Well: Emergency Rooms Are No Place for the Elderly

Doctor and Patient

Dr. Pauline Chen on medical care.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who'd watched him hobble down the building's stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

"Of course, if things get worse before the week's up," I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, "come back here right away."

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man's face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. "Just admit him," she whispered. "It'll cost more, but it's the only way you'll be sure he's getting the right care."

I remembered the nurse's advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.

The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.

But given longstanding trends in American medicine, it's hard to imagine a health care setting more ill suited for the elderly than today's emergency rooms.

Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment's notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.

More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.

But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.

For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.

To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must "geriatricize" their emergency departments.

And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.

Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.

"Older adults aren't the kind of patients people gravitate toward," said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. "There's a reason you don't see the frail, cognitively and functionally impaired older patient on television medical shows."

Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual's experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.

"We can really become partners in improving care, instead of just putting a Band-Aid on the problem," Dr. Hwang said. "We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them."

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Well: What Running Can Do for the Heart

Phys Ed

Gretchen Reynolds on the science of fitness.

An ingenious new study of marathon runners and their non-running spouses should reassure anyone headed for a spring marathon that prolonged training doesn't damage the heart, a concern that has been raised in previous research. At the same time, becoming fit as a marathoner doesn't seem to protect the heart to the extent you might expect, although it may have unexpected benefits for your spouse.

While we all know that exercise is healthy, some research has begun to raise questions about whether it's possible to overdo a good thing. A few studies have found that long-time endurance athletes can have a heightened risk for abnormal heartbeats, and even for scarring of the heart muscle. Likewise, experiments with lab animals have found possible links between prolonged, extremely strenuous running and undesirable changes in the structure and function of the heart.

But the actual incidence of runners having a heart attack during a marathon race is vanishingly small, a finding that seems to suggest that marathon training can't be excessively hard on hearts or there would be greater, obvious consequences.

Such inconsistencies in the data about prolonged endurance exercise and heart health prompted researchers to wonder if perhaps past studies had been too imprecise. It's difficult to isolate the risks associated with strenuous exercise from other lifestyle factors, said Beth Taylor, an assistant professor in the health sciences department at the University of Hartford who led the new study, which was published last month in BMJ Open. Runners whose hearts seemed to have been affected by their exercise habits might also have smoked, gorged on junk food or otherwise imperiled their hearts, separately from how much they worked out.

So Dr. Taylor and her colleagues decided to better control for such factors by studying marathon runners along with their domestic partners, who presumably would be sharing their lifestyles if not their physical exertions. If cardiac health differed among these couples, the scientists felt, they could reasonably conclude that training had played a role, since so many lifestyle factors would be the same.

With that idea in mind, Dr. Taylor and her colleagues contacted a slew of runners who had qualified and signed up for the 2012 Boston Marathon, inquired if they had non-running spouses or partners, and asked if both would be willing to have their hearts scanned and cardiovascular disease risk assessed.

Forty-two of the runners said yes, along with their spouses or partners. Half of the runners were women. Their ages ranged from 33 to 59, although most were in their mid- to late 40s. Their partners were around the same age but considerably less active, averaging fewer than two sessions of moderate exercise per week. Many did not formally exercise at all, although most reported frequently walking, gardening or undertaking other types of moderate activity.

The day before the 2012 race, the racers and their partners visited a makeshift lab next door to the race expo, where they filled out questionnaires about their exercise and health histories. Scientists then drew blood to determine the volunteers' cholesterol and triglyceride profiles and measured their height, weight, pulse rate, blood pressure and other vital signs. Finally, each volunteer underwent a noninvasive heart scan to reveal the buildup of arterial plaques, an indication of heart disease.

Not surprisingly, the marathon runners were significantly thinner than their partners, although few of the partners were overweight. The runners also generally had lower blood pressure, heart rates, bad cholesterol and other indicators of cardiac health.

But running did not insulate the racers altogether from heart disease, the scientists found. Some of the racers, particularly the oldest ones, carried large deposits of plaques in their arteries, a worrying sign. These older racers also tended to have the highest tallies on a numerical assessment of heart attack risk called the Framingham risk score, which considers medical and lifestyle factors that, along with genetics, can contribute to the development of atherosclerotic plaques.

In essence, the scans showed that marathon training did not cancel out the depredations of age, longstanding bad health habits or a family history of cardiac problems, Dr. Taylor said.

On the other hand, the scientists found no relationship between the number of hours the runners trained or how fast they ran and the levels of plaque in their arteries, indicating that marathon training had not directly damaged any of these racers' hearts.

Over all, Dr. Taylor said, the study's data suggests that if you're training for a marathon or otherwise doing frequent and prolonged endurance exercise, you're probably not hurting your heart and are likely strengthening it. But you should be aware of your past health habits and family history and monitor any symptoms, such as shortness of breath, that could be a sign of potential heart troubles.

Perhaps the more surprising takeaway of the study, Dr. Taylor said, is that marathon training's cardiac benefits may be transferable. "The spouses of the runners were quite healthy, too," she pointed out. More so than many people, they walked and moved around frequently, and had generally robust cardiac risk profiles. Dr. Taylor's conclusion: if you want improved heart health but can't be a runner, marry one.

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Science Times: Wired Well: Every Dog Has Its Data

Wired Well

Personal technology for health and fitness.

A half-century ago, dogs lived in barns or backyards, domiciled in shabby little doghouses. Now they have the run of our houses and apartments. They sleep in our beds (full disclosure). In some cases, they are considered by their owners to be like children, and possibly a bit cleaner.

