How older patients want to discuss health concerns

Credit: CC0 Public Domain

Nancy Schoenborn, M.D., assistant professor in the Department of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine, and colleagues went straight to the source and conducted three qualitative studies that put older adults at the forefront in order to gain a better understanding of if, and how, they prefer to discuss various health topics.

Let's Talk About Life Expectancy … or Not?

11 may 2018--In a small group study published in November 2017 in the Journal of the American Board of Family Medicine, researchers interviewed 40 older adults on how and when they preferred to discuss life expectancy with their primary care doctor. Schoenborn and team found that 32.5 percent of participants never wanted to discuss their life expectancy, 35 percent were open for discussion if expectancy were longer than one year, and 32.5 percent only wanted to have this discussion toward the end of life. Researchers also found that the majority of the participants, even the ones who never wanted to discuss, were open to be offered the opportunity to discuss life expectancy with their primary care doctor. This research also assessed how the discussion should be phrased when initiating the conversation about life expectancy with older adults.

Frailty Misconceptions

Due to the negative perception of the word "frail," older adults oftentimes overlook frailty as a medical syndrome. Researchers at Johns Hopkins Medicine conducted the first study in the United States that explored older adults' perception of frailty. It was published on Feb. 13, 2018, in BMC Geriatrics.
In a study of 29 participants, Schoenborn and team conducted focus groups with participants in various frailty statuses (frail, prefrail, nonfrail) and at different ages to evaluate existing ideas about frailty. Three major themes were established through this research. First, older adults' ideas about frailty were different from the medical definition of frailty. Many of the participants associated old age with frailty, but not everyone who ages develops the medical syndrome of frailty. Second, participants who were in the nonfrail or prefrail stages were strongly against discussing frailty with their physicians. However, frail participants were more open to having the discussion, but without being labeled "frail." Third, participants in all frailty statuses wanted information regarding prevention of frailty or ways to improve their current condition. This study provides insight on how older adults perceive frailty, but further research needs to be conducted to understand the proper way in which physicians should communicate about frailty.

To Stop or Not to Stop Cancer Screening in Older Adults

Screening for cancer in older adults with limited life expectancy can oftentimes be more harmful than beneficial. However, studies have shown that clinicians may feel uncomfortable stopping cancer screenings on patients with limited life expectancy. In a study published on Aug. 1, 2017, in JAMA Internal Medicine, Schoenborn and other Johns Hopkins researchers conducted interviews with 40 older adults who were 65 years or older to understand what this population thought about stopping cancer screening when life expectancy is limited. Researchers found that the participants were open to considering cessation of cancer screenings. In addition, their willingness to consider stopping screenings was dependent on trusting their physicians. The participantsexpressed that they would commend their physicians for even providing this option. This study showed that older adults do not use life expectancy as a factor when deciding to stop screening; they are more likely to use age and health status to make this decision. Even though life expectancy was not used as a factor when deciding, the group was divided on whether or not physicians should discuss life expectancy in the cancer screening conversation. Researchers also found that the way a physician words the message about life expectancy is very important during the discussion about cancer screening cessation.

More information: Nancy L. Schoenborn et al. Older adults' perceptions and informational needs regarding frailty, BMC Geriatrics (2018). DOI: 10.1186/s12877-018-0741-3

Nancy L. Schoenborn et al. Older Adults' Preferences for When and How to Discuss Life Expectancy in Primary Care, The Journal of the American Board of Family Medicine (2017). DOI: 10.3122/jabfm.2017.06.170067


