Mrs. Davis hasn’t seen me in over a year. It’s a burden for her family to bring her in but I haven’t yet been able to add house calls to my busy schedule. She recently turned 94 but lost the gift of cognizance some time ago. It’s only been a few months since her husband passed away though it is unlikely she is aware of that fact, she’s long forgotten who he was. She was once a respected professional, well-known in our city and a philanthropist of several now forgotten causes. She shuffles into my office, sitting with her head in her hands. She knows who she is, but that is all. She is well-cared for by family members who call themselves fortunate to share her home.
I look at her vital signs. The 15 pound weight loss jumps out at me. “Is she eating?”. Her caretaker responds, “bits and pieces of this and that, she’ll drink an occasional Boost”. “Does she appear to be in any pain?” “No, she sleeps a lot, doesn’t interact much.” I perform a not too-detailed exam and determine that she has no skin breakdown. In addition to her cachectic appearance, I notice a difference between sounds in the two sides of her lungs. One side sounds dull, though she breathes shallowly and perhaps it is the other side that is hyper-resonant. I look at her caregiver who is also a nurse. “She’s lost a fair amount of weight and there is a difference between the two lungs when I listen.” We lock eyes. After a few moments he responds, “And what would we do differently if we explored this.” I look at the patient. She looks a little tired but not uncomfortable. “Nothing, I would hope.” “Then we’ll be saying goodbye and thanks for refilling her meds.” I nod, ask him to call me with any problems and move on to my next patient.
There is a wonderful expression used by the French when referencing an older woman. She is “a woman of a certain age” (une femme d’un certain age) Recently. a patient who fits in that category, began suffering from vaginal dryness causing burning and pain. This is impacting her sexual function as well as being just plain uncomfortable. So I prescribed a vaginal estrogen which serves to increase the vascularity in the area and “plump” up the cells. This improves things in general and reduces the discomfort of sexual activity. Her insurance company, a prominent one in our city, requested that I obtain a Prior Authorization but still denied payment for the prescription because it is a “high risk medication in the elderly.”
Oral estrogens are high risk in the elderly, defined as over 65, increasing the risk of stroke, breast cancer and memory problems. This woman is not at all elderly in the sense of being infirm. She walks daily, volunteers weekly, travels widely, has an active sexual life with her husband and could no doubt run circles around half the people involved in the denial of her medication. The lowest cost vaginal estrogen preparation costs about $168 a tube and there isn’t a generic alternative. In an article published in the American Journal of Obstetrics and Gynecology in 1981, there was NO systemic absorption with low dose vaginal estrogen.(1) A study in 1983 published in the Journal of Clinical Endocrinology and Metabolism showed essentially no changes in the systemic markers of estrogen.(2) While I suspect that no one at the insurance company is maliciously denying claims, did their pharmacy committee bother to do its homework regarding the difference between vaginal estrogen and oral meds?
Low-dose topical estrogen is significantly safer in women over the age of 65 than oral preparations. This should be a choice between a patient and her doctor NOT a “member” and her insurance company.
1. American Journal of Obstetrics and Gynecology. 1981 Apr 15; 138(9):967-8. – See more at: http://www.popline.org/node/385377#sthash.kkgLZIvI.dpuf 2.Biological Effects of Various Doses of Vaginally Administered Conjugated Equine Estrogens in Postmenopausal Women http://press.endocrine.org/doi/abs/10.1210/jcem-57-1-133
Typically my call weekends are light. I don’t get a lot of messages. Saturday there was one remarkable only in my inability to do much for the caller. My associate’s elderly patient was in the ER, sent there by her physician. He is 94 and was falling more lately, had reduced appetite, just didn’t feel well with occasional episodes of shortness of breath. His daughter called because they were “40 patients deep” in the queue and she wanted to know what could be done to improve the chance that he would be seen more expeditiously. I thought about it. I certainly understand why she was concerned about her elderly father sitting on hard chairs in the emergency room with goodness knows what illnesses surrounding him. At the same time it didn’t sound like there was anything emergently wrong, as opposed to urgently. He might have a pneumonia or urinary tract infection, so common in the frail old patient. Was it appropriate to try to push the emergency room to see him ahead of the other 39 people who no doubt also felt that their problems were of utmost importance? I explained to the daughter there was no certainty anything I said would get her father seen more quickly and she responded that her experience was when a physician called things got done. Sometimes that is true if I have knowledge the ER is lacking as to why a patient is seriously ill. But I didn’t really have that. How quickly does one wear out their welcome with the ER if I cry wolf? On the other hand the patient is 94, sounds frail and certainly was at risk to sit in emergency room for several hours. My own mother is not too far from that age so I intimately understand the daughter’s concern. What was the right thing to do?
Mrs. Smith is adamant, “That amlodipine is making me tired! I can’t take it.” Ms. Smith is 86 years old and her blood pressure is reaching a systolic of 200. She’s still mentally alert and volunteers at a local hospital every week, drives herself to places nearby and lives alone. It is scaring me because I don’t want her to stroke. This is the third BP med she has rejected in as many months. I’ve checked for other causes but think her age is just catching up to her. Previously she has had a systolic in the 150’s and several years ago we tried several meds, all of which she refused to take. I gave up then but now I’m much more concerned. She has no family to speak of…we go over the pros and cons of the medication. She reluctantly agrees that if she dies from a stroke that would be fine but being in a nursing home unable to talk or walk would be horrible. She will try the medication for another month. “But doctor if I can’t do the things I want to do, I am not going to keep taking it!” She agrees to try it and surprises me with a hug as she walks out the door. “It’s OK Dr. Nieder, I’m not going to live forever.” Tim Jones slammed his finger in a door and sees the hand doctor on Monday for a non-displaced fracture of his little finger. He wants to ride this weekend in a 100 mile bike ride for some charity or other. “Honestly, what is the risk?” We discuss the fact that the ride itself could cause swelling of the fingers and lots of pain, not to mention if he falls and hits it. “They splinted it really well at the immediate care center. I promise not to take too much ibuprofen.” I give my blessing and hope he is safe. Mary White arrives, late as usual. My staff is used to that, so they try to schedule her at the end of the day. She has a short litany of minor issues, brings me up to speed on her minor medical problems with specialists, has her yearly exam, we discuss her perfect blood chemistries and she is out the door. After 25 years, my patients have me well-trained. And vice-versa–they only call me at night with true emergencies and they apologize when they wake me, they rarely call for last minute refills because they forgot, they bring their meds with them when they come for an appointment and they arrive on time because I’m on time (well, at least I was until Electronic Health Records began three weeks ago). Reflecting on my practice it occurs to me that this is what I hoped my patient relationships would be like at this point in my professional life. Mission accomplished. Wonder what comes next?