Fall 2023
PMH STORY
The patient’s spouse suffered cardiac arrest. Bystander CPR was not done. It was quite devastating to the spouse. 911 was called. CPR was initiated in the home.
EMS administered multiple doses of cardiac medications. Heart rhythm was restored in the emergency department. The patient was admitted by the cardiology and pulmonary team to the intensive care unit. Collaboration with and sometimes reliance on the teams at the hospital is becoming the usual course of hospital care. The PMH doctor will continue to visit, collaborate with the team, and assist. It is a professional, collegial, and collaborative effort. It is a change compared to 10 years ago.
Dr. Kelly went to the ICU to examine the patient and to meet with the family and ICU team. The ICU nurse and Dr. Kelly reviewed events and the patient’s exam and condition. The nurse was a 45–50-year-old experienced male ICU clinician. The nurse asked Dr. Kelly to talk to the wife, who was distraught. Before Dr. Kelly left, the ICU nurse stated, “I am so glad to see you, Dr. Kelly. You and your brother are God sends in cases like this, where there has been a severe and life changing event. The family knows you and you know the patients and can assess and communicate so well with the family.” I acknowledged this and went to see the patient’s wife.
Caring for ill patients, especially critically ill patients, is not a solo effort. Taking care of patients in the hospital is today best done as part of a team. This has become clear in the last year. However, the PMH physician will assist the patient, the family, and the team with continuing care.
Robert H. Kelly, MD FACP
DEMENTIA RISKS
A productive area of research examines how established, effective medications can have different and unlabeled long-term effects. Metformin is an excellent and inexpensive medication for the treatment of diabetes and can help fight obesity that is caused by other diabetic medications. Mayo recently published an important study done at the Veterans Health Administration and repeated at Kaiser Permanente comparing 2 common diabetic treatments – Metformin and Sulfonylurea – on the risk for developing dementia. They showed conclusively that metformin decreased risk of dementia compared to sulfonylurea. A more recent analysis confirmed this finding. The benefit may relate to reduced episodes of hypoglycemia. Metformin and sulfonylurea have been used for decades – now we know the choice affects the risk of dementia. Use the metformin!
Another recent report looked at cigarette use and dementia. Volunteers had cognitive testing in 1996-1998 and then had retesting in 2011-2013. The risk of dementia was 33% higher amongst smokers compared to those who had never smoked. Former smokers (who had quit in the interval between the two evaluations) had a 25% increased risk of dementia compared to those who never smoked. The conclusion was that as the time since quitting increased, the risk of dementia diminished. We have long known that smoking increases the risk of cancer and heart attack. Now we also know that smoking worsens dementia risk. Quitting reduces the risks. It is time to stop using these toxins.
Call if you need help.
Robert H. Kelly, MD FACP
HEARING LOSS and DEMENTIA
There has been talk in the last year or two about hearing loss having an effect on dementia, with the implication that it is a cause of impaired cognitive function or dementia. There is no science that establishes this link. Hearing loss and dementia are both signs of degenerative change. But cause and effect are less clear.
The Washington Post had in its headlines that “hearing loss is a major risk factor for dementia. Hearing aids can help” (10/2022). National Public Radio’s Weekend Edition said that there was a direct link between hearing loss and dementia and featured a scientist who said that hearing loss “actually affects the brain’s structural integrity as if people with poor hearing are also demented or will be soon. Some proponents of this viewpoint argue that hearing loss leads to a focal atrophy of the auditory cortex. There is no randomized trial to establish that cause and effect. The risk of stigmatization prompted the American Geriatric Society to combat the claim that hearing loss causes or worsens dementia.
Hearing better can help you communicate and interact more effectively in a social setting – maybe it helps you think better. Hearing aids can improve hearing ability, and so improve cognitive performance in those with dementia by reducing the extra work that impaired hearing imposes. But they do not change the structure of the brain. Whether it is Beethoven or Helen Keller, there need be no lack of intelligence in persons with poor hearing or who self-identify as deaf or use sign language for communication. There is no reason to say that people with impaired hearing have impaired cognition.
