Clinical and Ethical Issues in Geriatric Care Highlights from the Dr. Ira Pollock Clinic Day and Wulf Grobin Memorial Lecture at Baycrest Centre for Geriatric Care, April 16, 2004
Kristin Casady, Managing Editor, Geriatrics & Aging
Dr. Michael Gordon, Vice President of Medical Services and Head of Geriatrics and Internal Medicine at Baycrest Geriatric Centre, commenced a day of lectures and workshops in the Wagman Centre at Baycrest originally scheduled for one year prior but postponed by 2003’s SARS scare. Conference participants’ patience was rewarded with a series of lectures and workshops that addressed many pressing clinical and ethical concerns facing those who treat the aging population. The following presents highlights of the morning lectures.
Hypertension in Older Adults
Dr. Barry Goldlist, Director of Geriatrics for UHN and Toronto Rehab Conjoint Program, and Editor in Chief of Geriatrics & Aging, was first to the podium, offering his consideration of the diagnostic criteria for and treatment of hypertension in older adults. Goldlist upheld the target rate of 120/80 as a general ideal, including for the geriatric population. He described systolic hypertension as more common and of greater prognostic value to the clinician. He offered that concerns that have heretofore reigned about the dangers of low blood pressure’s association with greater mortality as the outdated product of older population-based studies in which mortality outcomes were due to comorbidity (i.e., the reduction of BP that comes with cancer). In his discussion of pharmacological treatment of high blood pressure in the aging, he addressed the “raging” question of whether results depend on the choice of drug or degree of blood pressure reduction. He described that the only relevant matter is lowering elevated BP and that broad differences of drug class are minor. Most patients, he further noted, will require at least two drugs to meet the target of 120/80. Goldlist reviewed recent drug data and summed up his own judgments in favour of low-dose thiazides as offering the best results at lowest cost.
The Aging Driver
Next, Dr. Calvin Cheng, Consultant Geriatrician at Baycrest, addressed the concerns of clinicians assessing the capacity of their older patients’ driving skills and the appropriateness of reporting to the relevant authorities. Cheng reviewed statistics pertaining to the one million drivers in Canada over the age of 65, often challenging conventional wisdom about seniors at the wheel. Seniors have the lowest rate of accidents compared with other age groups; their rates begin to spike slightly over the age of 80. Seniors’ rates appear to rise when compared on the basis of number of accidents per kilometre driven, but even then rate better from this perspective than males age 16–24. Older adults’ collisions tend to happen at intersections and junctions, involve multiple vehicles, and tend not to involve elevated speed. Impairment to driving skills pertains to age-related changes in reaction time and vision. As for the obligation of physicians to report concerns about a driver’s capacity, there are some provincial differences. Cheng pointed out that were physicians to fill out a Medical Condition Report for every concern about an older driver, the system would be quickly overwhelmed. He recommended that physicians consult the Canadian Medical Association guide for recommended approaches to the older driver. He further advised that concerned parties seek out www.dementiaeducation.ca for its resources on driver testing.
Anti-Depressant Use in Geriatric Patients
Dr. David Conn, Head of Psychiatry at Baycrest, addressed the multiple indications for antidepressant use in the older population, reminding listeners that depression, as a cause of worldwide disability, corresponds to worsened health outcomes in the treatment of CVD, cancer, and fractures. Further, depression is associated with increased mortality in myocardial infarction and in those in long-term care—all of particular relevance to an older population. Conn reconsidered the current focus on full remission of depressive symptomatology. While he ultimately concluded that remission must remain the objective in treating major depression, simple alleviation of depression is worth pursuing. This is of great import, for the over-65 population has the highest suicide rate of any age group, according to a 1999 CDC study. He emphasized particular vigilance, given the finding that one-third of older men saw their primary care physician in the week before committing suicide, and 70% within the previous month. In terms of pharmacotherapy, Conn positively evaluated the new generation of anti-depressants, serotonin noradrenaline re-uptake inhibitors (SNRIs) and noradrenergic and specific serotonergic antidepressants (NaSSAs). His overall conclusion was that the new generation of pharmacotherapy for depression offers a wider array of mechanisms of action as well as offering action against multiple disorders (i.e., the finding that buproprion is a nicotine agonist).
What’s New: Guidelines and Standards
Osteoporosis
Dr. Gillian Hawker of Sunnybrook and Women’s College Health Sciences Centre and Director of the in-house Osteoporosis Research Program discussed changes to treatment guidelines. She provided highlights to the 2002 Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada for the Osteporosis Society of Canada. These were the first evidence-based guidelines focussing on the prevention of primary osteoporosis. The notable shift in the guidelines is the focus on bone strength, not bone mass, as the key to defining osteoporosis; the guidelines further emphasize risk factors for fragility fracture.
Cholinesterase Inhibitors
Dr. Tiffany Chow followed with her consideration of new indications for cholinesterase inhibitors. She evaluated recent findings on the efficacy of acetylcholinesterase inhibitors in AD, with particular focus on rivastigmine for dementia with Lewy bodies and donepezil for the same.
The Wulf Grobin Memorial Lecture: Conscientious Objection
Finally, Dr. Michael Gordon concluded the lecture session with “Is There a Place for ‘Conscientious Objection’ in the Care of the Elderly?” Here he made primary reference to a case study involving an 85-year-old female under care in the Baycrest facility. In the wake of a debilitating stroke, her family had concluded that her feeding tube should be removed. This raised a host of troublesome questions for the family, staff, and physicians. What were the legal implications of removing the tube? What is the ethical basis for such a decision? What is the responsibility of the surrogate decision maker, and can that involve the right to withdraw from the care process? In this case, the family had pushed ahead with the order to disconnect the feeding tube, and events unfolded such that not all staff members—many of whom had developed a connection with the patient during her current and previous treatment—were conferred with. Many had ethical and legal objections. The compromise reached in this case involved having the patient moved to a palliative care unit where she was allowed to die in comfort. While not all were pleased with the compromise solution, the family was content and the staff (despite lingering concerns) accepted the situation.
For Gordon, this situation could have been handled more smoothly were there a clearer understanding of conscientious objection and its place in health care. Gordon considered the history of the concept from its biblical origins through its contemporary military/political application, ultimately advocating acceptance of the concept within the health care context. Conscientious objection will often be hastened by a “moral distress” we must recognize as legitimate. It may spell allowing health care professionals to withdraw from the administration of treatments. The onus will be on these professionals, to some extent, to make their belief systems known and to provide alternative care arrangements. He concluded with the hope that nurses and physicians might be able to realize their personal values in their occupational setting without compromising the fact that the needs and wishes of those under care must remain at the centre of all professional and ethical efforts.
Apparently, not yet. However, promising results from a study in the New England Journal of Medicine capitalize on our understanding of the genetic basis behind colon cancer. Colon cancer arises when four or five genes become mutated. In more than 90% of cases, it is mutations in the adenomatous polyposis coli (APC) gene that initiate colorectal tumours. The researchers investigated whether it was possible to detect APC mutations in fecal DNA using a new developed method known as digital protein truncation, a technique that could identify mutations in a sensitive and specific manner. Stool samples were collected from 28 patients with nonmetastatic colorectal cancers, 18 patients with adenomas that were at least 1 cm in diameter and 28 control patients. The test managed to identify mutations in 26 of the 46 patients with neoplasia (57%), and in none of the control patients.