Dr Lipski’s opinions based on 42 years of medical practice.
We seek expert medical opinions when a relative is sick. However, 50% of medicine is evidence-based but 50% is based on clinical experience. Doctors need to analyse and decide which published research studies are valid, have robust data and results, and relate to their patients. There are many flawed and dodgy studies out there which do not extrapolate to reproducible good, safe patient outcomes. Many drug studies under-report side-effects of drug treatment and bias outcomes with specific patient selection and exclusions. Many research studies do not include very old frail patients. Accepted current peer medical practice is based on these observations. Doctors should always use their clinical judgement when deciding if a research drug study is relevant and safe for their individual patients.
Tricyclic potent anti-cholinergic antidperessant drugs are still being inappropriately used for insomnia and chronic neuropathic nerve pain (neuropathy). These drugs will increase risk of confusion, dementia and falls. It is highly addictive and very difficult to get off. It must never be used for sleep. It is a last resort for severe neuropathic pain when nothing else works, but only in the lowest dose.
Those patients with dementia taking Acetylcholinesterase Inhibitor “memory drugs” should not be drinking any alcohol which is a neurotoxin, will worsen the memory loss, and counteract any benefits from the memory drugs. Alcohol causes detectable memory impairments beginning after just one drink. As you drink more, so does the severity of the memory impairments. Alcohol also impairs balance, motor coordination, mood and decision making. This is much more severe in patients who already have impaired brain function and abnormal brain scans. They have little brain reserve to cope with any extra stress on brain function. This is even worse when they are taking other sedative drugs such as anti-depressants, sleeping pills, anti-anxiety drugs and anti-pyschotic medications.
When a relative says a frail older driver is a “good driver”, this is unreliable, particularly in the setting of a medical consultation for memory loss. Relatives are generally very protective of their loved ones and don’t want to upset them or for them to lose their driving licence, even when they are cognitively impaired. Relatives’ assessment of “good” driving performance has a very low positive predictive value, but those relative who identify “bad” drivers has a very high positive predictive value.
When relatives try to help and correct their loved one during cognitive testing, or make excuses for incorrect answers this usually means they have dementia. This is even more so when the patient turns their head and looks towards the relative for the answer to every question asked of them.
Some of the first signs of dementia are generally slowing up physically and cognitively, unexplained weight loss, loss of interest in things before memory loss becomes more evident.
There is a new trend from government medical regulators to restrict access to anti-psychotic medication for the treatment of severe behavioural complications of dementia. These distressing symptoms of severe anxiety, agitation, aggression, paranoid delusions, frightening hallucinations cause enormous suffering for the patient and carers. Many of these patients respond dramatically to low dose of anti-pyschotic, sedative and anti-depressant medications. Appropriate treatment results is huge benefits of symptom relief for patients and carers, and improves quality of life. The over-emphasis on “behavioural management strategies” which are grossly exaggerated and promoted as useful interventions, simply harm dementia patients by delaying appropriate medical treatment. Most of the severe behavioural complications of dementia in those people in nursing homes have already been addressed with “non-drug strategies” without success by nursing staff. Unfortunately I now see large numbers of untreated dementia patients in nursing homes suffering from these severe distressing complications of dementia because the doctors and nursing homes are fearful of being reported to regulators if they use these drugs, and there are severe restrictions on their use. These drugs for the treatment of the severe behavioural complications of dementia are now called “chemical restraint” by regulators who describe it as a practice or intervention that involves the use of medication or a chemical substance for the primary purpose of influencing a care recipient’s behaviour. However , it does not include the use of medication prescribed for the treatment of, or to enable treatment of, the care recipient for a diagnosed mental disorder, a physical illness or a physical condition or end of life care for the care recipient. So if you are a psychiatric patient you can have proper drug treatment, with these same drugs but if you have dementia you cannot have these drugs to improve your comfort and quality of life.
