Slow Medicine is a philosophy and a set of principles and practices meant to help elders, families, friends, and caregivers face aging and decline in late life.
By Dennis McCullough
A scene in Leo Tolstoy’s Anna Karenina, written more than a century ago, illustrates the complexity of human responses when approaching life’s end. Nikolai Levin has been declining slowly from consumption (tuberculosis) over the span of several years, and is now more rapidly approaching death. His sister-inlaw, Kitty, who knows medicine has nothing left to offer him, sits by his bed, urging acceptance and faith. In time, he relents. As she concludes her task and turns to leave, he surprises her (and Tolstoy’s readers) by asking why she can’t go and find him “the best doctor in Moscow” (Tolstoy, 1946).
Slow Medicine: Rebalancing Our Understanding and Approach to Aging
As an advocate for Slow Medicine (McCullough, 2008), which is a philosophy and a set of principles and practices meant to help elders, families, friends, and caregivers face aging and decline after eighty, I know how challenging it is to square realities with a hope for something better. Tolstoy dramatically captures this internal conflict for Nikolai, who is clearly close to death. I believe he also speaks to the internal conflicts (Kleinman, 2011) that come in later years for many of us when we think: “Please give me something to extend my hope for being healthier and living longer.”
For many in our culture ourhopes reside in medical care and medication. Although advice from the long-lived in other cultures might be “Walk, sleep a lot, eat your vegetables, have friends, and be happy,” in our Fast Medicine culture we are more inclined to believe our future depends upon test results. We may pay lip service to habits that matter, but we fill our pill boxes with medications that promise us longer and better lives
Slow Medicine is based on a better understanding of aging, emphasizing the need to go beyond focusing on diseases and their treatments to appreciating the individual patient and his or her values and concerns at each point in the aging journey. Not only does this require a better grasp of the changing physiology of older patients, but it also extends to issues of emotional, psychological, social, spiritual, and familial consequences of growing older, more vulnerable, and more dependent upon others. Its goal is to promote
care, which paces all decisions and allows for a deeper understanding of the scope and possible outcome of available choices. Central to this approach is a better understanding of what prescription and non-prescription medications may offer in failing health and advanced age.
Medications come in two broad categories: curative and symptom-directed (those that improve the way you feel), and preventive (those that promise a future with fewer problems). Historically, most medications were prescribed to relieve symptoms. When a symptom or disease presents, doctors treat it, and there is
an expectation that one will feel better. Within hours or days, the patient knows whether the medication is working or not. Antibiotics, pain-relief medications, and drugs for heart or lung diseases are examples of this traditional approach. The medication is taken for a limited period of time and then stopped.
As longevity has grown over the past century, many diseases that were once life-ending—cancers, heart disease, diabetes—have become chronic illnesses. Wanting to lessen symptoms and to keep them from developing have created a growing market for more and more prevention drugs. Advertisements for prescription and non-prescription drugs flood the media with choices and promises (Abramson, 2004). Increasingly, we can’t measure the value of these drugs by how we feel. We are persuaded to judge effectiveness based on large population studies to assess outcomes over time.
Prevention drugs, especially for heart disease, diabetes, and hypertension, make sense for younger adults; much research supports this, especially in the case of men. Studies providing evidence for women and older people have been slower in coming. Researching prevention is inherently difficult because chronic diseases play out slowly, and it takes years and a great deal of money to assess treatment value. Two problems stand out in designing this type of research for elders. The first is that older people become more and more singular as they age; it is difficult to create comparable groups of elders to study. The second is that additional medical problems emerge in later years, forcing people to drop out or to be dropped from studies. It is difficult to isolate the effects of a drug in elders with multiple problems. As a result of these difficulties, there is a paucity of research guiding doctors in using prevention drugs wisely for older people (Sloan, 2009).
Recommending drugs for elders is increasingly based on extrapolating the usefulness of those drugs in much younger (and different) study participants. This practice is nevertheless widely employed, despite being scientifically unsound. There are clear dangers for elders in this excessive and inappropriate use of medication.
Excessive drug use by frail elders also results from over-diagnosis (Welch, Schwartz, and Woloshin, 2011). As we expand threshold criteria for diagnosing common conditions such as high blood pressure, diabetes, and high cholesterol, attaching a disease diagnosis (or “pre-disease diagnosis”) to more individuals, a larger number of people of all ages are encouraged to use drugs to prevent long-term problems.
