Key clinical point: Soy isoflavones significantly reduced the frequency and duration of migraine attacks, clinical indices, and calcitonin gene-related peptide (CGRP) levels and improved the quality of life in women with migraine.

Major finding: At 8 weeks, soy isoflavones vs placebo significantly reduced migraine frequency (mean change [MC] −2.36 vs −0.43; P < .001) and duration of attacks (MC −2.50 vs −0.02; P < .001), Migraine Headache Index score (MC −10.46 vs −1.47; P < .001), and CGRP levels (MC −12.18 vs −8.62 ng/L; P  =  .002) and significantly improved migraine-specific quality-of-life score (MC 16.76 vs 2.52; P < .001). No adverse effects were reported.

Study details: Findings are from a phase 3 trial including 88 adult women with migraine who had not reached menopausal/perimenopausal age and were randomly assigned to receive 50 mg/day soy isoflavones or placebo supplementation for 8 weeks.

Disclosures: This study was supported by Isfahan University of Medical Sciences, Iran. The authors declared no conflicts of interest.

Source: Babapour M et al. Effect of soy isoflavones supplementation on migraine characteristics, mental status and calcitonin gene-related peptide (CGRP) levels in women with migraine: results of randomised controlled trial. Nutr J. 2022;21:50 (Jul 30). Doi: 10.1186/s12937-022-00802-z

Key clinical point: Soy isoflavones significantly reduced the frequency and duration of migraine attacks, clinical indices, and calcitonin gene-related peptide (CGRP) levels and improved the quality of life in women with migraine.

Major finding: At 8 weeks, soy isoflavones vs placebo significantly reduced migraine frequency (mean change [MC] −2.36 vs −0.43; P < .001) and duration of attacks (MC −2.50 vs −0.02; P < .001), Migraine Headache Index score (MC −10.46 vs −1.47; P < .001), and CGRP levels (MC −12.18 vs −8.62 ng/L; P  =  .002) and significantly improved migraine-specific quality-of-life score (MC 16.76 vs 2.52; P < .001). No adverse effects were reported.

Study details: Findings are from a phase 3 trial including 88 adult women with migraine who had not reached menopausal/perimenopausal age and were randomly assigned to receive 50 mg/day soy isoflavones or placebo supplementation for 8 weeks.

Disclosures: This study was supported by Isfahan University of Medical Sciences, Iran. The authors declared no conflicts of interest.

Source: Babapour M et al. Effect of soy isoflavones supplementation on migraine characteristics, mental status and calcitonin gene-related peptide (CGRP) levels in women with migraine: results of randomised controlled trial. Nutr J. 2022;21:50 (Jul 30). Doi: 10.1186/s12937-022-00802-z

Key clinical point: Soy isoflavones significantly reduced the frequency and duration of migraine attacks, clinical indices, and calcitonin gene-related peptide (CGRP) levels and improved the quality of life in women with migraine.

Major finding: At 8 weeks, soy isoflavones vs placebo significantly reduced migraine frequency (mean change [MC] −2.36 vs −0.43; P < .001) and duration of attacks (MC −2.50 vs −0.02; P < .001), Migraine Headache Index score (MC −10.46 vs −1.47; P < .001), and CGRP levels (MC −12.18 vs −8.62 ng/L; P  =  .002) and significantly improved migraine-specific quality-of-life score (MC 16.76 vs 2.52; P < .001). No adverse effects were reported.

Study details: Findings are from a phase 3 trial including 88 adult women with migraine who had not reached menopausal/perimenopausal age and were randomly assigned to receive 50 mg/day soy isoflavones or placebo supplementation for 8 weeks.

Disclosures: This study was supported by Isfahan University of Medical Sciences, Iran. The authors declared no conflicts of interest.

Source: Babapour M et al. Effect of soy isoflavones supplementation on migraine characteristics, mental status and calcitonin gene-related peptide (CGRP) levels in women with migraine: results of randomised controlled trial. Nutr J. 2022;21:50 (Jul 30). Doi: 10.1186/s12937-022-00802-z

Key clinical point: Patients with diabetes who were screened for diabetic retinopathy (DR) had a lower risk of having migraine; however, DR was not a protective marker of incident migraine.

Major finding: The prevalence of migraine was 17% lower in patients with vs without diabetes (odds ratio [OR] 0.83; 95% CI 0.81-0.85), with the risk being lower in patients with vs without DR (OR 0.69; 95% CI 0.65-0.72). The risk of developing migraine was significantly lower in patients with diabetes and DR level ranging between 1 and 4 compared with matched individuals without diabetes (hazard ratio [HR] 0.66; 95% CI 0.55-0.80), but the risk was independent of the presence of DR.