Governments are restricting pain killer medications. GP’s (Primary Care Physicians) are restricted in prescribing narcotic analgesics and threatened with sanctions from medical regulators if they prescribe narcotics for severe pain. Narcotic analgesics in low dose have dramatically improved chronic pain management in the older patient. Chronic pain in the elderly is associated with an increased incidence of adverse outcomes, including impairment of daily general function, falls, depression, impaired sleep and decreased appetite. Older people have an increased risk of adverse drug reactions with pain killers which can also interact with other multiple pills that they are taking. Therefore the dose of pain killers should always start low and the patient should be regularly monitored for side effects. I see many older patients with severe chronic back pain limiting mobility and quality of life. They are frequently sent home from the public hospital emergency department without proper pain medications. There is a trend to use non-narcotic pain medications such as Gabapentin, Pregabalin and Amitriptyline which all have a high side effect profile including confusion and falls risk. The number of patients needed to treat with these drugs to cause harm is only 9.
Public and private hospitals must work more closely together. It doesn’t make any sense for a patient to be “Private” in a public hospital. The public hospitals want to use up the private patient funds, then try to off-load the patient to the private hospital. Unfortunately the health insurers decide how long they will cover the private funding for, so commonly after 10 days of acute care in the public hospital the private health funding runs out so the private hospital can’t take them. There are lots of beds in the private hospital system not being used. When the private hospital can manage the patient, then they should be transferred directly from the emergency department to the private hospital.
Paramedic ambulance officers must allowed to refer patients from home directly to a private hospital specialist. If the private hospital and private specialist can manage the patient, then they should be admitted directly into the private hospital. This will free up public hospitals enormously and stop ambulance ramping/queuing at the front door to the emergency department.
Private and public hospitals should be assessed for merit awards so that good holistic comprehensive geriatric medical care is rewarded with extra funding, but poor care takes away funding- a penalty to provide incentives to do better- not to routinely reward bad care.
General Practitioner (Primary Care Physician) practices have to change to meet the needs of the rapidly growing older population. They can’t simply practise “milk bar medicine” any longer opening at 9am and closing at 5pm. Many older people at home and in nursing homes get sick after hours. Then they need immediate medical care to prevent a medical crisis and an avoidable acute public hospital emergency department presentation. The government must provide major financial incentives and resources including a huge increase in after hours billing revenue, a practice nurse and admin support to General Practitioners so they can provide a medical service from 5pm to 11pm, sharing on call with other local medical practices. This is much more cost effective than building more hospitals and emergency departments. Also General Practitioners mus have spaces during the day to see acutely unwell older patients. How can you expect a sick older patient to make an appointment and wait days when they are acutely unwell and need medical help immediately. How would they know when they will get sick- so what’s the point of making an appointment when urgent help is needed!
Private Health Fund Insurance needs to radically change now as it is rapidly becoming unaffordable. We need proper Private Health Insurance where the patient is fully covered for everything without any out of pocket extra expenses. Patients in Private Health Funds should not be charged extra fees. They are already paying big dollars for expensive Private Health Insurance which is on a self destruct pathway by allowing extra charges and limited cover for the very people who pay to keep the Private Health Funds and Private Hospitals going. What type of insurance is it anyway when you are not fully covered? Why have it? Why bother? You might as well be better off saving your monthly premium in a term deposit account and use the money when you need better health care. My White Paper on Health Reforms shows that there are massive cost savings for Private Health Funds and Private Hospitals with spectacular health outcomes with holistic comprehensive geriatric medical care for older complex patients.
Doctors appear obsessed with checking serum Vitamin B12 and folate levels in geriatric patients as a “dementia screen” when it has little impact on their general health and dementia risk. I have never seen a patient get dementia from Vitamin B12 or folate deficiency! But yes we should measure serum Vitamin B12 and folate levels in patients with anaemia and Vitamin B12 for symptoms of peripheral neuropathy and replace if deficient. However, geriatric patients would be better served by detailed cognitive testing if dementia is suspected.
Hypothyroidism (under-active thyroid gland) is overrated in elderly patients. Whilst the symptoms of hypothyroidism are very non-specific, including lethargy, weight gain, constipation, fatigue, weight gain, cold intolerance, hoarseness, constipation, muscle aches I have only ever seen one older patient with confusion caused by an extremely underactive thyroid gland (severe hypothyroidism with serum TSH over 200- normal is less than 5) and fixed with slow thyroid hormone tablet replacement. I have never seen hypothyroidism cause dementia in an older patient! However, yes hypothyroidism must be treated when found.