So it is not so strange that the connected technologies that are creeping into the lives of humans are doing the same for pets.

Wearable pet activity trackers keep tabs on Bella's or Bear's exercise. Some go further, monitoring dogs' heart and respiratory rates and tracking locations in case they escape their homes. Webcams allow people who are away from home to monitor, communicate and play games with their pets, breaking up the monotony of lonely days.

What's making all these devices possible is an abundance of increasingly inexpensive miniature components created for the smartphone business: wireless chips, motion sensors and high-resolution camera lenses that can be jammed into pet-friendly devices. Smartphone apps, meanwhile, are giving people a way to visualize the biometric data these devices collect and to snoop on pet behavior from anywhere with a wireless connection.

These device manufacturers are chasing the growing pile of money people are lavishing on animals. Total annual spending on pets in this country, including food, veterinary care and medicine, more than tripled over the past two decades to $55.5 billion last year, according to the American Pet Products Association.

The tighter bond between household animals and the people formerly known as owners has established pet wellness as a serious business, and tech firms are taking note.

"It is the idea of being able to interact with your pet in a more meaningful way," said Con Slobodchikoff, an emeritus professor of biology at Northern Arizona University. "Right now, pretty much all people have is voice to interact with their pets or touch. People want more."

Heidi Hurn recently clipped one of these gadgets, the Whistle Activity Monitor, to the collar of Hoosier, her 11-year-old chocolate Labrador retriever. This $130 brushed metal device, about the dimensions of a ketchup bottle cap, records when he is active, for how long and at what intensity level.  It is the canine equivalent of the Jawbone UP, a fitness tracker that Ms. Hurn bought for her fiancé.

Through an app on her iPhone, Ms. Hurn, 32, who works in medical device sales in Seattle, can see a bar chart showing how hard and for how long her dog walker is exercising Hoosier. She can see how active he is when she and her fiancé are not at home. (Revealed: Hoosier is sacked out from five minutes after they leave until the moment they get home.)

Ms. Hurn said she and her fiancé got the device because Hoosier's veterinarian emphasized that keeping him active is likely to extend his life. She said the detailed logs of his exercise make the couple feel more responsible.

"We are very attentive parents," she said. "He's our only child."

I, too, recently put a Whistle on the collar of Mitzi, my 5-year-old pit bull/Labrador retriever mix. After a few days, I was able to compare her activity level to other mixed-breed dogs. I felt small glow of pride when the Whistle app sent me a congratulatory text after Mitzi surpassed her daily exercise goal four days in a row.

More wearable tech for pets is on the way.  Already on sale is a collar device called Tagg that combines activity monitoring with location tracking to help recover lost pets. Voyce, an activity tracker available later this year, also monitors a dog's heart and respiratory rates.

"We really see ourselves as the wellness coach for the life of the dog," said Jeff Noce, president of i4C Innovations, the maker of Voyce.

It's possible the data from these devices could eventually help medical researchers better understand pet ailments. According to a 2012 study commissioned by the Association for Pet Obesity Prevention, more than 52 percent of dogs and more than 58 percent of cats are overweight or obese, conditions which can lead to diabetes and worsen arthritis.

A 14-year study commissioned by Purina, the pet food company, found that a dog's median life span can be extended by 15 percent by restricting the diet to maintain ideal weight, or almost two years for the Labrador retrievers in the survey. Veterinarians have used expensive motion sensors for years to study pet activity levels, but they say the new devices aimed at pet owners have the potential to be used far more broadly.

"I'm very excited about the activity monitors," said Dr. Ernie Ward, a veterinarian and founder of the Association for Pet Obesity Prevention.

The solitude of pets is another concern that technology is tackling. Many animals spend hours alone at home while their owners are at the office. Separation anxiety, lack of exercise and other factors can lead to destructive tendencies.

Dropcam is a wireless security camera that can also be used as a pet monitor. It has a microphone and speaker so people can both speak to and hear their pets via a mobile app.  I used a Dropcam to spy on Mitzi, who had positioned herself on a couch in my living room while I was out of the house.

Through the speaker, I ordered her down. She cocked her head like the RCA dog and stared at the camera — and didn't move. I'm hoping for an update of the product that includes pet obedience.

A device called Petcube, coming out in May, combines a webcam, microphone and speakers with a low-intensity laser pointer, the direction of which can be controlled remotely through a smartphone. Owners will be able to play games with their cats and dogs using the laser, assuming the animals are receptive to the idea of chasing a bright red light around a room.

People will be able to invite Facebook friends to play with their pets, too, by sharing access to their Petcubes.

While cats seem to pursue lasers without problems, Dr. Margaret Gruen, a veterinary behaviorist at North Carolina State University, said using a laser pointer with dogs could lead them to become shadow and light chasers, a compulsive behavior. Dr. Gruen said it was unclear what effect owners talking to their pets through a webcam could have.

"When they can't see them, will that be confusing or comforting?" she said. "I don't think we know yet."

There are effective medications and behavior changes for treating separation anxiety in pets, and playing classical music while an owner is gone can relax dogs, too, Dr. Gruen said. While it isn't clear yet whether these new technologies actually improve the lives of pets, they are certainly likely to answer the emotional needs of many pet parents. Remember the Baby Einstein DVDs, said to enhance the intellectual development of infants?

"There's this industry that springs up around selling highly specialized products that will allow you to feel like you're doing a better job of parenting," said Aaron Easterly, the chief executive of the dog-sitting website Rover.com. "It's really the exact same pitch for these products."

