It is admirable that our efforts to prevent mortality and morbidity are based on scientific evidence. But few clinical trials have been carried out in the frail elderly and virtually none at all in rural areas of developing countries.
Our project guidelines have been designed to be simple to apply. We do not ask a nurse to make a therapeutic decision based on the age or frailty of a patient. Some of those decisions come to the expatriate doctor.
I took this photograph of a 104-year-old man who is attending one of the health centres where our mentoring approach is improving chronic disease management. His blood pressure is well controlled on just one medication but he is taking a statin to reduce his cholesterol (which we have never actually measured). I know of no evidence that 40mg of atorvastatin will prolong or improve the quality of his life. He readily agreed to have his photograph taken, especially when I told him that he was ten years older than my own father!
The JUPITER trial (dontcha just love the fancy names given to trials?) showed some benefits for statin therapy over the age of 70, but they don’t necessarily benefit everyone. Twenty-nine patients over 70 need to take a statin to avoid one cardiovascular death. But statins have side effects. Lots of older patients complain about statin-related muscle pains, and there is an increased risk of cataracts and diabetes. Also, it takes three to five years for the benefits of statins to accrue.
A mentor asked me to review an 85-year-old man with atrial fibrillation (irregular heartbeat) whose blood pressure was erratic. Electronic blood pressure machines have difficulty when the blood pressure changes from beat to beat. Our approach is to take three readings and calculate the average. I spent some time listening with my super digital amplified stethoscope while taking his blood pressure. The highest systolic figure I got was 150mm of mercury, which I thought was acceptable. He was complaining of dizziness, however. When I palpated his neck, his carotid arteries were calcified like the stem of a clay pipe. He probably needed 150mm pressure to pump blood to his brain! I considered that the benefits of aggressive blood pressure reduction were outweighed by the risk of postural hypotension resulting in falls and fractures.
When assessing a patient, we tend to look at the numbers. How well is a patient’s diabetes or hypertension controlled? We check the HbA1c and the blood pressure. The numbers inform us what we should do next. The nurses asked me to see one old lady (she didn’t know her age but she told me that she was married with three children at the time of Kenyan Independence in 1963) whose diabetes was not well controlled. Her HbA1c was high at 9.6 despite treatment with maximum oral medication. Insulin was the next step. She was terrified of having to use “the needle”, because everyone knows that when you have to start using injections, you are going to die soon.
We had a chat about her diet and compliance with medication. Yes, she often missed doses but she said her diet was fine. I asked if she liked her tea. She brightened up and said that she did. She made “breakfast tea” for the whole family in one pot, stewed with milk and sugar. That was her favourite drink of the day. Now we couldn’t ask her to stop adding sugar to the pot, but perhaps she could reduce the amount? Or only have one cup of breakfast tea in the morning? If she did that and took her medication as prescribed every day, we could review her in a month and repeat the tests to see if she really did need to start insulin. She readily agreed.
It was a negotiation. Not President Trump style, but a balanced discussion, taking into account the patient’s views and lifestyle.
Our project aims to do some operations research, perhaps even to publish in a peer-reviewed journal or to present the results at an international conference.
Unfortunately, our project is planned to last for just five years and we don’t have the high numbers of patients needed to do research. But I’d like to know more about the safety of reducing blood glucose levels in older people with diabetes (with the risk of hypoglycaemia); what blood pressure should we aim for in patients who are in their 80s or 90s, and whether or not the risk of treatment with statins and aspirin is worthwhile in these age groups.
Our patients find it difficult coping with polypharmacy, taking lots of different pills for their NCD, with resulting drug interactions and side effects.
Sometimes, less is more.