Short Takes
A summary of recent medical news stories we find interesting (and hope you will too)
Frailty, thy name is dementia
“What a drag it is getting old,” sang Mick Jagger in 1966, when the lead singer of The Rolling Stones was a wizened 23-year-old.
Today, at age 81, Jagger still shows remarkable suppleness and vitality, but the same cannot be said for a large majority of his peers, many of whom are frail of mind and/or body.
And as a current study shows, a pattern of acceleration of physical decline, labeled “the frailty trajectory,” may be a harbinger for dementia in the not-too-distant future.
Researchers in the US and the UK looked at data from four prospective studies on aging, memory, and dementia, and found that, among nearly 30,000 participants, frailty trajectories were seen to accelerate from 4 to 9 years before a diagnosis of dementia.
“These findings suggest that frailty measurements may be used to identify high-risk population groups for preferential enrolment into clinical trials for dementia prevention and treatment. Frailty itself may represent a useful upstream target for behavioral and societal approaches to dementia prevention,” the researchers write in the journal JAMA Neurology.
Frailty is a physical health state marked by increasing vulnerability due to multiple age-related health problems and a loss of physical resiliency. The investigators, led by David D. Ward, PhD, for the University of Queensland, Australia, note that, “at any age, frailty is positively associated with all-cause mortality and to a greater degree than are common laboratory-based estimates of biological age, indicating that higher frailty reflects older biological age.”
Previous studies have shown that frailty is a risk factor for death within 1 year of non-heart surgery, and that among community-dwelling elderly with pulmonary diseases, frailty was a predictor of both hospitalization and death.
Thanks, but I’d rather die somewhere else
Making money off of someone else’s death may further fatten the wallets of venture capitalists, but it’s not good for patients, results of a new study suggest.
A survey of caregivers showed that end-of-life care provided in hospices owned by private-equity firms or for-profit companies is significantly worse than that provided in non-profit hospices.
Researchers at Emory University in Atlanta and other centers looked at surveys from caregivers of persons who died in hospice to compare the quality of hospice facilities owned either by private equity firms (PEFS), publicly traded companies (PTCs), or not-for-profit entities.
“Although all for-profit ownership models are oriented toward profit maximization, PEF and PTC ownership structures are distinct in being incentivized to generate short-term and above-market returns for investors, raising questions about the potential influence of financial objectives on quality,” they wrote, in a research letter published in JAMA, the journal of the American Medical Association.
They examined eight individual measures of quality included in the Consumer Assessment of Healthcare Providers and Systems Hospice Survey (CAHPS). The measures included how well the hospice staff communicated with others, the timeliness of care, whether family members were treated with respect, whether emotional and religious support were provided, help with patient symptoms, hospice care staff training, Medicare’s hospice rating, and the willingness to make recommendations.
“Hospices owned by PEFs or PTCs performed significantly worse across CAHPS measures relative to not-for-profit and non-PEF/PTC for-profit agencies,” the researchers found. “Although prior research has highlighted poorer user experiences in for-profit vs not-for-profit hospices, this study found that PEF/PTC ownership was an especially problematic category of for-profit hospice.”
Too much, too late?
And since we’re on the subject of limited life expectancy, a study of men with clinically localized, low-risk prostate cancer treated in the Veteran’s Administration health system suggests that many near the end of life are still being treated, even when it’s highly unlikely to help them, and could have harmful side effects.
For older men whose prostate cancer is not likely to cause them trouble before they die from other causes, prostate cancer specialists often recommend active surveillance, also known as “expectant management,” or simply “watch and wait.”
This involves periodic testing to see whether the cancer is growing, and treating only if it appears life-threatening or begins to cause symptoms. It is considered a good option for older men with small tumors, those confined to a single area of the prostate, or slow-growing tumors. Men with other conditions that may limit their life expectancy, such as advanced heart failure, may also opt for active surveillance alone.
In line with this approach, Timothy J. Daskivich, MD, MSHPM from the Cedars-Sinai Medical Center in Los Angeles and colleagues found that, among 243,928 men with clinically localized prostate cancer treated in the VA system, the proportion with low-risk disease and a life expectancy of less than 10 years who were overtreated with surgery, radiation, or both declined between January 2000 and December 2019, from 37.4% to 14.7%.
During the same period, however, there was increase in overtreatment among men with the same limited life-expectancy but intermediate-risk disease, from 37.9% to 57.8%. Among men who received definitive therapy, with the goal of cure or long-term relief, three-fourths were treated with radiotherapy.
“Our data showed that while overtreatment by tumor risk has improved markedly in the active surveillance era, overtreatment based on limited life expectancy has worsened,” the researchers write.
“Although this issue is complex, any meaningful change to reducing overtreatment by life expectancy will require a multifaceted approach, including multidisciplinary society advocacy, data infrastructure to support life expectancy prediction, patient-centered communication of life expectancy, and a commitment by physicians to incorporate life expectancy into their clinical routines.
The study is published in JAMA Internal Medicine.
The frailty and dementia study was supported by the Frailty and Dementia Special Interest Group and grants to authors from other sources. Author disclosures are reported in the source material.
The hospice quality study was supported by a grant from the National Institute on Aging. Author disclosures are reported in the source material.
The study on prostate cancer and life expectancy was supported in part by the US Department of Veterans Affairs. Daskivich reported personal fees from the Medical Education Speakers Network, EDAP, and RAND; research support from Lantheus and Janssen; and a patent pending for a system for health care visit quality assessment outside the submitted work. No other disclosures were reported.
Neil Osterweil is an award-winning medical journalist with more than 40 years of experience reporting on medicine and health care.