming months.
It takes a very patient-centered approach, to adopt the current jargon. “The health care approach has historically been to tell patients what to do, what benefits them,” Dr. McNabney said.
“We need to ask, ‘What do they want? How can they tell me what they want?’ Not just tell them, ‘This is what the guidelines say.’”
The tip sheet’s suggestions sound common-sensical: Patients and family members need to get as much information as they can about treatments, understand the inevitable trade-offs between benefits and risks, make sure health professionals understand their priorities.
The guide even acknowledges what many patients don’t realize: There’s scant research on how older people respond to certain treatments, in part because they have often been excluded from clinical trials.
Maybe being able to walk without dizziness is more important to an older patient than somewhat prolonged survival.
Maybe less frequent blood testing is worth the greater freedom, untethering an older person from constant clinic visits, even if that means less stringent monitoring.
“A patient may need to honestly tell their health care provider, ‘I can’t do this,’” Dr. McNabney said. “’I can’t take 18 medications. I’m not doing it.’” Eighteen meds? “It’s not an extreme example,” he said.
Questioning treatments and prescriptions, knowing and expressing one’s own needs, becoming a partner in decisions — these won’t come easily to some older people.
Their boomer children, the ones who grew up with “Question Authority” bumper stickers, will often need to serve as record-keepers, questioners, interpreters — as many of us already do.
Plus, how many doctors have, or can develop, the communicative and collaborative personality to operate this way? You hope they are reading the panel’s full report, about “assessing the complexity and feasibility of treatment options,” among other things, as their patients are reading the tip sheet.
Still, this approach represents a potential step toward rethinking the way older people and their doctors reach medical decisions.
“It feels right,” said Dr. McNabney.
Since he began work on the project, “I’ve had different conversations with patients,” he said. “I feel a pretty dramatic turn.”
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”
Fuente: The New York Times
Fuente: The New York Times