Malnutrition in the elderly is the greatest moral medical challenge of our time! It is the most important risk factor for falls, infections, pressure sores, delirium, adverse drug reactions and acute public hospital emergency department presentations. This is all avoidable and treatable but commonly ignored by doctors and hospitals! Why? It is quite a paradox of modern medicine that most doctors pay little attention to the nutritional status of the elderly when it is such a common problem, leading to potentially catastrophic outcomes, yet is potentially reversible! Hospital bureaucracy is usually even less interested in it! Those elderly with 5% to 10% weight loss have a 30% higher risk of all-cause mortality, and those with more than 10% weight loss have a 290% higher risk of death. Malnutrition is fatal in the elderly but treatable if screened for, looked for and managed in a holistic general medical multi-disciplinary setting. It is a win win situation for the Government with reduced health care costs and better health outcomes for older patients. For every $ spent on better nutritional care of the elderly $10 is saved in health care costs!
The greatest threat to the health and well-being of older people are family relatives who blame “old age” and “ageing” as the cause for treatable medical symptoms such as forgetfulness, becoming vague , confusion, slowing up, breathlessness, dizziness, falls, back pain, weight loss and more. Those relatives who blame “old age” for the physical and cognitive decline in older people are simply in denial which prevents or delays an accurate medical diagnosis and treatment. Older people do not become frail and unwell from “old age”. This is a myth but many believe it which is why so many older people who do suffer a decline in their physical and mental health from a medical illness do not get proper medical care. When relatives say foolish, unreasonable and ludicrous statements such as “ what do you expect for her age?”, “you know she is 85 years old”, “he is not bad for his age”, “memory loss and confusion is normal in old age” and “I couldn’t tell you who the Prime Minister is” or “I couldn’t remember those 3 words!” then you know they are in complete denial and use “old age” as a reassurance and an excuse to ignore physical and cognitive decline and illness in their older relatives!
Almost all older drivers who use a walking frame should not be driving a car. Most have significant brain disease with neurodegenerative walking and balance disorders causing significant slowing of movement and reflexes, impaired cognitive function, speed of information processing, inability to process multiple visual stimuli simultaneously and react quickly, all necessary for safe driving. They just don’t have the brain processing power and ability to allocate attentional resources appropriately to manage complex traffic situations which is why most impaired older drivers have crashes at intersections and roundabouts. Many of these people have undiagnosed cognitive impairments and dementia.
Those people who call a picture of a rhinoceros a hippopotamus during cognitive testing have a very high risk of having dementia. This simple observation has a very high positive predictive value for identifying dementia.
Hypoglycemia or low blood glucose less than 6mmol/L is common in frail elderly hospitalised inpatients and predicts increased in-hospital mortality. Hypoglycaemia is common and an underecognised serious complication in frail older diabetic patients. Elderly people are more prone to hypoglycemia during hospitalisation because of frailty, malnutrition, poor dietary intake, multiple comorbidities and polypharmacy (just too many drugs with side-effects). Hypoglycemia is commonly missed in the frail elderly due to cognitive and functional impairment that interfere with early identification and appropriate treatment of hypoglycemia. Older patients do not get the obvious, typical symptoms that younger diabetics get with low blood glucose such as sweating, shaky, looking pale, hunger, headache, palpitations. Hypoglycemia causes functional brain failure and brain cell neuronal death. Achieving target blood glucose levels whilst avoiding hypoglycaemia is a major challenge in the management of elderly patients with diabetes. Elderly patients with diabetes often have impaired renal function, which interferes with drug elimination and thus predisposes them to prolonged life-threatening hypoglycaemia. Repeated episodes of hypoglycaemia cause significant physical and cognitive decline, worsen dementia and Parkinson’s disease, makes them more confused, worsen neurodegenerative walking and balance disorders and old stroke weakness, worsens depression and general day to day function. Many such patients with overtreated diabetes and low blood glucose commonly report a “foggy head”, dizziness, drowsy, “woosy” lack of energy, worsening confusion, agitation and increasing falls and and cardiac events. Frail older people with diabetes have a higher risk for hypoglycemia due to reduced physiologic reserve and responses to low glucose levels. Unfortunately many Doctors and Nurses insist on treating blood glucose levels in elderly diabetic patients to the same lower level as that of younger diabetic patients who require much tighter diabetic control over many years to prevent vascular complications such as blindness, kidney disease, stroke, heart attack and loss of circulation in lower limbs. Keeping an older person’s blood glucose below 6mmol/L is just like a sledge hammer hitting the the brain to worsen neurological function. Older diabetics must be treated differently from younger diabetics with the priority of hypoglycaemia avoidance. The paradox is that we sometimes need to run the blood glucose higher in frailer older patients to prevent hypos.
