June 17, 2015

The “Less Is More” Medical Campaign – Part 6

In the last blog, research was encouraged to discover harms when more medicine is practiced, but not when less medicine is practiced. This is one of the weaknesses of the 'less is more' medical campaign. This is why as a conclusion I would encourage you to read these two blogs, 1) a blog by Rocky Bilhartz, MD and 2) a blog by Leslie Kernisan, MD who rightly poke holes in the 'less is more' advocated so openly by many doctors.

Both use some statistics to show why and urge caution when thinking 'less is more' when dealing with the people over the age of 65. They also reference the lack of research that does not happen for people in this age group and Dr. Bilhartz says that population medicine (medicine for all ages) is not always what should be followed. He correctly states that many doctors only want you to believe that less is always more in public medicine. This takes the individual out of medicine and often harms the individual when the full medical history is not given the attention it deserves. They prefer that you should only do for the individual in medicine what is best for the entire group as seen from their perspective. And, they are wrong about that.

What does not make good sense is that even the few clinical trials that do include the people over the age of 65 are very restrictive of who is included in the trials. This makes many of them unreliable for use in comparing them for the average patient over 65. Many of the over 65 patients have multiple conditions (comorbidities) that affect their health and make healthcare more complicated. Some of these conditions or diseases can include – diabetes, multiple sclerosis, cardiovascular disease, hypertension, and many, many others. This is just one more reason that the individual medical history is important and should trump 'less is more' medicine. Granted this does not mean that more is always better, but the individual needs to be front and center and not lumped into the general population.

Dr. Kernisan deals with the topic of hypertension and blood pressure medications. She works with elder patients and often sees patients that are over medicated. In the process of reviewing patient history, she often discovers that patients are being prescribed more hypertension medications than necessary to manage blood pressure.

Even the study she uses was not totally accurate because the fall situation prior to the study was not disclosed. Dr. Kernisan says that people aged 70+ are more at risk of falls by being treated for high blood pressure than is recognized by clinicians and patients. She also notes that real-world Medicare beneficiaries often have more chronic conditions that the older adults who are enrolled in randomized trials of blood pressure treatment.

Dr. Kernisan does state that preventing or reducing the risk of cardiovascular events is laudable, but it has been hard to prove a benefit for medicating most people to keep blood pressure below 150/90. She firmly believes that doctors should be especially careful when it comes to patients who seem prone to falls, or who are experiencing blood pressure levels well below the target of 150/90.

The following is important enough to quote from her blog. “Because right now, when it comes to treating high blood pressure in older adults, we are often not careful. Meaning that many clinicians don’t:
  • Ask about falls or near-falls before starting or adjusting blood pressure meds.
  • Get more blood pressure data points before making an adjustment in therapy. The convention is to treat at a visit based on the blood pressure that the staff just obtained. It would be better to base treatment on multiple readings, preferably taken in the patient’s usual environment.
  • Check on blood pressure soon after making an adjustment in therapy. Often patients have their meds adjusted and nobody checks on things until the next face-to-face visit…which might be 6 months away.
  • Find out what the patient is actually taking before making adjustments. When looking at a given BP number, we should confirm that the patient is actually ingesting the meds we think they are, at the dose we think they are. Needless to say, this isn’t always the case! Also occasionally important to have figured out when medications were taken relative to when the BP was checked.
  • Act to reduce BP meds in vulnerable elders. If a frail older person on BP meds sits in front of me and registers SBP of less than 120, I generally look into things a little more. (I ask about falls, and I check orthostatics.) Why? Because now we seem to be fair ways below my usual target SBP of 140s. Is this person on more medication than they need? Are they dropping their BP into worrisome low range when they stand up?”

Both blogs are important, Dr. Bilhartz covers one aspect, and Dr. Kernisan covers another aspect.

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