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The New Old Age Blog: Music Born of Magical Thinking

Outside, the sleet came down like needles, a perfect night for slipper socks and 1940s weepers on Turner Classic Movies. But no: I have tickets to "My Mother Has 4 Noses," a one-woman musical written and performed by the singer/songwriter Jonatha Brooke about the harrowing years when she saw her mother through the final stages of Alzheimer's disease.

It can't be funny, I told myself. The tunes might be fabulous — after all, Ms. Brooke won critics' praise for setting Woody Guthrie's journal entries to music. But oh, those monologues about her mother would be unbearable.

How much better to stay home and cry over doomed romance than inexorable death.

But off I went to the Duke Theater on 42nd Street for a performance both funny and wrenching, one I suspect would resonate with caregivers everywhere. I met Ms. Brooke later for a conversation about her mother and the events described on stage. Lanky in the jeans and flannel shirt she wears during performances, her long hair tied loosely back, she could have been any of us with little time for glamour.

Among the more than 15 million Americans providing unpaid care for family and friends with Alzheimer's and other dementias, at least three – Ms. Brooke, 50; her manager/director/husband, Patrick Rains, 64; and his sister, Julie, 60, underemployed and "couch surfing" – managed to find endless humor in a family crisis that unfolded from 2010 to 2012, as Ms. Brooke's mother descended deeper into Alzheimer's.

Ms. Brooke had a lifetime of practice dealing with her mother, whose florid wackiness and succession of illnesses, long before Alzheimer's, would have sent most children running for the hills. Instead the two were linked, said Ms. Brooke, as if there were "an electrical current running between us."

She was one of three children — the youngest, the only girl and the lone skeptic in a devout family of Christian Scientists in Boston. The language of the religion, its lessons and allegiances, "never leave you once you've been indoctrinated,'' Ms. Brooke said.

Those four noses, it turns out, are the collected prostheses her mother, Darren Stone Nelson, wore after untreated skin cancer had turned her into a "maxillofacial work of art," as Ms. Brooke put it. The cure for what ailed her mother, in the Christian Science view, was Mary Baker Eddy's unwavering belief that divine love "always will meet every human need."

The same was true when Mrs. Nelson had a uterine tumor. By comparison, her terrible arthritis seemed a mere inconvenience.

"Mom was a magical thinker," Ms. Brooke said. "So I was burdened with reality."

If the material world were an illusion, as she was taught, then so is sickness and death. Ms. Brooke took her first Advil at 30. She has attended just one funeral, her father-in-law's.

Perhaps it's understandable that dementia didn't occur to Ms. Brooke as an explanation for her mother's increasingly erratic behavior until she was well down the road. This was a woman who found a rainbow wig in the town dump and wore it constantly when her daughter was an easily embarrassed seventh grader. It was the postman who hesitantly suggested that Mrs. Nelson didn't belong alone at home anymore.

An independent or assisted living facility seemed the solution, as it does to so many of us. Ms. Brooke quickly settled her mother into a home for aged Christian Scientists in Massachusetts. She visited, dined with her mother's new friends, each with more grievously untreated maladies than the next. "Mental malpractice,'' Ms. Brooke calls it now.

Mrs. Nelson's hygiene was wanting, a common Alzheimer's symptom, and the staff let her get away with excuses rather than insisting she shower. "Now isn't a good time," she'd say. Or "I'm in the middle of something." Ms. Brooke eventually realized that "hymns three times a week is not going to cut it.''

Terrified and ignorant, but determined and mindful, she said, that "I'm my mother's only daughter,'' Ms. Brooke brought her to New York City. Home was, and remains, Apartment 7K in a rental building on upper (waaaaaaay upper) Fifth Avenue. Ms. Brooke rented an apartment on the third floor and moved her mother there. "I could see her window from my living room,'' she said.

Their first enormous challenge, as Ms. Brooke describes it in the play, was dealing with her mother's painful, unrelenting constipation. Once, just ''clipping her toenails creeped me out.'' Now, it was suppositories and enemas — and "poetry in this terrible intimacy,'' a transition many caregivers will recognize. Before long, Mrs. Nelson "became the crazy lady screaming down the hall.''

Hoping to relieve her mother's excruciating arthritic pain, Ms. Brooke agreed to have her undergo a knee replacement. There was not a word of warning from doctors that this wasn't a great idea for a woman too cognitively impaired for physical therapy. After surgery, Mrs. Nelson hallucinated for a week, Ms. Brooke recalled, and attempts at rehabilitation were like scenes from "One Flew Over the Cuckoo's Nest.'' Within months of the ill-advised operation, a hospice team joined the crowd in Mrs. Nelson's apartment.

Still this hardy woman lingered, from hospice's arrival in October until the next January. On a Saturday night, the nurses said her mother was "actively dying,'' common end-of-life parlance but alien vocabulary to a Christian Scientist. Ms. Brooke longed for her brothers, "lovely, beautiful men." But they were too steeped in their religion, she said, for a deathbed vigil.

Mrs. Nelson's caretakers read her Mary Baker Eddy's version of the 23rd Psalm. They watched Christian Science church services online. "We really tried to speak the language, honor the lessons,'' Ms. Brooke said, but religion seemed to have lost her power, and her mother seemed more enamored of Chanel No. 5, her favorite perfume, which her daughter sprayed in the air.

Monday became Tuesday. Mrs. Nelson's breathing was thready. When her time came, "she really did just slip away," Ms. Brooke said.