Study details: The data come from a cross-sectional study including patients with diabetes who attended DR screening (n = 205,970) and age- and sex-matched patients without diabetes (n = 1,003,170).

Disclosures: This study was funded by the The Velux Foundation, Denmark. The authors declared no competing interests.

Source: Vergmann AS et al. Investigation of the correlation between diabetic retinopathy and prevalent and incident migraine in a national cohort study. Sci Rep. 2022;12:12443 (Jul 20). Doi: 10.1038/s41598-022-16793-0

Key clinical point: Patients with diabetes who were screened for diabetic retinopathy (DR) had a lower risk of having migraine; however, DR was not a protective marker of incident migraine.

Major finding: The prevalence of migraine was 17% lower in patients with vs without diabetes (odds ratio [OR] 0.83; 95% CI 0.81-0.85), with the risk being lower in patients with vs without DR (OR 0.69; 95% CI 0.65-0.72). The risk of developing migraine was significantly lower in patients with diabetes and DR level ranging between 1 and 4 compared with matched individuals without diabetes (hazard ratio [HR] 0.66; 95% CI 0.55-0.80), but the risk was independent of the presence of DR.

Study details: The data come from a cross-sectional study including patients with diabetes who attended DR screening (n = 205,970) and age- and sex-matched patients without diabetes (n = 1,003,170).

Disclosures: This study was funded by the The Velux Foundation, Denmark. The authors declared no competing interests.

Source: Vergmann AS et al. Investigation of the correlation between diabetic retinopathy and prevalent and incident migraine in a national cohort study. Sci Rep. 2022;12:12443 (Jul 20). Doi: 10.1038/s41598-022-16793-0

Key clinical point: Patients with diabetes who were screened for diabetic retinopathy (DR) had a lower risk of having migraine; however, DR was not a protective marker of incident migraine.

Major finding: The prevalence of migraine was 17% lower in patients with vs without diabetes (odds ratio [OR] 0.83; 95% CI 0.81-0.85), with the risk being lower in patients with vs without DR (OR 0.69; 95% CI 0.65-0.72). The risk of developing migraine was significantly lower in patients with diabetes and DR level ranging between 1 and 4 compared with matched individuals without diabetes (hazard ratio [HR] 0.66; 95% CI 0.55-0.80), but the risk was independent of the presence of DR.

Study details: The data come from a cross-sectional study including patients with diabetes who attended DR screening (n = 205,970) and age- and sex-matched patients without diabetes (n = 1,003,170).

Disclosures: This study was funded by the The Velux Foundation, Denmark. The authors declared no competing interests.

Source: Vergmann AS et al. Investigation of the correlation between diabetic retinopathy and prevalent and incident migraine in a national cohort study. Sci Rep. 2022;12:12443 (Jul 20). Doi: 10.1038/s41598-022-16793-0

Key clinical point: Bariatric surgery significantly reduced the frequency of migraine attacks, headache severity, and improved the quality of life and disability in patients with chronic migraine and severe obesity.

Major finding: After a mean period of 7.5 ± 2.3 months, there was a significant reduction in the number of migraine attacks (20.9 to 8.3 days; P < .001), headache severity score (7.7 to 4.8; P < .001), Migraine-Specific Quality-of-Life score (44.6 to 26.8; P < .001), and Migraine Disability Assessment Scale score (64.4 to 25.5; P < .001) in patients with chronic migraine who underwent bariatric surgery.

Study details: Findings are from a prospective study including 60 patients with chronic migraine and severe obesity who were referred for bariatric surgery.

Disclosures: This study was supported by Isfahan University of Medical Sciences, Iran, and others. The authors declared no conflicts of interest.

Source: Etefagh HH et al. Bariatric surgery in migraine patients: CGRP level and weight loss. Obes Surg. 2022 (Aug 3). Doi: 10.1007/s11695-022-06218-2

Key clinical point: Bariatric surgery significantly reduced the frequency of migraine attacks, headache severity, and improved the quality of life and disability in patients with chronic migraine and severe obesity.

Major finding: After a mean period of 7.5 ± 2.3 months, there was a significant reduction in the number of migraine attacks (20.9 to 8.3 days; P < .001), headache severity score (7.7 to 4.8; P < .001), Migraine-Specific Quality-of-Life score (44.6 to 26.8; P < .001), and Migraine Disability Assessment Scale score (64.4 to 25.5; P < .001) in patients with chronic migraine who underwent bariatric surgery.

Study details: Findings are from a prospective study including 60 patients with chronic migraine and severe obesity who were referred for bariatric surgery.

Disclosures: This study was supported by Isfahan University of Medical Sciences, Iran, and others. The authors declared no conflicts of interest.