Provided by Johns Hopkins University

Time for PAD to Come Out of the Shadows, Say GetABI Researchers

September 7, 2007 (Vienna, Austria) — Screening for peripheral arterial disease (PAD) should be performed routinely in all elderly patients and younger ones with cardiovascular risk factors, says Dr Curt Diehm (Affiliated Teaching Hospital, Karlsbad-Langensteinbach, Germany), who reported the results of the German epidemiological study on ankle brachial index (getABI) during the hotline session at the European Society of Cardiology congress today. And those found to have PAD should be treated in the same way as patients with coronary artery disease (CAD), he said, stressing that PAD patients are currently undertreated.
GetABI shows that PAD patients have a substantially increased risk of death — dying, on average, 10 years earlier than their peers — and that asymptomatic PAD patients are as much at risk as symptomatic ones, a vital fact that was not previously appreciated, he said. This latter point is very important; "This is the first time, in such a big study, that we have found no difference in mortality between asymptomatic and symptomatic PAD patients. We learned that PAD patients are usually asymptomatic, and we say in the guidelines that symptomatic patients have to be treated in a different way, but now we need to change the guidelines."
It is also imperative that the traditional view of PAD is changed, he said. "It used to be considered a disease of impaired walking distance, quality of life, or of amputation, or just a smoker's disease — so-called smokers leg," Diehm said. But they found that half of the patients who had PAD had never smoked: "Today we see this disease in a new light."
Mortality Almost Twice as High in PAD Patients
GetABI began in 2001 and included a total of 6,880 unselected patients who underwent ankle brachial index (ABI) testing by their primary care physician in 344 offices. The mean age of the patients was 72.5 years, 46% were past or current smokers, 74% had hypertension, 24% diabetes mellitus and 52% lipid disorders. The study is ongoing, but so far visits have occurred at baseline and six, 12, 36 and 60 months, and outcomes include death and severe vascular events — myocardial infarction (MI), coronary/carotid/peripheral revascularization, stroke or amputation due to PAD.
The study is of high quality, he added — being monitored, which is unusual for an epidemiological study, with the supervision of centers by experts. In addition, very few patients have been lost to follow-up — so far, the survival status of 99.5% of patients is known.
Diehm explained that in healthy individuals, the systolic blood pressure at the ankle should be at least as high as the pressure in the arm — ie, ABI should be 1 or greater. An ABI of < 0.9 indicates PAD, and an ABI of < 0.5 indicates severe PAD. In the study, asymptomatic PAD was defined as an ABI of < 0.9 and symptomatic PAD as ABI < 0.9 with intermittent claudication or PAD-related amputation or revascularization.
At the end of the five-year observation period, all-cause mortality was 23.9% in the 596 patients with symptomatic PAD (hazard ratio 1.8; p < 0.001), 19.1% in the 835 patients with asymptomatic PAD (HR 1.6; p < 0.001) and 9.4% in the 5390 patients without PAD. Even after adjusting for all other known cardiovascular risk factors, PAD has the best ability to predict future death, stroke or MI, Diehm said.
ABI: An Important Prognostic Factor — Simple, Quick, and Cost-Effective
Diehm said that although it has been known for five years that the lower the ABI, the greater the mortality, this study replicated the finding, indicating that ABI is an important prognostic factor.
Screening for PAD using ABI is very simple, he explained — measurement is quick, taking just eight minutes, the equipment costs only a few hundred dollars and nurses can be trained in its use "within 15 minutes." It is also highly specific for leg artery stenosis (> 50%) and highly sensitive (> 95%), he noted.
Diehm added that in this trial, they used the higher of the two values for blood pressure in the leg, as per the American Heart Association recommendations, "but in our opinion, this is absolutely wrong because you miss distal occlusions." He said if the lower of the two leg values is used, the prevalence of PAD comes out as much higher.
The new results illustrate the feasibility of using ABI in primary care, he says. "The good news is that the ABI test is not limited to expert use but can be performed in general practice. We need to implement ABI as a screening tool in GPs [general practitioners'] offices to identify high-risk patients, and we have to change this very quickly now."
Discussant of the study, Dr Don Poldermans (Erasmus Medical Center, Rotterdam, the Netherlands) added that it is imperative to screen PAD patients for disease in additional affected vascular beds. "Only a very small number of patients will have only one affected vascular bed. We are only seeing the tip of the iceberg," he noted. PAD patients should primarily be screened for aortic aneurysms, carotid disease and CAD, he said.
Treat PAD Patients as You Would CAD Patients
Diehm explained that PAD patients are severely undertreated compared with CAD patients. Most PAD patients should be on aspirin or clopidogrel, he said, plus a statin, beta-blocker and angiotensin-converting enzyme inhibitor. Sub-group analyses of large trials such as 4S with a statin, or HOPE-2 with an angiotensin-converting enzyme inhibitor, have shown the benefit of these agents in patients with intermittent claudication, he noted.
Despite this data, "many doctors are still afraid that beta-blockers are contra-indicated in this disease, which is absolute nonsense," Diehm said. Poldermans agreed wholeheartedly. "We have known since 1990 that beta-blockers are not contra-indicated in PAD. We all know that these patients will benefit from medical therapy, but we just don't do it. We need to keep medical therapy optimized."
Diehm concluded: "Family physicians can identify high-risk patients and initiate and maintain effective treatment in this large group. PAD patients should no longer be treated as second-class atherothrombotic patients — whether you are asymptomatic or symptomatic, you die 10 years early. A huge number of lives could be saved if patients with atherosclerosis would be identified with ABI and treated timely."
GetABI was funded through an unrestricted educational grant from Sanofi-Aventis. Diehm reported no conflict of interest with regard to present data.
European Society of Cardiology (ESC) World Congress 2007. Presented September 4, 2007.