Waiting for the undertaker, Ms. Brooke, her husband and sister-in-law, and the caregivers sang sublime hymns and ridiculous ditties like "How Much Is That Doggie in the Window.'' A man arrived with a black body bag, loaded it, disinfected his hands, rode down to the lobby and pushed the gurney down Fifth Avenue to his van.

The gurney fit easily in the elevator, Ms. Brooke said, because long ago the apartment building had been a nursing home. That detail is not in the performance, but, Ms. Brooke said, "the irony isn't lost on me."

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The New Old Age Blog: Geriatricians Question Five Common Treatments

It tells you something about American health care that scores of medical societies have joined a major campaign aimed at telling patients and doctors what not to do.

That's not exactly the language the Choosing Wisely initiative uses, admittedly. It has recruited more than 60 groups, representing specialties from dermatology to thoracic surgery, to come up with lists delicately called "Five Things Physicians and Patients Should Question."

"Question" sounds better than "flee," doesn't it? And it allows for individual differences in a way that a campaign called "Danger: Unacceptable Side Effects Ahead," or "Watch Out: Useless Procedures," might not.

Still, Choosing Wisely wants to help us select drugs and tests and procedures that are backed by evidence, that don't duplicate other treatments, that are "truly necessary" and won't hurt us. Since 2012, its lists have included hundreds of drugs, tests and practices that fail to meet those standards, with more to come. Point made.

We reported the American Geriatrics Society's first "Five Things" list last year. The society has just published its second list, so I again turned to Dr. Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the panel that developed both lists, to help explain what else older adults should be dodg — um, questioning. (You can see all 10 items here.)

Topping this year's list is a caution against dementia drugs called cholinesterase inhibitors — Aricept is the most widely used — without following up to see whether they're really helping. Dementia is so feared, and the eventual prognosis so grim, that doctors and patients want to do something, anything, to stop its progress.

But while the drug may produce cognitive improvement that is statistically significant in a clinical trial, "it's not clear that it's big enough for a caregiver to even notice, or big enough to make a difference in a patient's quality of life," Dr. Lee said. "We're learning, after more experience with these drugs, that they benefit a minority of patients."

On the other side of the equation, most patients who take them will experience gastrointestinal problems like nausea, cramping and diarrhea that often cause weight loss. So the society urges extensive discussion before doctors prescribe cholinesterase inhibitors and suggests no more than a three-month trial. If there's no meaningful improvement by then, there won't be later. "This is not a medication to start and then forget about," Dr. Lee cautioned.

Grouped second on the list are several tests we've often written about: mammograms for breast cancer, colon cancer screenings and P.S.A. tests for prostate cancer. Older people who are already frail or coping with several chronic diseases, and have life expectancies of less than 10 years, are not likely to benefit from finding such cancers — but they will face the short-term risks of complications and overtreatment from screening. "It may not make sense to expose them to these harms," Dr. Lee said.

Next to avoid: appetite stimulants in cases of weight loss, including high-calorie supplements like Boost and Ensure, or prescription drugs like megestrol acetate (brand name Megace) or the antidepressant Remeron. "The evidence that they actually improve outcomes is very, very thin," Dr. Lee said.

For the few patients who have trouble swallowing because they have head and neck cancer or esophageal cancer, these drugs or supplements may make sense. But in general, they may add a couple of pounds without improving survival or quality of life, because they don't address the underlying reasons for weight loss.

"Sometimes, families think patients are dying because they're losing weight," Dr. Lee said. "I tell them, they're losing weight because they're dying of something else." There's no evidence that adding calories, increasing fat but not muscle mass, will help them recover. And the drugs have side effects; the hormone-based Megace increases the risk of blood clots, for instance.

The geriatrics society's list also warns doctors not to prescribe new medications without reviewing the drugs that older patients are already taking, since so many can interact in harmful ways.

"In a busy practice, it's hard to look at everything someone is on, every time you prescribe a new drug," Dr. Lee acknowledged. Older adults can be taking a dozen drugs daily. But at the least, the panel said, doctors should review all medications annually.

Finally, the list concludes by cautioning against the use of restraints — tying down hands or legs, using vests or mitts, keeping people in beds with rails or in reclining chairs they can't climb out of. Federal regulations already largely prohibit restraints in nursing homes, but they're still widely used in hospitals, especially in intensive care units, where older patients frequently develop delirium.

But when agitated patients are in restraints, "they generally get more agitated," Dr. Lee said. And when forced to remain in bed, "they can lose strength and muscle mass very quickly. Instead of restraints, we should be thinking about keeping them as active as possible." Family members or "sitters" who can help them walk safely would help, along with tested anti-delirium strategies.

You can read fuller explanations of the list in the current issue of The Journal of the American Geriatrics Society.

Overall, Dr. Lee said, these aren't things that should never happen. "They're things that may be appropriate rarely but are being done frequently," he said, "things that are commonplace and should be much, much less common."

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Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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Well: Think Like a Doctor: Sweating It Solved!

On Thursday, we challenged Well readers to figure out why a 25-year-old man who had recently given up heroin, cocaine and marijuana had a sudden attack of nausea and vomiting so severe that he had to go to the hospital. Two big clues were provided. His nausea and vomiting eased when he took a hot shower, and he regularly used an herbal product that he bought in a neighborhood store called Spice, said to be synthetic marijuana.