But elders have shortened life expectancies, and early-stage problems are less likely to progress quickly. One recent example of this trend is the growing evidence questioning the value of screening for prostate cancer by a PSA (Prostate-Specific Antigen) test, and the dangers of treating this disease in older men. With borderline diabetes, hypertension, or osteoporosis, the possible benefits of drug treatment may be small. Often, for elders with multiple diseases, mixing medication protocols can lead to confusion and adverse interactions. The question we must consider is whether or not a new diagnosis and another medication will improve an elder’s quality of life now and in their remaining years (Steinman and Hanlon, 2010).
The placebo effect is well-documented with all drugs (Freedman, 2010). In drug trials where one group takes a genuine drug and the comparison group a placebo, generally both groups improve, often as much as 30 percent. To help distinguish this effect, study groups are often reversed for an equal period of time Yet in clinical practice, physicians are not readily inclined to “cross over” and see how the patient does without the drug to determine the drug’s real effect. In geriatric practice, a strong case can be made for this “trial and error” approach to determine a drug’s value to the individual.
Safety and Side Effects
Initial drug trials to evaluate safety and effectiveness are necessarily done on small groups of people. As new drugs are pushed to the market more and more quickly, these trials do not test adequate numbers of people, nor do they allow sufficient time to note longer-term side effects (Abramson, 2004). If a drug side effect only appears in one in 1,000 people, that may seem a limited risk for the 1,000 individuals in that trial. However, when 100,000 to 500,000 people are taking a drug with a risk of 1:1,000 for a side effect, the 100 to 500 people suffering the side effect constitutes a real problem. Although the individual risk remains the same, the consequences for the population are much greater.
Roughly one in five elders takes ten or more drugs; in the extremely vulnerable populations in nursing homes the percentage is even higher (Field et al., 2007). Yet we are learning that the risk of drug interactions and side effects increases much more rapidly when the patient is taking six or more drugs.
As for duration of use, a rule of thumb for the cautious physician is to be wary of drugs that have not been tested by large numbers of people for a minimum time period of five to seven years (PublicCitizen, n.d.).
The Changing Body: Aging, Heterogeneity
As the science of aging has progressed, physicians have to come to understand much more about the decline of organ functions, particularly of the kidney and liver, which eliminate drugs from the body over time. Body composition (bone, muscle, fat, water content) also changes as we age, causing a different distribution of a drug. Drug doses need to be calculated to allow for these changes, which are often dramatic with aging. The stomach and intestine may absorb drugs differently or not at all; the brain is more fragile in elders (consider the larger effect of a knock on the head for the older brain).
The best illustration to explain this to elders and families is the aging skin. Abrade a shin or forearm and a full layer of skin may peel off; large bruises arise from the least trauma. We are fragile everywhere as we age, and this vulnerability needs to be considered whenever we subject an older person to a new drug circulating “untargeted” through the body. The rule of thumb is “Start low, go slow” when prescribing a new medication.
With many drugs for elders we have failed to consider over time the changing risk-to-benefit ratios. Commonly, prevention medications are given with the advice that “you will need to be on this for the rest of your life” (Groopman, 2008). But, we know that if a person lives beyond age 80 or so, her body will change and may not tolerate a medication at the original dose. It may not be possible in an elder’s shortened time frame to achieve the promised outcome. To reduce known dangers of excessive, inappropriate, and inadequately reviewed medication, doctors and families must constantly and persistently reassess an elder’s medications.
It is difficult for us to talk openly about how aging alone becomes the most important risk factor for our health and well-being. Simply put, using prevention drugs to modify risk factors and, theoretically, improve quality of life and life expectancy has a role of diminishing importance as one ages.
For example, age alone accounts for 75 percent of the ten-year risk for developing heart disease in a group of seventy-five-year-olds with cholesterol elevation of 280 mg/dL, but only 12.5 percent of the risk for a group of forty-fiveyear-olds with the same cholesterol elevation (National Institutes of Health [NIH], NIH Heart, Lung and Blood Institute, 2001). After age 65, “age” rapidly surpasses all other risk factors in importance, and, along with family history, cannot be changed.