Source: Etefagh HH et al. Bariatric surgery in migraine patients: CGRP level and weight loss. Obes Surg. 2022 (Aug 3). Doi: 10.1007/s11695-022-06218-2

Key clinical point: Bariatric surgery significantly reduced the frequency of migraine attacks, headache severity, and improved the quality of life and disability in patients with chronic migraine and severe obesity.

Major finding: After a mean period of 7.5 ± 2.3 months, there was a significant reduction in the number of migraine attacks (20.9 to 8.3 days; P < .001), headache severity score (7.7 to 4.8; P < .001), Migraine-Specific Quality-of-Life score (44.6 to 26.8; P < .001), and Migraine Disability Assessment Scale score (64.4 to 25.5; P < .001) in patients with chronic migraine who underwent bariatric surgery.

Study details: Findings are from a prospective study including 60 patients with chronic migraine and severe obesity who were referred for bariatric surgery.

Disclosures: This study was supported by Isfahan University of Medical Sciences, Iran, and others. The authors declared no conflicts of interest.

Source: Etefagh HH et al. Bariatric surgery in migraine patients: CGRP level and weight loss. Obes Surg. 2022 (Aug 3). Doi: 10.1007/s11695-022-06218-2

Key clinical point: Once-monthly 120 mg galcanezumab was more effective than placebo in reducing total pain burden (TPB) in patients with chronic or episodic migraine who previously did not benefit from 2-4 categories of migraine preventive medication.

Major finding: At 3 months, galcanezumab vs placebo led to a significantly higher overall percentage change in TPB in patients with chronic (mean difference [MD] −40.4%; P < .001) or episodic (MD −53.1%; P < .001) migraine and significant reductions in monthly number, duration, and severity of migraine headache days in the overall population (all P < .001).

Study details: Findings are from a post hoc analysis of a phase 3 trial, CONQUER, including 458 patients with chronic or episodic migraine who previously did not benefit from 2-4 categories of migraine preventive medication and were randomly assigned to receive galcanezumab or placebo.

Disclosures: This study was sponsored by Eli Lilly and Company. Four authors declared being current or former employees or stockholders of Eli Lilly. J Ailani reported ties with various sources, including Eli Lilly and Company.

Source: Ailani J et al. Effect of galcanezumab on total pain burden in patients who had previously not benefited from migraine preventive medication (CONQUER Trial): A post hoc analysis. Adv Ther. 2022 (Aug 5). Doi: 10.1007/s12325-022-02233-y

Key clinical point: Once-monthly 120 mg galcanezumab was more effective than placebo in reducing total pain burden (TPB) in patients with chronic or episodic migraine who previously did not benefit from 2-4 categories of migraine preventive medication.

Major finding: At 3 months, galcanezumab vs placebo led to a significantly higher overall percentage change in TPB in patients with chronic (mean difference [MD] −40.4%; P < .001) or episodic (MD −53.1%; P < .001) migraine and significant reductions in monthly number, duration, and severity of migraine headache days in the overall population (all P < .001).

Study details: Findings are from a post hoc analysis of a phase 3 trial, CONQUER, including 458 patients with chronic or episodic migraine who previously did not benefit from 2-4 categories of migraine preventive medication and were randomly assigned to receive galcanezumab or placebo.

Disclosures: This study was sponsored by Eli Lilly and Company. Four authors declared being current or former employees or stockholders of Eli Lilly. J Ailani reported ties with various sources, including Eli Lilly and Company.

Source: Ailani J et al. Effect of galcanezumab on total pain burden in patients who had previously not benefited from migraine preventive medication (CONQUER Trial): A post hoc analysis. Adv Ther. 2022 (Aug 5). Doi: 10.1007/s12325-022-02233-y

Key clinical point: Once-monthly 120 mg galcanezumab was more effective than placebo in reducing total pain burden (TPB) in patients with chronic or episodic migraine who previously did not benefit from 2-4 categories of migraine preventive medication.

Major finding: At 3 months, galcanezumab vs placebo led to a significantly higher overall percentage change in TPB in patients with chronic (mean difference [MD] −40.4%; P < .001) or episodic (MD −53.1%; P < .001) migraine and significant reductions in monthly number, duration, and severity of migraine headache days in the overall population (all P < .001).

Study details: Findings are from a post hoc analysis of a phase 3 trial, CONQUER, including 458 patients with chronic or episodic migraine who previously did not benefit from 2-4 categories of migraine preventive medication and were randomly assigned to receive galcanezumab or placebo.

Disclosures: This study was sponsored by Eli Lilly and Company. Four authors declared being current or former employees or stockholders of Eli Lilly. J Ailani reported ties with various sources, including Eli Lilly and Company.