We got more than 300 responses. Several of you correctly identified the syndrome as cannabinoid hyperemesis. But given that this young man had a urine toxicology screen that showed he had no cannabinoids in his system, I was also looking for you to link that syndrome to his use of Spice.

Several of you did just that, but the first was Dr. Martine Lamy, an intern in child psychiatry at Cincinnati Children's Hospital Medical Center. Dr. Lamy told me that she had cared for a patient who had the exact same presentation. The young man she had seen, an athlete on a college team, had first developed cannabinoid hyperemesis when he smoked marijuana. Once the college started drug-testing all athletes, she tells me, the whole team switched to Spice, which does not show up on urine screens.

The correct diagnosis is…

Cannabinoid hyperemesis caused by smoking synthetic marijuana.

The Diagnosis:

Cannabinoid hyperemesis, first described in 2004, is a syndrome of nausea and vomiting, compulsive bathing and chronic marijuana use. Dr. James H. Allen, an internist in Adelaide Hills, Australia, became intrigued with a patient who had been repeatedly admitted to the hospital with what was then called psychogenic cyclic vomiting – vomiting because of psychological rather than physiological causes. Oddly, the patient was also constantly showering.

Dr. Allen noticed that the symptoms improved during hospitalization with no intervention and recurred once the patient was sent home. He also noted that at home the patient was a chronic heavy marijuana user and hypothesized that the vomiting might be caused by the drug, while easing of symptoms was linked to abstinence.

Over the next several years, Dr. Allen noted similar patterns in other patients admitted with vomiting disorders. In 2004, he published a report on 10 patients found to have with what he called cannabinoid hyperemesis.

Each patient in his case series smoked marijuana daily; each had developed intermittent nausea and vomiting. All had used marijuana for years before they developed these episodic bouts of nausea and vomiting. And remarkably, nine of the 10 patients reported that hot showers eased their symptoms when everything else failed. All symptoms resolved when these patients gave up marijuana – and then reappeared when they resumed their cannabis use.

A Marijuana Syndrome, Without the Marijuana:

Dr. Allen's case series prompted recognition of similar patients around the world. The mechanism by which marijuana – a drug otherwise recognized for its antiemetic properties – induces vomiting in some chronic heavy users is not well understood. There are several hundred organic compounds in marijuana, and many have been noted to have complex effects on both the brain and the gut.

However, this patient had no marijuana in his system. He said he hadn't smoked it in several months. He did, however, acknowledge using so-called synthetic marijuana. This product, sold under such names such as Spice and K2, has been sold in smoke shops and small stores throughout the United States and Europe since the mid-2000s.

The product looks like dried herbs and, though the labeling often carries the warning "not for human consumption," it is frequently smoked or brewed into tea. The list of ingredients often includes herbal components that have long had the reputation of having marijuana-like psychoactive properties. However, when analyzed, these compounds are often not found, and the effect is provided by chemicals that resemble marijuana's cannabinoids sprayed onto the dried plants.

Many of the most popular of these synthetic cannabinoids were developed in the 1980s by a researcher from Clemson University who created several molecules that bind to the cannabinoid receptors in the brain, stimulating it in a way that is similar to that of the original. Pharmaceutical companies were investigating these molecules to treat pain but abandoned the effort because of the difficulty of isolating the desired qualities of the drug from the unwanted psychoactive effects. Chemical analyses of the products sold as synthetic marijuana has been shown to contain one or more of these chemicals.

In the United States, the Drug Enforcement Agency has tried, with limited success, to ban these products. Several states have also passed laws prohibiting their sale. Nevertheless they are still easy to find around the country.

How the Diagnosis Was Made:

The patient had been admitted to the hospital with a diagnosis of pancreatitis, an inflammation of the pancreas. However, after Dr. Virginia Brady, the resident who talked with and examined the patient that day at Waterbury Hospital, she wasn't sure that was what he had.

Nausea and vomiting are common symptoms of pancreatitis, and he did have very high levels of the enzymes made by the pancreas in his blood. But pancreatitis is an excruciating injury to a very delicate organ, and this patient had no abdominal pain. That made no sense to the young doctor.

Moreover, his story had a familiar ring. The nausea he described – starting in the early hours of the morning, causing terrible and unremitting vomiting that ebbed with a hot shower – sounded like a syndrome she'd seen many times before in patients who smoked pot regularly. Despite marijuana's potent anti-nausea properties, some regular users get episodes of nausea and vomiting that is, strangely, made better when they take a hot shower. Somehow the water – as hot as they can stand it – makes the nausea disappear. It was the defining quality of the syndrome when it was first described by Dr. Allen in 2004.

But this guy said he hadn't smoked marijuana in months. The people Dr. Brady had seen with cannabinoid hyperemesis usually smoked every day. Maybe the patient had relapsed after all.

Dr. Brady ordered a urine toxicology screen; that would show if he had used marijuana recently. However, she knew that methadone clinics like the one this young man visited since he had stopped using heroin tested their patients regularly, so she suspected that he was telling the truth. He probably hadn't smoked pot.

But he did smoke Spice. Could that have caused the young man's illness? Dr. Brady hurried to a computer and looked for a link between Spice and pancreatitis. Nothing. There were a few reports suggesting a link between marijuana and pancreatitis, but nothing about this synthetic marijuana. Moreover, the people in those case reports had the typical symptoms of pancreatitis – nausea, vomiting and abdominal pain. This patient had no pain.

What about the vomiting? Could this so-called synthetic marijuana cause cannabinoid hyperemesis – even if it wasn't the real thing? It seemed unlikely, and yet his symptoms were so typical. She turned to Google to search for the terms cannabinoid hyperemesis and Spice.

