Seniors are getting urine over-tested and joints over-injected

fallhospitalIt’s the 21st century, and excellent information is more available than ever due to communication and technology advances. But doctors and hospitals keep harming patients by testing and treating them in ways that are unsupported by rigorous medical evidence, and by carrying out safety recommendations in extreme ways.

Just consider:

For patients and their advocates, incidences of over-testing, over-diagnosis, and over-treatment are serious matters. New research finds that doctors themselves worry how small and “incidental” issues in treatment can blow up fast, leading to “cascades of care” — costly, invasive, and destructive episodes in which, in the extreme, treatments escalate in the equivalent of trying to get a rid of gnat with a howitzer.

When locking down older patients causes them harm

Ask any nurse, doctor, or hospital if this notion makes sense: If taking one pill a day is good for you, why not take four or more, because that certainly must be beneficial?

That’s wrong, of course. But, so, too may be the excessive mentality about regulatory compliance that hospitals and their staff may be exercising when trying to safeguard seniors from falls. As the Washington Post explained:

“Falls remain the leading cause of fatal and nonfatal injuries for older Americans. Hospitals face financial penalties when they occur. Nurses and aides get blamed or reprimanded if a patient under their supervision hits the ground. But hospitals have become so overzealous in fall prevention that they are producing an ‘epidemic of immobility,’ experts say. To ensure that patients will never fall, hospitalized patients who could benefit from activity are told not to get up on their own — their bedbound state reinforced by bed alarms and a lack of staff to help them move. That’s especially dangerous for older patients, often weak to begin with. After just a few days of bed rest, their muscles can deteriorate enough to bring severe long-term consequences.”

The newspaper quotes experts about the obstacles and benefits patients confront in trying to stay mobile to preserve their fitness and boost their health:

“Cynthia J. Brown, a professor at the University of Alabama at Birmingham, has identified common reasons older patients stay in bed: They feel too much pain, fatigue or weakness. They have IV lines or catheters that make it more difficult to walk. There’s not enough staff to help them, or they feel they’re burdening nurses if they ask for help. And walking down the hallway in flimsy gowns with messy hair can be embarrassing, she added. Yet walking even a little can pay off. Older patients who walk just 275 steps a day in the hospital show lower rates of readmission after 30 days, research has found.”

Doctors, nurses, and hospitals, of course, should protect patients from injury due to falls. And care giving staff certainly have huge burdens to handle, with this task a priority, too.

But as patients and families can attest the institutions and their people make some of their own problems. Staffing is expensive and challenging. But this can mean that there are never enough nurses and aides to help patients with a big chore that ends up too often with their injury: getting up to get to the bathroom. Experts say hospital rooms too often are designed for medical personnel — not for patients, so bathrooms, even in swanky singles, may be too far to get to easily. They may lack the grab bars to make them safer. Room lighting also can be a challenge, as are floor surfaces. Because hospitals revolve around medical personnel and even food service worker schedules, patients also get wakened and fed mostly at the same time. This also adds to the jam for bathroom help — even as nurses now must deliver an array of complex, time-consuming medical services, all while also dealing with vast arrays of complicated, noisy technology.

Isn’t there a middle ground for hospitals in both protecting patients and not sapping them of capacities they will need to thrive? Institutions may need to worry more about the financial penalties they may incur for patient falls. The nation is graying rapidly, with 10,000 baby boomers turning age 65 each day. This trend is expected to keep up for a decade, meaning hospitals will be caring for a ton of seniors who neither should be injured by mishap (falls) or intention (loss of vitality and even readmission).

Drop that cup routine

The blue-ribbon United States Preventive Services Task Force, in essence, has urged doctors to halt wasteful and unnecessary screening for and treating asymptomatic bacteriuria, because the almost reflexive urine testing in older patients provides no benefit and has potential harms. The group has issued this recommendation — in 2019, 2008, 2004, and 1996.

The advisory has been seconded, Span reported, thusly:

“The Infectious Diseases Society of America, which updated its recommendations this spring, also [has] cautioned against screening and treating, except for pregnant women and patients about to undergo invasive urologic procedures. The Choosing Wisely campaign has similarly weighed in against routine urine testing in older adults.”

Still, as she added, “A recent study in 46 Michigan hospitals, for instance, found that of 2,733 patients [tested and found] with asymptomatic bacteriuria (average age: 77), almost 83% received a full course of antibiotics.”