Source: Ailani J et al. Effect of galcanezumab on total pain burden in patients who had previously not benefited from migraine preventive medication (CONQUER Trial): A post hoc analysis. Adv Ther. 2022 (Aug 5). Doi: 10.1007/s12325-022-02233-y

Key clinical point: A dose of 120 mg galcanezumab monthly was effective and well tolerated in patients with episodic migraine.

Major finding: The reduction in mean monthly migraine headache days (MMHD) over 3 months was significantly higher with galcanezumab vs placebo (least squares mean change −3.81 vs −1.99 days; P < .0001), with a higher proportion of patients receiving galcanezumab vs placebo achieving ≥50%, ≥75%, and 100% reductions in MMHD (all P < .0001). The occurrence of serious adverse events was low, with none leading to treatment discontinuation.

Study details: Findings are from the phase 3, PERSIST trial including 520 patients with episodic migraine who were randomly assigned to receive monthly 120 mg galcanezumab or placebo.

Disclosures: This study was funded by Eli Lilly and Company. J Zhuang reported being a full-time employee, and 8 authors reported receiving clinical research fees from Eli Lilly. S Yu reported serving as an associate editor for the Journal of Headache and Pain.

Source: Hu B et al. Galcanezumab in episodic migraine: The phase 3, randomized, double-blind, placebo-controlled PERSIST study. J Headache Pain. 2022;23:90 (Jul 28). Doi: 10.1186/s10194-022-01458-0

Key clinical point: A dose of 120 mg galcanezumab monthly was effective and well tolerated in patients with episodic migraine.

Major finding: The reduction in mean monthly migraine headache days (MMHD) over 3 months was significantly higher with galcanezumab vs placebo (least squares mean change −3.81 vs −1.99 days; P < .0001), with a higher proportion of patients receiving galcanezumab vs placebo achieving ≥50%, ≥75%, and 100% reductions in MMHD (all P < .0001). The occurrence of serious adverse events was low, with none leading to treatment discontinuation.

Study details: Findings are from the phase 3, PERSIST trial including 520 patients with episodic migraine who were randomly assigned to receive monthly 120 mg galcanezumab or placebo.

Disclosures: This study was funded by Eli Lilly and Company. J Zhuang reported being a full-time employee, and 8 authors reported receiving clinical research fees from Eli Lilly. S Yu reported serving as an associate editor for the Journal of Headache and Pain.

Source: Hu B et al. Galcanezumab in episodic migraine: The phase 3, randomized, double-blind, placebo-controlled PERSIST study. J Headache Pain. 2022;23:90 (Jul 28). Doi: 10.1186/s10194-022-01458-0

Key clinical point: A dose of 120 mg galcanezumab monthly was effective and well tolerated in patients with episodic migraine.

Major finding: The reduction in mean monthly migraine headache days (MMHD) over 3 months was significantly higher with galcanezumab vs placebo (least squares mean change −3.81 vs −1.99 days; P < .0001), with a higher proportion of patients receiving galcanezumab vs placebo achieving ≥50%, ≥75%, and 100% reductions in MMHD (all P < .0001). The occurrence of serious adverse events was low, with none leading to treatment discontinuation.

Study details: Findings are from the phase 3, PERSIST trial including 520 patients with episodic migraine who were randomly assigned to receive monthly 120 mg galcanezumab or placebo.

Disclosures: This study was funded by Eli Lilly and Company. J Zhuang reported being a full-time employee, and 8 authors reported receiving clinical research fees from Eli Lilly. S Yu reported serving as an associate editor for the Journal of Headache and Pain.

Source: Hu B et al. Galcanezumab in episodic migraine: The phase 3, randomized, double-blind, placebo-controlled PERSIST study. J Headache Pain. 2022;23:90 (Jul 28). Doi: 10.1186/s10194-022-01458-0

Rare gene variants are associated with a reduced risk for multiple types of liver disease, including cirrhosis, researchers say.

People with certain variants in the gene CIDEB are one-third less likely to develop any sort of liver disease, according to Aris Baras, MD, a senior vice president at Regeneron, and colleagues.

“The unprecedented protective effect that these CIDEB genetic variants have against liver disease provides us with one of our most exciting targets and potential therapeutic approaches for a notoriously hard-to-treat disease where there are currently no approved treatments,” said Dr. Baras in a press release.

Dr. Baras and colleagues published the finding in The New England Journal of Medicine.

The finding follows on a similar discovery about a common variant in the gene HSD17B13. Treatments targeting this gene are being tested in clinical trials.