Sure enough, there it was – two recent case reports describing several regular synthetic marijuana users who developed a syndrome that was indistinguishable from cannabinoid hyperemesis caused by the real stuff.

Smoking a Lot of Spice:

Dr. Brady went back to the patient. How much synthetic marijuana did he smoke? A lot, he told her. Sometimes 3 to 4 grams a day. With real marijuana, a couple of tokes in the morning would keep him relaxed for most of the day. With the synthetic stuff, the feeling of being relaxed never lasted, and he was constantly chasing it by smoking more and more.

She asked him if he'd heard about cannabinoid hyperemesis. He had. But he hadn't smoked pot since November, he told her. She explained that she was concerned that the stuff he was smoking – the synthetic version – might be a good enough fake to give him the same symptoms.

When the team visited the patient the next morning, he was already dressed and ready to go. No abdominal pain, no nausea. He hadn't vomited in over 12 hours. He was worried that he wouldn't get out of the hospital in time to get his methadone.

What about Spice? the doctor asked. If he went back to smoking it, he'd end up back in the hospital. Never again, he promised. He never wanted to feel that way again. He was out the door within the hour.

How the Patient Is Doing:

I spoke with the patient recently. After several days, he did go back to smoking Spice. And he's been back in the hospital twice in the month since Dr. Brady first saw him.

It's strange, but perhaps not unexpected. In the original case reports of cannabinoid hyperemesis, few of the pot smokers diagnosed with this syndrome were willing to give up their drug, even when they knew it made them so sick. It's perhaps just one more way that the synthetic stuff is like the real thing.

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The New Old Age Blog: Geriatricians Question Five Common Treatments

It tells you something about American health care that scores of medical societies have joined a major campaign aimed at telling patients and doctors what not to do.

That's not exactly the language the Choosing Wisely initiative uses, admittedly. It has recruited more than 60 groups, representing specialties from dermatology to thoracic surgery, to come up with lists delicately called "Five Things Physicians and Patients Should Question."

"Question" sounds better than "flee," doesn't it? And it allows for individual differences in a way that a campaign called "Danger: Unacceptable Side Effects Ahead," or "Watch Out: Useless Procedures," might not.

Still, Choosing Wisely wants to help us select drugs and tests and procedures that are backed by evidence, that don't duplicate other treatments, that are "truly necessary" and won't hurt us. Since 2012, its lists have included hundreds of drugs, tests and practices that fail to meet those standards, with more to come. Point made.

We reported the American Geriatrics Society's first "Five Things" list last year. The society has just published its second list, so I again turned to Dr. Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the panel that developed both lists, to help explain what else older adults should be dodg — um, questioning. (You can see all 10 items here.)

Topping this year's list is a caution against dementia drugs called cholinesterase inhibitors — Arricept is the most widely used — without following up to see whether they're really helping. Dementia is so feared, and the eventual prognosis so grim, that doctors and patients want to do something, anything, to stop its progress.

But while the drug may produce cognitive improvement that is statistically significant in a clinical trial, "it's not clear that it's big enough for a caregiver to even notice, or big enough to make a difference in a patient's quality of life," Dr. Lee said. "We're learning, after more experience with these drugs, that they benefit a minority of patients."

On the other side of the equation, most patients who take them will experience gastrointestinal problems like nausea, cramping and diarrhea that often cause weight loss. So the society urges extensive discussion before doctors prescribe cholinesterase inhibitors and suggests no more than a three-month trial. If there's no meaningful improvement by then, there won't be later. "This is not a medication to start and then forget about," Dr. Lee cautioned.

Grouped second on the list are several tests we've often written about: mammograms for breast cancer, colon cancer screenings and P.S.A. tests for prostate cancer. Older people who are already frail or coping with several chronic diseases, and have life expectancies of less than 10 years, are not likely to benefit from finding such cancers — but they will face the short-term risks of complications and overtreatment from screening. "It may not make sense to expose them to these harms," Dr. Lee said.

Next to avoid: appetite stimulants in cases of weight loss, including high-calorie supplements like Boost and Ensure, or prescription drugs like megestrol acetate (brand name Megace) or the antidepressant Remeron. "The evidence that they actually improve outcomes is very, very thin," Dr. Lee said.

For the few patients who have trouble swallowing because they have head and neck cancer or esophageal cancer, these drugs or supplements may make sense. But in general, they may add a couple of pounds without improving survival or quality of life, because they don't address the underlying reasons for weight loss.

"Sometimes, families think patients are dying because they're losing weight," Dr. Lee said. "I tell them, they're losing weight because they're dying of something else." There's no evidence that adding calories, increasing fat but not muscle mass, will help them recover. And the drugs have side effects; the hormone-based Megace increases the risk of blood clots, for instance.

The geriatrics society's list also warns doctors not to prescribe new medications without reviewing the drugs that older patients are already taking, since so many can interact in harmful ways.

"In a busy practice, it's hard to look at everything someone is on, every time you prescribe a new drug," Dr. Lee acknowledged. Older adults can be taking a dozen drugs daily. But at the least, the panel said, doctors should review all medications annually.

Finally, the list concludes by cautioning against the use of restraints — tying down hands or legs, using vests or mitts, keeping people in beds with rails or in reclining chairs they can't climb out of. Federal regulations already largely prohibit restraints in nursing homes, but they're still widely used in hospitals, especially in intensive care units, where older patients frequently develop delirium.