As we head into our eighties and nineties, the potential value, or risk-benefit ratio, of reducing cholesterol counts or aggressively managing high blood pressure or diabetes is of diminishing significance, while risks for drug side effects increase (Oates et al., 2007). Honing our thinking may help us shift our understanding of what we are and aren’t getting in return for the drugs we use. It is never wrong to concentrate on healthy habits and medications that make us feel better, but most prevention drugs have accomplished what they could when we were much younger. Recognizing the limits of medical care is a part of accepting the aging process.
Inconvenience of Medication Changes
It might seem surprising that so few medications are regularly reassessed in any significant way. Particularly with frail elders, doctors naturally tend toward the “if it ain’t broke, don’t fix it” school of medication management, despite knowing about changes in medication absorption, metabolism, and elimination that come with aging.
Medication changes, which in general must be based on a trial-and-error approach because older people vary so widely from one another, require time to plan and carefully follow up. In current medical practice, doctors are pressed for time and will often forgo more thoughtful approaches to medications, instead sticking with the “blood pressure check and medication renewal” quick visit.
But there is value in “medication vacations,” which allow a patient to discover what it feels like to be without side effects. For many chronic medications, there is little risk with periodic monitored “vacations” (Teel, 2011; Sloan, 2009).
One might expect nursing home staff to regularly carry out medication vacations (many patients take ten to twelve medications or more) because of available surveillance. Unfortunately, even here traditional medical practice usually prevails. If anything, more and more medications are added, but few are discontinued or their doses reduced. Of special importance in nursing homes is the need to continually reduce psychopharmacologic and anti-dementia medications, for we know that the so-called behaviors being treated wax and wane quite on their own.
Changing Horses Near the End of Life: Trust
Change, whether in providers, philosophies, or medications, when beliefs and habits are longestablished, is difficult (Gawande, 2010). The first challenge in addressing medication use near the end of life happens when helping hospice and palliative care patients weather the emotional transition to accepting dying (Cohen, 2010). Building a new, trusted relationship usually trumps rational explanations for why some medications might no longer be of value.
seem to arrive at a place where they understand the limits of medical care (Groopman and Hartzband, 2011). Medicare hospice enrollments have been increasing steadily over the past several years, but, unfortunately, the pattern of hurried and short enrollment periods before death—usually weeks, not months—continues. Nearly all older hospice (and palliative care) patients can be described as “frail” as a result of advanced diseases and illnesses, and many enrolleesare frail due to age alone.
For the group affected by both age and advanced chronic illnesses, many might be termed “pre-hospice” for years. Over these many later years, frail elders are much less likely to benefit from medications designed for long-term prevention of problems beginning in middle life. Instead, these elders are an “at-risk” group for all medication prescribing.
Earlier enacted, more thoughtful, and more honest approaches to medication prescribing would allow a less stressful and awkward transition to appropriate end-of-life medication use. Patients and families may not have thought critically about medications, but entering into hospice almost always involves considering risk-benefit ratios of both symptomatic and prevention medications.
Appropriately, hospice strategy emphasizes the potential positive effects of discontinuing, or slowly reducing, long-term medications that are not specifically useful for diminishing present symptoms. This approach to medication reduction or discontinuation is not a difficult case to make. Along with some reduction in stress for patient and family when entering end-of-life care, subtle, unappreciated side effects from long-term medication use, including nausea, appetite reduction, constipation, sedation, and fatigue can be eliminated in the frail and compromised patient.
Many symptoms go unnoticed because they came on slowly over many months or years as a result of fixed doses of medications affecting a changing and diminishing body with reduced capacity to tolerate drugs. Use of non-drug therapies to reduce pain, stress, and anxiety for patients (and families), and to address other symptoms is also helpful.
As troublesome physical symptoms lessen in intensity, good end-of-life care can then address the spiritual issues of acceptance and meaning. In its most extreme form, after stopping both curative and long-term preventative treatments, one may see the so-called hospice cure, where patients gradually feel better. This was wellpublicized by humorist Art Buchwald in his book, Too Soon to Say Goodbye (Buchwald, 2006), which describes his improvement and eventual “graduation” from hospice. (He later returned to hospice.) Restoring a higher quality daily life is common, and patients’ lives can extend beyond prognoses made while under the stress of aggressive treatment.
Dennis McCullough, M.D., is a community geriatric consultant and associate professor of Community and Family Medicine at Dartmouth Centers for Health and Aging, Dartmouth Medical School, Hanover, New Hampshire.
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