Many older patients with walking/balance problems and high falls risk who use a walking frame commonly leave the frame in the car when going out with family. Their excuse is “we are only going a short distance so I hang onto my daughter”. This is an unsafe practice and dramatically increases the risk of falls. They should always use the walking frame wherever they go. Also almost all of these people twist and turn their body with their feet stuck on the ground when changing direction using a walking frame instead of walking forward in a large circle. Twisting and turning is a high risk complex movement which dramatically increase falls risk, but almost all people do it!!
We need to dismantle the current health system in Australia (as well as in all OECD countries health systems including New Zealand, Canada, USA and UK) and rebuild them as they are no longer fit for purpose with rapidly ageing populations. For example Australia is getting older, faster. By 2026, more than 22 percent of Australians will be aged over 65 — up from 16 percent in 2020, which was already double the 8.3 percent at the start of the 1970s. By the year 2062, the number of Australians aged 65 and older is projected to more than double, while those aged 85 and older are expected to more than triple. This is like a 600 metre tsunami that will rapidly hit the health system in all of these countries who are just not prepared for it at all! The health system is too acute hospital focused, wrong Doctors, wrong training. We just don’t have enough properly trained Doctors who can provide comprehensive holistic general medical care to complex older patients. The “SOD” (Single Organ Doctor) or Specialists just do not offer comprehensive general medical care to manage these complex older patients, just sticking to their own small specialised area of medicine. This costs governments up to 1000% mark up in medical care instead of a single Geriatrician or General Physician caring for these older patients and dealing with all of their complex medical problems. I am not saying that you can’t have a sub-specialty interest in medicine, I am not saying you can’t be an expert or Specialist in one area of medicine, you just can’t be a SOD and practise SOD medicine- you must provide comprehensive general medical care. My White Paper from 2007 on major health reforms is relevant for all OECD medical systems. The highest levels of Australian Government and NSW Health agreed with my White Paper in 2008 but then did nothing! Since then I had no response from Politicians including Federal and Local Members of Parliament. When I first started hospital medicine at Westmead Hospital in 1982 there were no bureaucrats and managers not qualified to run health. Rather the Doctors ran the hospital. Now there are more of these bureaucrats and managers than Doctors. Governments are using consultancy firms with no medical qualifications to advise on health- not Doctors. I propose the “CLEG” (Clinical Leadership Expert Group of Geriatrician or General Physician, General Nurse and General Surgeon) to run health-and reporting directly the state Premier. No politicians and no Health Ministers. Health requires portfolio-specific expertise- Doctors not politicians who have no medical training. Politicians have not solved the crisis in Australian hospitals and ambulance ramping in front of Emergency Departments in many years. I can’t see how non-medical hospital managers and bureaucrats controlling Doctors is helpful. The health system must stop the Hospital centric focus . Most good is done outside the hospital. Comprehensive Geriatric Medical Assessments improve patients outcomes and prevent hospital admissions. We also need the greatest attitude shift to the elderly and ageing in 40 years- that you are never “too old” for good medical care and that blaming “old age” for illness simply denies older people early and appropriate medical care. We are all living longer and want better health. There are massive cost saving for Governments by preventing unnecessary Hospital Emergency Department admissions with early treatment at home and restructuring General Practice-NOT blaming “old age”- early diagnosis and management is the key. Australia could buy 3 Virginia Class nuclear submarines ($4.3 billion each ) every 2 years with cost savings of $6 billion yearly from my White Paper health reforms. The USA could buy 6 x $13 billion Gerald Ford Aircraft Carriers per year with cost savings of $80 billion per year from my White Paper.