But when agitated patients are in restraints, "they generally get more agitated," Dr. Lee said. And when forced to remain in bed, "they can lose strength and muscle mass very quickly. Instead of restraints, we should be thinking about keeping them as active as possible." Family members or "sitters" who can help them walk safely would help, along with tested anti-delirium strategies.

You can read fuller explanations of the list in the current issue of The Journal of the American Geriatrics Society.

Overall, Dr. Lee said, these aren't things that should never happen. "They're things that may be appropriate rarely but are being done frequently," he said, "things that are commonplace and should be much, much less common."

---

Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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Well: Allergies Are Everywhere

People hoping to find an allergy-free haven may be out of luck. A new study has found that no region of the United States is allergy-free, but the kind of allergy people are likely to suffer from varies by region, race and socioeconomic status.

Researchers gave blood tests to 8,124 people, 856 of them children under 6, to detect immunoglobulin E antibodies, or IgEs. The presence of an IgE antibody that reacts to a specific substance increases the risk of having an allergy-related illness ike allergic asthma, hay fever or rash.

The scientists tested people for antibodies to a range of potential allergens, including cats, dogs, milk, cockroaches, peanuts, grass, ragweed and shrimp.

No matter where they lived, about 45 percent of people over 6 had positive tests for at least one allergen, and so did 36 percent of the children 1 to 5 years old.

"To me, the biggest surprise is that the level of sensitivities didn't differ region to region," said the senior author, Dr. Darryl C. Zeldin, a scientific director at the National Institute of Environmental Health Sciences. "This goes completely against what most people would have said. The bottom line is that sensitization patterns differ by region, but overall sensitization rates are high."

Grass and ragweed sensitivities were higher in the West, mold allergy more common in the East. Positive tests for indoor allergens were higher in the East than the West, but there were almost no regional differences for peanut, shrimp, egg, dog, cat, rat and mouse sensitivities.

The most common positive tests among the adult group were for dust mites, grass and ragweed, with almost 20 percent of the population showing sensitivity to each. About 12 percent of people over 6 were sensitive to dogs or cats, and among the youngest children, milk and eggs were the most common positive tests. Inhalant allergies like ragweed and grass peaked in the teens and 20s, then decreased later in life.

Race and socioeconomic status also made a difference. Non-Hispanic blacks had the highest sensitivity to all tested allergens except Russian thistle and egg. Sensitivity to cockroaches and shrimp were associated with lower economic status, and dog and cat allergies were more common in higher income groups.

In large metropolitan areas, 50 percent of the population was sensitized to at least one allergen, but only 40 percent in rural areas. Outdoor allergens like grass and ragweed affected 37.8 percent of the urban population, but less than a quarter of people in nonmetropolitan areas, possibly because respiratory allergies are associated with air pollution.

The study, published online in The Journal of Allergy and Clinical Immunology, also found that allergies cluster in groups: people sensitive to dust mites are also likely to be sensitive to grass and tree pollen; sensitivity to peanuts, usually considered a food allergy, tends to cluster with plant allergies; cockroach and shrimp sensitivity are a common pair, probably because they contain a similar allergen, a protein called tropomyosin.

Ganesa Wegienka, an epidemiologist at Henry Ford Hospital in Detroit who was not involved in the research, said that the paper provided "a nice snapshot of what's going on in the U.S.," and she was especially impressed with the data on clusters of sensitivities. "This has implications for doctors and patients," she said. "If a child is sensitized to one allergen in a cluster of allergens, maybe the doctor should be looking at other allergens in the cluster to think about treatment plans."

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Well: Why High-Impact Exercise Is Good for Your Bones

This article appeared in the March 9, 2014 issue of The New York Times Magazine.

Bones should be jarred, for their own good. Past experiments have definitively established that subjecting bones to abrupt stress prompts them to add mass or at least reduces their loss of mass as people age. What has been in dispute, however, is how much force is needed to stimulate bone — and how to apply that force in daily life.

Recently researchers at the University of Bristol gathered male and female adolescents — the body accumulates bone mass rapidly at this time of life — and had them go about their daily routines while they wore activity monitors. The bone density of the volunteers' hips was also measured.

A week later, the scientists reclaimed the monitors to check each teenager's exposure to G forces­, a measure of impact. Those who experienced impacts of 4.2 G's or greater — though these were infrequent — had notably sturdier hipbones. Additional work done by the same researchers showed that running a 10-minute mile or jumping up onto and down from a box at least 15 inches high was needed to produce forces that great. The significance of these findings is that people should probably run pretty fast or jump high to generate forces great enough to help build bone.

Unfortunately, few older adults are likely to be doing so. In follow-up experiments, the same researchers equipped 20 women older than 60 with activity monitors and ran them through an aerobics class, several brief and increasingly brisk walks and a session of stepping onto and off a foot-high box. None of the women reached the 4-G threshold ­— none, in fact, generated more than 2.1 G's of force at any point during the various exercises.

The implications are somewhat concerning. Dr. Jon Tobias, a professor of rheumatology at the University of Bristol who led the experiments, says that while impacts that produce fewer than 4 G's of force may help adults maintain bone mass — a possibility that he and his colleagues are exploring in ongoing experiments — it's unclear what level of force below 4 G's is needed.

So, Dr. Tobias says, young people and healthy adults should probably pound the ground, at least sometimes. Sprint. Jump off a box 15 inches or higher at your gym and jump back up. Hop in place. A study by other researchers published in January found that women between 25 and 50 who hopped at least 10 times twice a day, with 30 seconds between each hop, significantly increased their hipbone density after four months. Another group of subjects, who hopped 20 times daily, showed even greater gains.

