Sunday, November 02, 2014

Thoughts on an upcoming annual physical: for seniors with momentum, less treatment is more; concerns over arrhythmia

As my own annual Medicare physical approaches (Nov. 7 this year), I always wonder if there is the possibility of some kind of disruption based on the exam itself, as opposed to a symptomatic (and, at my age, possibly  suddenly catastrophic) illness.

For example, I have noticed a mild and stable heart arrhythmia for over twenty years.   It never has shown much on the ECG, although the ECG in Minnesota at the end of 2001 (the ING annual physical, that happened right before the layoff) showed signs of damage due to hypertension. That’s when atenolol started.
In 2012, the doctor noticed a slow heartbeat and changed the prescription to Losartan potassium.  Right after the medication changed, I did notice an increased tendency for jumpy heart rhythms, which declined back to “normal” with time.  He mentioned the idea of a pacemaker, but it wasn’t pursued.  The exam in 2013 went very well, without much comment. 
In 2010, some elevation of the PS antigen was noted, but it went back to normal on its own in 2011, with the stress of mother over with after her passing, and probably a lower fat diet (since there was no caregiver cooking).
I believe in my own momentum and in doing little.  That used to be the philosophy when I was growing up. You were dealt a hand, you lived your life, didn’t expect too much at the end, and then you died, because everyone will die of something.  People often reached normal or long lifespans, even with bad health habits, with relatively little medical disruption, until sudden death.  That was viewed as desirable.  So far, I’ve had only one major hospitalization, after an accidental and freakish hip fracture in early 1998 in Minnesota;  with new surgical technology I recovered fully and relatively quickly.  My paternal grandfather died at age 89 after breakfast on a Saturday morning, never missing a day.  My father died of advanced prostate cancer on New Year’s Day, 1986, just before his 83rd birthday, but he had been ill only four weeks.  But my mother had a long decline, starting with hip fracture in 1996, heart attack and several angina in 1999 which was finally resolved by coronary bypass surgery, and then doing pretty well until starting to decline in 2007, and steeply and requiring care after the middle of 2009 (to pass near the end of 2010, at 97).  On mother’s side, one uncle had a sudden seizure from a brain tumor at 60 and lived eight months.  That might suggest something running in the family, but it hasn’t happened to anyone else, so environmental exposure of some kind must have been involved.   Another maternal uncle died of cardiomyopathy at age 70 in 1995.  He had a sudden cardiac arrest at age 68 walking into a restaurant in South Carolina.   That was never explained, but medication issues (or accidental overdose) can lead to sudden death or sudden arrests. 
Physicians today feel pressure to do a lot, partly because of malpractice of other secondary liability concerns, and partly because of reimbursement incentives.  It might be a good thing to look into the arrhythmia, but that would mean many disruptive tests (stress test, echocardiogram, and a Holter Monitor with pre-shaving) and then likely pressure to do something.  I can see the idea of doing something like that in the winter, after New Years, and staying out of circulation socially for six weeks or so if that is necessary.  Any “elective” surgery and hospitalization could disrupt my being online, and I have no “social capital” to draw on.  
In a practical sense, I am with the “conservatives” and “The Washington Times” in believing that a lot of seniors do better if left alone – spending little and remaining productive well into old age, possibly before a more sudden end, or shorter period of disability at the very end (which will inevitably come from something).  But we know there are others to consider.  Individual health also relates to public health and safety.
Consider driving.  In more recent years, there has been more public attention to senior driver safety than there had been even a decade ago.  In Virginia, and probably in all states, medical professionals can write to the DMV and recommend that licenses be revoked (link here).  That could set up a situation where the senior must consent to a period of lengthy and intrusive tests and surgeries whether he or she really wants them (and needs them for “momentum”).  That could even be medically counterproductive.  Generally, if someone has a seizure, stroke resulting in unconsciousness, or cardiac arrest, the person is not allowed to drive for six months – which may make sense since something has really “happened”.  But could driving privileges be suspended if tests showed that an incident had a higher than usual probability of happening?  This sounds like the public health debate we are having with Ebola. 
Do arrhythmias fall into this area?  WebMD has some guidelines, that factor in the idea that an ICD or a pacemaker (not the same things, link  ) could have been implanted, here. Generally, if a patient has had an episode which required a shock from an ICD (or defibrillator machine), the person is not allowed to drive for six months.  But without such an episode, someone can generally drive a few days after surgery.
I used to joke, "never go to the doctor."  You know what happened to David Letterman in 2000.  He did not pass Go, he did not go home.  Right into coronary bypass surgery.  They were all ready for him, and he didn't know he was walking into a trap, to get cracked open like a lobster.  When he came back on the air, he belonged to the Zipper Club.

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