The challenge here is not just with the testing but also with the subsequent treatment. Span noted that doctors have made it a routine to insist on urine testing with older patients, many of whom may “have urinary systems colonized by bacteria; they will have a positive urine test almost every time, but they’re not sick.”

When patients receive antibiotics, as with any medical treatment, there are risks. As Span reported: “Antibiotics can cause side effects ranging from nausea and rashes to impaired kidney function and interactions with other commonly used drugs, like cardiac medications and antidepressants.”

But, further, the antibiotics can work too well, wiping out beneficial bugs in seniors’ systems, leaving them targets for serious bouts with bacteria like Clostridioides difficile aka C. difficile or C. diff. It’s virulent, hard to get rid of, and has become a significant cause of costly and even lethal hospital acquired infections.

The other major issue with urine testing is that it leads to antibiotic over prescribing and overuse — which is becoming a nightmare, notably for seniors with full-blown urinary tract infections aka UTIs. As Span reported of this condition, quoting Lindsay Petty, lead author of that Michigan study, a doctor, and an infectious disease specialist at the University of Michigan:

“Beyond its effect on individuals, ‘antibiotic resistance is one of the greatest public health crises of our time,’ Dr. Petty said. When bacteria develop resistance to overused drugs, doctors are left with fewer and riskier weapons with which to fight infections. Because UTIs occur so commonly — 40% to 60% of women, in whom they’re far more common than in men, will experience at least one in their lifetimes — it’s easy for doctors and patients to engage in so-called scapegoating, blaming a supposed UTI for problems that may have little to do with the urinary tract.”

Span said that hospitals are trying various tactics to deal with antibiotic over use and abuse, especially in seniors. These include toughening requirements, so doctors can’t routinely order urine tests for seniors.

A call to reduce knee-jerk joint injections

Experts have been hard-pressed to explain the explosion of older patients needing treatment, especially replacements, for bad knees and hips. A collateral course of care for painful joints, alas, has become steroid injections, as Hamblin reported in the Atlantic magazine:

“Doctors have long considered a single injection of steroids—the type that come from the adrenal glands and modulate the body’s stress response—to be a pretty harmless way to temporarily relieve pain in a joint. The worst-case scenario was that the shot didn’t help the pain. Some people get temporary relief, and some do not. Such injections are done by podiatrists, rheumatologists, orthopedists, spine neurosurgeons, anesthesiologists, and others at major hospitals around the world.”

But researchers in Boston, France, and Germany have studied and published in a medical journal about 459 patients who got steroid injections, in the hips or knees, in 2018, finding:

“Of those patients, 8% had complications that worsened the state of their joints. In some cases, the arthritis actually sped up. Others developed small fractures under the cartilage or had complications that compromised the blood supply to bone. In the worst cases, patients had … ‘rapid joint destruction.’”

These findings build on others, Hamblin reported:

“In 2015, Cochrane Musculoskeletal did a meta-analysis to see if the intervention was even helpful. After collating data from 27 knee-arthritis trials carried out around the world, the authors concluded that the quality of evidence was low and overall inconclusive. Some of the studies they analyzed found small to moderate improvements in pain and physical function, but the results were not statistically reliable. Whether there is truly any positive effect, the authors concluded, is ‘unclear.’”

Further, he noted, that research published in 2017 noted that, “people with knee arthritis reported that their pain was no different if they received injections of steroids or saline. What’s more, the people who got the steroid injections saw more erosion in the cartilage in their knees.”

Hamblin said steroid injections are still recommended “in certain cases by the American College of Rheumatology and the Osteoarthritis Research Society International, with caution. The latest guidelines from the American Academy of Orthopaedic Surgeons equivocate on the injections, saying the evidence is not strong enough to recommend for or against them.”

Specialists have found the over-the-counter painkillers can be helpful to patients with joint pain, as can physical therapy and even alternative medicine treatments like acupuncture. These can be preferable to prescription painkillers and staying mobile, especially with physical therapy, may delay or avert the need for surgery, including replacement.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the benefits they can enjoy by staying as healthy as possible — and far from hospitals, doctors, and various kinds of medical care. Hospitals, with the risk of health care acquired infections, can pose many and different perils to patients, some fatal. So can misdiagnoses. Medical error, too, is a far too prevalent and major problem in health care. We have lots of work to do to ensure the safety, efficiency, and excellence of more accessible and affordable medical care — without costly and wasteful over testing, over diagnoses, and over treatment.

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