To search for more such genes, the researchers analyzed human exomes – the part of the genome that codes for proteins – to look for associations between gene variants and liver function.

The researchers used exome sequencing on 542,904 people from the UK Biobank, the Geisinger Health System MyCode cohort, and other datasets.

They found that coding variants in APOB, ABCB4, SLC30A10, and TM6SF2 were associated with increased aminotransferase levels and an increased risk for liver disease.

But variants in CIDEB were associated with decreased levels of alanine aminotransferase, a biomarker of hepatocellular injury. And they were associated with a decreased risk for liver disease of any cause (odds ratio per allele, 0.67; 95% confidence interval, 0.57-0.79).

The CIDEB variants were present in only 0.7% of the persons in the study.

Zeroing in on various kinds of liver disease, the researchers found that the CIDEB variants were associated with a reduced risk for alcoholic liver disease, nonalcoholic liver disease, any liver cirrhosis, alcoholic liver cirrhosis, nonalcoholic liver cirrhosis, and viral hepatitis.

In 3,599 patients who had undergone bariatric surgery, variants in CIDEB were associated with a reduced nonalcoholic fatty liver disease activity score of –0.98 beta per allele in score units, where scores range from 0-8, with a higher score indicating more severe disease.

In patients for whom MRI data were available, those with rare coding variants in CIDEB had lower proportions of liver fat. However, percentage of liver fat did not fully explain the reduced risk for liver disease.

Pursuing another line of investigation, the researchers found that they could prevent the buildup of large lipid droplets in oleic acid-treated human hepatoma cell lines by silencing the CIDEB gene using small interfering RNA.

The association was particularly strong among people with higher body mass indices and type 2 diabetes.

The associations with the rare protective CIDEB variants were consistent across ancestries, but people of non-European ancestry, who might be disproportionately affected by liver disease, were underrepresented in the database, the researchers note.

The study was supported by Regeneron Pharmaceuticals, which also employed several of the researchers.

A version of this article first appeared on Medscape.com.

Rare gene variants are associated with a reduced risk for multiple types of liver disease, including cirrhosis, researchers say.

People with certain variants in the gene CIDEB are one-third less likely to develop any sort of liver disease, according to Aris Baras, MD, a senior vice president at Regeneron, and colleagues.

“The unprecedented protective effect that these CIDEB genetic variants have against liver disease provides us with one of our most exciting targets and potential therapeutic approaches for a notoriously hard-to-treat disease where there are currently no approved treatments,” said Dr. Baras in a press release.

Dr. Baras and colleagues published the finding in The New England Journal of Medicine.

The finding follows on a similar discovery about a common variant in the gene HSD17B13. Treatments targeting this gene are being tested in clinical trials.

To search for more such genes, the researchers analyzed human exomes – the part of the genome that codes for proteins – to look for associations between gene variants and liver function.

The researchers used exome sequencing on 542,904 people from the UK Biobank, the Geisinger Health System MyCode cohort, and other datasets.

They found that coding variants in APOB, ABCB4, SLC30A10, and TM6SF2 were associated with increased aminotransferase levels and an increased risk for liver disease.

But variants in CIDEB were associated with decreased levels of alanine aminotransferase, a biomarker of hepatocellular injury. And they were associated with a decreased risk for liver disease of any cause (odds ratio per allele, 0.67; 95% confidence interval, 0.57-0.79).

The CIDEB variants were present in only 0.7% of the persons in the study.

Zeroing in on various kinds of liver disease, the researchers found that the CIDEB variants were associated with a reduced risk for alcoholic liver disease, nonalcoholic liver disease, any liver cirrhosis, alcoholic liver cirrhosis, nonalcoholic liver cirrhosis, and viral hepatitis.

In 3,599 patients who had undergone bariatric surgery, variants in CIDEB were associated with a reduced nonalcoholic fatty liver disease activity score of –0.98 beta per allele in score units, where scores range from 0-8, with a higher score indicating more severe disease.

In patients for whom MRI data were available, those with rare coding variants in CIDEB had lower proportions of liver fat. However, percentage of liver fat did not fully explain the reduced risk for liver disease.

Pursuing another line of investigation, the researchers found that they could prevent the buildup of large lipid droplets in oleic acid-treated human hepatoma cell lines by silencing the CIDEB gene using small interfering RNA.

The association was particularly strong among people with higher body mass indices and type 2 diabetes.

The associations with the rare protective CIDEB variants were consistent across ancestries, but people of non-European ancestry, who might be disproportionately affected by liver disease, were underrepresented in the database, the researchers note.

The study was supported by Regeneron Pharmaceuticals, which also employed several of the researchers.

A version of this article first appeared on Medscape.com.