Alas, a kind of Catch-22 confronts older individuals who have not been engaging in high-impact exercise: Their bodies and bones may not be capable of handling the types of activity most likely to improve bone health. Dr. Tobias and his colleagues hope to better understand what level of impact will benefit these people. In the meantime, anyone uncertain about the state of his or her bones should consult a physician before undertaking high-impact exercise (a caveat that also applies to those with a history of joint problems, including arthritis). For his part, Dr. Tobias says, "I plan to keep running until my joints wear out."

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Well: How Fat May Hurt the Brain, and How Exercise May Help

Phys Ed

Gretchen Reynolds on the science of fitness.

Obesity may have harmful effects on the brain, and exercise may counteract many of those negative effects, according to sophisticated new neurological experiments with mice, even when the animals do not lose much weight. While it's impossible to know if human brains respond in precisely the same way to fat and physical activity, the findings offer one more reason to get out and exercise.

It's been known for some time that obesity can alter cognition in animals. Past experiments with lab rodents, for instance, have shown that obese animals display poor memory and learning skills compared to their normal-weight peers. They don't recognize familiar objects or recall the location of the exit in mazes that they've negotiated multiple times.

But scientists hadn't understood how excess weight affects the brain. Fat cells, they knew, manufacture and release substances into the bloodstream that flow to other parts of the body, including the heart and muscles. There, these substances jump-start biochemical processes that produce severe inflammation and other conditions that can lead to poor health.

Many thought the brain, though, should be insulated from those harmful effects. It contains no fat cells and sits behind the protective blood-brain barrier that usually blocks the entry of undesirable molecules.

However, recent disquieting studies in animals indicate that obesity weakens that barrier, leaving it leaky and permeable. In obese animals, substances released by fat cells can ooze past the barrier and into the brain.

The consequences of that seepage became the subject of new neurological experiments conducted by researchers at Georgia Regents University in Augusta and published last month in The Journal of Neuroscience. For the studies, the scientists gathered mice bred to overeat and grow obese, which, after a few weeks of sitting quietly in their cages and eating at will, the animals had obligingly accomplished. As they grew rotund and accumulated more fat cells, the researchers found, their blood showed increasingly hefty doses of a substance called interleukin 1 that is created by fat cells and known to cause inflammation.

In these mice, as interleukin 1 migrated to the head, it passed the blood-brain barrier and entered areas such as the hippocampus, a part of the brain critical for learning and memory. There, it essentially gummed up the works, the researchers found when they examined tissue from the animals' brains, which had high levels of interleukin 1 together with widespread markers of inflammation. While inflammation can represent a healthy response to invading molecules, it hurts cells if it persists.

The researchers also noted extremely low levels in these mice brains of a biochemical associated with healthy synapse function. Synapses are the structures that connect one neuron to another and shunt messages between them. Healthy synapses respond to demands on the brain by slowing or speeding messages, keeping the brain's nervous-system traffic manageable. But low levels of the marker of synapse health suggested to the researchers that in these obese animals' inflamed brains, synapses were no longer functioning properly and messages between neurons likely jerked, hiccuped or stalled.

That possibility was borne out by subsequent tests on the memory and thinking of some of the remaining obese mice. They performed miserably.

But whether excessive fat cells alone were the underlying cause of the changes in the animals' brains was not clear. Other physiological factors "could have been contributing," said Alexis Stranahan, a professor at the Medical College of Georgia at Georgia Regents, who oversaw the study. So, to isolate the impact of the fat, the researchers simply removed most of it, surgically excising the large bands of fat that each mouse bore around its middle.

After recovery, these slenderized mice showed almost no interleukin 1 in their bloodstreams and, Algernon-like, soon were acing cognitive tests that had stumped them before surgery.

Conversely, when the scientists implanted the preserved fat pads into previously lean mice — and haven't we all had nightmares about something like that happening to us in our sleep? — the animals almost immediately grew dimmer, performing far worse than previously on cognitive tests, although nothing else in their lives had changed.

The results convincingly implicated fat cells as the primary cause of the mice's cognitive decline.

But while provocative, the findings had little practical value for people, the scientists realized, since even the most extensive liposuction procedure in humans would remove far less fat than had been excised from the obese mice.

So the scientists turned, as a less-invasive alternative, to exercise. Gathering more of the obesity-prone mice, they allowed all of them to grow heavy, but then started half on a daily 45-minute program of treadmill running, with encouragement provided by small puffs of air if they began to flag. The other mice remained sedentary.

After 12 weeks, the running mice still weighed about the same as the unexercised animals. But they had lost significant amounts of fat from around their middles, while adding lean muscle. More telling, they did much better on cognitive tests than the sedentary mice and, when the researchers examined tissue from their hippocampi, showed little evidence of inflammation and robust levels of the chemical marker of synaptic health. The results suggested that, as the scientists write in the study, "treadmill training normalized hippocampal function," even in animals born to be fat and that remained heavy.

Of course, these studies were conducted in mice, not people, whose brains may respond very differently. But the possibility that humans, too, may respond in similar ways is tantalizing, Dr. Stranahan said, and the takeaway from her study worth repeating. "Get out and move," she said, even — and especially — if you carry extra weight. Talk with your doctor about a safe and tolerable exercise program, and then try to stick with that routine so that extra pounds won't weigh too heavily on your mind.

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