Robert H. Kelly, MD FACP
LESS IS MORE
Critically ill patients require nutritional support because they’re not eating. But often starting nutritional support leads to significant glucose abnormalities that require additional intervention like insulin to control glucose level. Then this can cause hypoglycemia, and hypoglycemia is dangerous and can cause death.
Research in the New England Journal of Medicine in September looked at the role of early IV nutritional therapy on outcomes.
The details are complex, but the conclusions are straightforward: early initiation of insulin was of no value to the patient, and the early initiation of IV nutritional support was counterproductive. As the editorial state: “Despite a century of insulin use in clinical practice, the ideal blood glucose target in critically ill patients remains unclear…” After over a century of use, there are still questions about how best to use insulin. The practice of medicine is constantly challenged by trying to do better. When we see that our current therapies are superior to more intensive, complex, and hazardous treatments, we are making progress. New is not always better. When it is, we will embrace it. When research shows us that the old is better, we are happy about that, too.
Allan R. Kelly, MD FACP
RISK FACTORS
The association of cigarette smoking with lung cancer was initially just an observation famously first published by Drs, Oshner and DeBakey in New Orleans. But further study showed causation in trials, both in animals and humans. Even though we have not had a randomized-controlled trial in human beings to prove that cigarette smoking causes lung cancer, the observational studies are so dramatic that we have confidence. Doctors continue to study what risk factors have the biggest effect on bad health outcomes. Researchers at Wayne State University’s School of Medicine in Detroit, Michigan report on observational studies done over 20 years in men and women first evaluated at 20 years of age. Looking at the extensive statistical analysis, three factors were highly associated with risk of stroke and/or death during 20 years of follow-up: Body mass index, blood pressure systolic over 130, and fructose consumption. In other words, what a person is doing at age 20 has an impact on the risk of trouble at age 40. The researchers went on to say that: “Risk increases exponentially with age.” Age creates risk, as do personal choices. Watch your weight and blood pressure. Cut the sugar way down.
Allan R. Kelly, MD FACP
PMH STORY
Continuity of care.
The patient is now in his 90s. When I first met this patient 20 years ago, he was oriented and alert, and he was pleased that I was his doctor. Why? Because my father had taken good care of his parents and that gave him a sense that he was working with someone he could trust.
Approximately eight years ago, his dementia began to take a toll. He started to call me by my father’s name, Gordon. Over the past few years, when he sees me, he greets me by name sometimes as Dr. Kelly, and sometimes as Gordon. He thanks me for taking such good care of his parents. He will call across the room, “Thank you Dr. Kelly for taking care of my parents.” As appropriate, I will try to reorient him, but his error is innocent and the reminder friendly.
What is it that makes people feel comfortable, cared for, grateful, good? Doctors, like nurses and other caregivers, want to provide that to our patients. It is complicated. In my life and career, I think continuing to give care over years is a part of the good that we can give to people, backed up of course by diligence, thoughtfulness, commitment, and quality. Continuity of care is important and reassuring. It helps doctor, patient, and family. People like knowing their doctor and his past work.
Allan R. Kelly, MD FACP
QUOTES
“In the 2022 National Geriatrics Fellowship Match, only 177 positions were filled out of 411 positions offered: 43%, the lowest percentage of all fellowships across 71 specialties of medicine. That is because geriatric medicine is one of the very few specialties for which fellowship training and board certification result in lower salary than if neither had been pursued…the median salary of geriatricians is 4% lower than that of general internist and 14% lower than that of hospitalist.”
Jerry Gurwitz, M.D., 2023
“Residency has shown me how pervasive the feeling of powerlessness is in medicine: physicians often do not have the answers patients desperately seek; but they are not powerless. They can always choose to treat patients with dignity and compassion.”
Julia Wagner, M.D., 2023
“Failing to implement telemedicine widely will result in patients losing the virtual option for medical care, leaving them unnecessarily burdened with in-person visits… Outpatients prefer telemedicine over brick-and-mortar clinic visits. Clinicians must be free to construct their outpatient telemedicine visits in such a way to meet the needs of the patient as well as the clinician.”
Stephen Klotz, 2023