Rare gene variants are associated with a reduced risk for multiple types of liver disease, including cirrhosis, researchers say.

People with certain variants in the gene CIDEB are one-third less likely to develop any sort of liver disease, according to Aris Baras, MD, a senior vice president at Regeneron, and colleagues.

“The unprecedented protective effect that these CIDEB genetic variants have against liver disease provides us with one of our most exciting targets and potential therapeutic approaches for a notoriously hard-to-treat disease where there are currently no approved treatments,” said Dr. Baras in a press release.

Dr. Baras and colleagues published the finding in The New England Journal of Medicine.

The finding follows on a similar discovery about a common variant in the gene HSD17B13. Treatments targeting this gene are being tested in clinical trials.

To search for more such genes, the researchers analyzed human exomes – the part of the genome that codes for proteins – to look for associations between gene variants and liver function.

The researchers used exome sequencing on 542,904 people from the UK Biobank, the Geisinger Health System MyCode cohort, and other datasets.

They found that coding variants in APOB, ABCB4, SLC30A10, and TM6SF2 were associated with increased aminotransferase levels and an increased risk for liver disease.

But variants in CIDEB were associated with decreased levels of alanine aminotransferase, a biomarker of hepatocellular injury. And they were associated with a decreased risk for liver disease of any cause (odds ratio per allele, 0.67; 95% confidence interval, 0.57-0.79).

The CIDEB variants were present in only 0.7% of the persons in the study.

Zeroing in on various kinds of liver disease, the researchers found that the CIDEB variants were associated with a reduced risk for alcoholic liver disease, nonalcoholic liver disease, any liver cirrhosis, alcoholic liver cirrhosis, nonalcoholic liver cirrhosis, and viral hepatitis.

In 3,599 patients who had undergone bariatric surgery, variants in CIDEB were associated with a reduced nonalcoholic fatty liver disease activity score of –0.98 beta per allele in score units, where scores range from 0-8, with a higher score indicating more severe disease.

In patients for whom MRI data were available, those with rare coding variants in CIDEB had lower proportions of liver fat. However, percentage of liver fat did not fully explain the reduced risk for liver disease.

Pursuing another line of investigation, the researchers found that they could prevent the buildup of large lipid droplets in oleic acid-treated human hepatoma cell lines by silencing the CIDEB gene using small interfering RNA.

The association was particularly strong among people with higher body mass indices and type 2 diabetes.

The associations with the rare protective CIDEB variants were consistent across ancestries, but people of non-European ancestry, who might be disproportionately affected by liver disease, were underrepresented in the database, the researchers note.

The study was supported by Regeneron Pharmaceuticals, which also employed several of the researchers.

A version of this article first appeared on Medscape.com.

Factors operating at the community level may help explain disparities in rates of hepatocellular carcinoma (HCC) across Texas.

Researchers found that the risk for HCC is higher in neighborhoods characterized by minority populations, socioeconomic disadvantage, and blue-collar workers from specific industries.

However, these relationships are not uniform across the state, report researchers from Baylor College of Medicine, Houston.

“HCC is a serious health concern in Texas, and our foundational work is a step forward to better prevent this deadly disease,” study investigator Hashem El-Serag, MD, PhD, said in a news release.

The study was published online in Clinical Gastroenterology and Hepatology.

HCC is the most common type of liver cancer in the United States, and Texas has the highest rate of HCC. Yet, within Texas, incidence rates vary by race, ethnicity, and geographic location.

The Baylor team examined these disparities at the neighborhood level, with a focus on measures of social determinants of health and the industries where most neighborhood residents work.

They identified 11,547 Texas residents diagnosed with HCC between 2011 and 2015, at a mean age of 63 years. Roughly three-quarters were men, and 44% were non-Hispanic White, 14% non-Hispanic Black, 37% Hispanic, and 5% other.

The researchers used demographics, socioeconomic status, and employment provided by the U.S. Census Bureau to characterize the neighborhoods where these people lived when they were diagnosed with HCC.

Among their key findings, the risk for HCC among African American and Hispanic residents was highest in West Texas, South Texas, and the panhandle. However, some factors, like age and socioeconomic status, were not affected by location.

Across the entire state, however, people older than 60 years and those of low socioeconomic status had a higher relative risk for HCC.

Two areas of employment – construction and service occupations – also stood out as being associated with a higher risk for HCC, whereas employment in agriculture was associated with lower risk.

The authors caution that the ecological nature of the study precludes any firm conclusions regarding a causal link between working in these industries and HCC.

“Further research, including longitudinal studies, [is] needed to clarify the roles of specific occupations in HCC risk,” corresponding author Abiodun Oluyomi, PhD, said in the news release.

