Friday Reflection 57 : Aging Is Not a Medical Problem

MP is an 88-year-old man who comes to the office for regular follow-up. He is doing well with stable weight and normal vital signs. He takes lisinopril for hypertension and a multivitamin. He does, however, have a few concerns.

He has noted fatigue for the last 7 years or so. Workup has been unremarkable with a normal CMP, CBC, TSH, and sleep study. He goes to sleep at about 10:00, wakes at 2 AM, is up until 3 AM, and only sometimes falls back to sleep. This leaves him tired some afternoons. He is also troubled by chronic knee pain, back pain, and nocturia. He also feels his memory is not what it used to be. He forgets names, sometimes struggles for words, and occasionally goes into a room and forgets why he did. This hasn’t changed much recently.

I love the Acquired podcast. The hosts, Ben Gilbert and David Rosenthal, do exceedingly deep dives into the history of companies. If you haven’t listened, pick a company, set aside a few hours, and give it a listen.^¹ When Ben and Dave (as we like to call them in our house) discuss successful companies, they often talk about “multiplying small numbers by big ones” — making a small profit on each transaction but making lots of transactions.

In my practice, there are two kinds of challenges. There are the difficult cases. These are often cognitively and interpersonally exhausting. Over the days, weeks, or months that they unfold, they wear me out. Of course, these cases are also satisfying. They allow me to put into practice everything I’ve learned over the last 36 years. Difficult cases usually present themselves a few times a month.

Then there are cases like MP; cases that I see every day. The degree of difficulty is lower, but given the prevalence, it is multiplied by a very large number. The prevalence is high because people are essentially reporting symptoms of the human condition. Although longevity folks try to convince us otherwise, human bodies age, and as we get older, more things hurt, we sleep less well, and our cognitive abilities decline.

What needs to be considered when seeing people with symptoms of aging? Like in all primary care, most concerns do not require evaluation and treatment, but some do. The doctor must avoid excessive evaluations while not missing the occasional needle in the haystack. For every hundred or so migraines or tension headaches, there is a case of idiopathic intracranial hypertension or giant cell arteritis.

You never want to attribute the symptoms of a treatable disease to aging. I evaluate every concern, but, in practice, that evaluation entails cognitive work rather than medical testing. If I ordered a test for every concern, I wouldn’t be practicing medicine. I would also lose most of my patients and possibly my job. We rely on our clinical acumen and diagnostic calibration to determine which concerns to consider and which to allocate resources and our patients’ time to evaluate.

Once you decide what needs further evaluation, you need to manage the symptoms that don’t. There is pressure to treat, diagnose, refer — generally medicalize — normal human aging. I had a mentor who once said, “Americans think death is optional.” Some of us have come to believe that aging is also a choice. It can take great care to tell people that their symptoms are a reward for making it to 70, 80, 90, or beyond.

Because it takes care to do this well, it is easier to write an order for imaging, a lab test, a prescription, or a referral.

Where does the pressure to evaluate or treat symptoms of aging like they are diseases come from? Sometimes patients push for the workup. Not unreasonable, as we all want there to be a simple cure for our ills. Sometimes I suspect I misread the desires of my patients. A patient may want reassurance and a sympathetic ear, and I assume they want a cure. This would not be the first area in which physicians systematically misread patients’ expectations.

Caring for people as they age is a privilege. A highlight of my work is hearing about people’s experiences and the wisdom they gained from them. Some of this wisdom pertains to how to deal with aging bodies and minds. The cost of this privilege is negotiating how to counsel people through this process – when to evaluate concerns, when to propose treatments, and when to encourage acceptance.

There are a few things that can always be recommended. For the doctor, offer attention, care, and support when evaluation and treatment are unnecessary. For the patient, do the things that actually support healthy aging: seek and maintain companionship, stay active, do what you love, and sleep and eat well.

Photo Credit: Danie Franco

1. Standard Oil, Epic, and Costco are probably my favorite episodes.