Don’t Ignore Patients Over 75
My last post was about the ways our healthcare system fails patients with chronic disease. A registered nurse that I worked with is a good friend. She saw the post and sent me this story about her husband. He is 79, and up until about a year ago he was very healthy. My friend said he was very active up until that point. He had never been tired before and worked hard all his life. Then he started feeling exhausted. Not tired. Exhausted. He saw his primary care doctor who referred him to cardiology and urology. He had some symptoms of an enlarged prostate. He went for an entire year without a diagnosis. “Nobody really did much…. My husband will be 80 in October. I feel people blew him off for months because he said at 79, he was exhausted.”
Finally, he was referred to a kidney doctor who ordered a lot of tests prior to being seen. He had the bloodwork done and two hours later the kidney doctor called telling him to go straight to ER. He had some critical levels. His magnesium was low, and he had to have it replaced IV. Eight days later he was discharged with diagnosis of stage 4 prostate cancer that had spread to his lung and bones. This week they are meeting with an oncologist to discuss their options. Fortunately, he has no pain.
His hemoglobin is 8 and so he is quite anemic. The prostate specific antigen (PSA) test goes up with prostate cancer. Normal is 4 or less. His PSA was 1203. He started having problems with gout. It took four months to get an appointment with a urologist. He continued to be exhausted with a 35-pound weight loss and no appetite. His diagnosis was only made when the kidney doctor drew blood that was so abnormal it precipitated emergency intervention. Scans showed cancer in the lungs and bones. A bone marrow biopsy showed prostate cancer there too. That is why he is anemic and has a low platelet count.
I think my nurse friend is right. I was taught that 90% of the diagnosis is to be found in the history you get from the patient. Men are notorious for minimizing symptoms. Sure, many 79-year-olds are fatigued, but a careful history would have revealed that this gentleman was remarkable for his good health and then that changed over a fairly short time to the point that he went to a doctor and complained of exhaustion. The complaint of exhaustion may be due to several factors that deserve fairly simple investigation. The common causes of this complaint in a man like this are anemia, new diabetes, thyroid problems, and chronic kidney disease. Adrenal failure is a very serious possibility and the list of potential suspects is long.
You have to ask yourself: why did his doctors not do more? There are several guidelines that call for an arbitrary reduction in tests and treatment in people who are 75 years old or more. For example, prostate cancer screening is not recommended for men over 70. The colon cancer screening guideline calls for screening for everyone until age 75. Breast cancers guidelines call for mammograms up until age 75. The American recommendation for statin therapy is a real puzzler. “Do not start a statin in patients ages ≥ 75 years who do not have known vascular disease or type 2 diabetes; start or continue a statin in all patients ages 75 to 84 with type 2 diabetes to prevent cardiovascular events and mortality; and start or continue a statin in patients ages > 75 years who have known vascular occlusive disease.” Age is the greatest risk factor for heart attack and stroke. There are two or three times as many heart attacks in people over the age of 80 compared with those between 65 to 69. The British guideline therefore recommends statin treatment for everyone over 75. That is rational. The higher the risk, the more protection statins provide.
Men who reach the age of 75 live 10.46 years longer on average. The average 75-year-old woman live over 12 more years. Remember this too. There is a huge variation in the health of 75-year-old people. People age at very different rates. An 89-year-old patient in my practice walked the golf course several times a week and shot his age twice. His physical age was 20 years younger than his age by the calendar. Arbitrary cut offs make little sense, and they have consequences beyond screening. It is probably part of the reason diagnosis was delayed in this man.
There is a danger beyond screenings and statin treatment. The implied message seems to be that people over 75 will be dead soon, so why bother. It seems my nurse friend is right; her husband’s complaint was not taken seriously because he is old. She put it this way: “There is no doubt he minimized his story. But numbers don’t lie. What really saved my husband is I switched his primary care nurse practitioner to a new one in town. From the first visit she took my husband seriously, asked questions and started testing. As the results started coming back. Each test opened another can of worms. She kept ordering more and would refer to specialists.” Every patient deserves a serious effort to identify a diagnosis and begin effective treatment. These clinicians missed the mark.