“Our findings validate factors previously associated with HCC, and our geographic analysis shows areas of Texas where specific intervention strategies may be most relevant,” Dr. Oluyomi added.

This research was supported by the Cancer Prevention & Research Institute of Texas. The authors have no relevant disclosures.

A version of this article first appeared on Medscape.com.

Factors operating at the community level may help explain disparities in rates of hepatocellular carcinoma (HCC) across Texas.

Researchers found that the risk for HCC is higher in neighborhoods characterized by minority populations, socioeconomic disadvantage, and blue-collar workers from specific industries.

However, these relationships are not uniform across the state, report researchers from Baylor College of Medicine, Houston.

“HCC is a serious health concern in Texas, and our foundational work is a step forward to better prevent this deadly disease,” study investigator Hashem El-Serag, MD, PhD, said in a news release.

The study was published online in Clinical Gastroenterology and Hepatology.

HCC is the most common type of liver cancer in the United States, and Texas has the highest rate of HCC. Yet, within Texas, incidence rates vary by race, ethnicity, and geographic location.

The Baylor team examined these disparities at the neighborhood level, with a focus on measures of social determinants of health and the industries where most neighborhood residents work.

They identified 11,547 Texas residents diagnosed with HCC between 2011 and 2015, at a mean age of 63 years. Roughly three-quarters were men, and 44% were non-Hispanic White, 14% non-Hispanic Black, 37% Hispanic, and 5% other.

The researchers used demographics, socioeconomic status, and employment provided by the U.S. Census Bureau to characterize the neighborhoods where these people lived when they were diagnosed with HCC.

Among their key findings, the risk for HCC among African American and Hispanic residents was highest in West Texas, South Texas, and the panhandle. However, some factors, like age and socioeconomic status, were not affected by location.

Across the entire state, however, people older than 60 years and those of low socioeconomic status had a higher relative risk for HCC.

Two areas of employment – construction and service occupations – also stood out as being associated with a higher risk for HCC, whereas employment in agriculture was associated with lower risk.

The authors caution that the ecological nature of the study precludes any firm conclusions regarding a causal link between working in these industries and HCC.

“Further research, including longitudinal studies, [is] needed to clarify the roles of specific occupations in HCC risk,” corresponding author Abiodun Oluyomi, PhD, said in the news release.

“Our findings validate factors previously associated with HCC, and our geographic analysis shows areas of Texas where specific intervention strategies may be most relevant,” Dr. Oluyomi added.

This research was supported by the Cancer Prevention & Research Institute of Texas. The authors have no relevant disclosures.

A version of this article first appeared on Medscape.com.

Factors operating at the community level may help explain disparities in rates of hepatocellular carcinoma (HCC) across Texas.

Researchers found that the risk for HCC is higher in neighborhoods characterized by minority populations, socioeconomic disadvantage, and blue-collar workers from specific industries.

However, these relationships are not uniform across the state, report researchers from Baylor College of Medicine, Houston.

“HCC is a serious health concern in Texas, and our foundational work is a step forward to better prevent this deadly disease,” study investigator Hashem El-Serag, MD, PhD, said in a news release.

The study was published online in Clinical Gastroenterology and Hepatology.

HCC is the most common type of liver cancer in the United States, and Texas has the highest rate of HCC. Yet, within Texas, incidence rates vary by race, ethnicity, and geographic location.

The Baylor team examined these disparities at the neighborhood level, with a focus on measures of social determinants of health and the industries where most neighborhood residents work.

They identified 11,547 Texas residents diagnosed with HCC between 2011 and 2015, at a mean age of 63 years. Roughly three-quarters were men, and 44% were non-Hispanic White, 14% non-Hispanic Black, 37% Hispanic, and 5% other.

The researchers used demographics, socioeconomic status, and employment provided by the U.S. Census Bureau to characterize the neighborhoods where these people lived when they were diagnosed with HCC.

Among their key findings, the risk for HCC among African American and Hispanic residents was highest in West Texas, South Texas, and the panhandle. However, some factors, like age and socioeconomic status, were not affected by location.

Across the entire state, however, people older than 60 years and those of low socioeconomic status had a higher relative risk for HCC.

Two areas of employment – construction and service occupations – also stood out as being associated with a higher risk for HCC, whereas employment in agriculture was associated with lower risk.

The authors caution that the ecological nature of the study precludes any firm conclusions regarding a causal link between working in these industries and HCC.

“Further research, including longitudinal studies, [is] needed to clarify the roles of specific occupations in HCC risk,” corresponding author Abiodun Oluyomi, PhD, said in the news release.

“Our findings validate factors previously associated with HCC, and our geographic analysis shows areas of Texas where specific intervention strategies may be most relevant,” Dr. Oluyomi added.

This research was supported by the Cancer Prevention & Research Institute of Texas. The authors have no relevant disclosures.

A version of this article first appeared on Medscape.com.

Adults who quit smoking significantly reduced their risk for mortality from pneumonia; the risk decreased even more with added years of not smoking, according to data from nearly 95,000 individuals.

Smoking is associated with an increased risk for pneumonia, but the extent to which smoking cessation reduces this risk long-term has not been explored, wrote Tomomi Kihara, MD, PhD, of the University of Tsukuba, Japan, and colleagues on behalf of the Japan Collaborative Cohort.

In the Japan Collaborative Cohort Study for Evaluation of Cancer Risk, known as the JACC Study, a community-based cohort of 110,585 individuals aged 40-79 years participated in health screening exams and self-administered questionnaires that included information about smoking. Other findings from the study have been previously published.

In the current study published in Preventive Medicine, the researchers reviewed data from 94,972 JACC participants who provided data about smoking status, including 59,514 never-smokers, 10,554 former smokers, and 24,904 current smokers. The mean age of the participants was 57 years; 57% were women.

The respondents were divided into groups based on years of smoking cessation: 0-1 year, 2-4 years, 5-9 years, 10-14 years, and 15 or more years. The primary endpoint was an underlying cause of death from pneumonia.

Over a median follow-up period of 19 years, 1,806 participants (1,115 men and 691 women) died of pneumonia.

In a multivariate analysis, the hazard ratio for those who quit smoking, compared with current smokers, was 1.02 for 0-1 year of smoking cessation, 0.92 for 2-4 years, 0.95 for 5-9 years, 0.71 for 10-14 years, and 0.63 (0.48-0.83) for 15 or more years. The HR for never smokers was 0.50. The analysis adjusted for competing risk for death without pneumonia in the study population.

Most of the benefits of smoking cessation occurred after 10-14 years, the researchers wrote in their discussion of the findings, and smoking cessation of 10 years or more resulted in risk for death from pneumonia similar to that of never-smokers.

“To our knowledge, no previous studies have examined the association between years of smoking cessation and pneumonia in a general population,” they added.

The study findings were limited by several factors, including the use of data on smoking and smoking cessation at baseline as well as a lack of data on the use of tobacco products other than cigarettes, although alternative tobacco products are rarely used in Japan, the researchers noted. Other limitations include the use of pneumonia mortality as an endpoint, which could have ignored the impact of smoking cessation on less severe pneumonia, and the inability to clarify the association between smoking cessation and pneumonia mortality by sex because of the small number of female former smokers. However, the results were strengthened by the large sample size and long observation period, they said.

“The present study provides empirical evidence that smoking cessation may lead to a decline in the risk of mortality from pneumonia,” and supports smoking cessation as a preventive measure, the researchers concluded.

The study was supported by the Japanese Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare, Health and Labor Sciences; and an Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center. The researchers had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.

Adults who quit smoking significantly reduced their risk for mortality from pneumonia; the risk decreased even more with added years of not smoking, according to data from nearly 95,000 individuals.

Smoking is associated with an increased risk for pneumonia, but the extent to which smoking cessation reduces this risk long-term has not been explored, wrote Tomomi Kihara, MD, PhD, of the University of Tsukuba, Japan, and colleagues on behalf of the Japan Collaborative Cohort.

In the Japan Collaborative Cohort Study for Evaluation of Cancer Risk, known as the JACC Study, a community-based cohort of 110,585 individuals aged 40-79 years participated in health screening exams and self-administered questionnaires that included information about smoking. Other findings from the study have been previously published.

In the current study published in Preventive Medicine, the researchers reviewed data from 94,972 JACC participants who provided data about smoking status, including 59,514 never-smokers, 10,554 former smokers, and 24,904 current smokers. The mean age of the participants was 57 years; 57% were women.

The respondents were divided into groups based on years of smoking cessation: 0-1 year, 2-4 years, 5-9 years, 10-14 years, and 15 or more years. The primary endpoint was an underlying cause of death from pneumonia.

Over a median follow-up period of 19 years, 1,806 participants (1,115 men and 691 women) died of pneumonia.

In a multivariate analysis, the hazard ratio for those who quit smoking, compared with current smokers, was 1.02 for 0-1 year of smoking cessation, 0.92 for 2-4 years, 0.95 for 5-9 years, 0.71 for 10-14 years, and 0.63 (0.48-0.83) for 15 or more years. The HR for never smokers was 0.50. The analysis adjusted for competing risk for death without pneumonia in the study population.

Most of the benefits of smoking cessation occurred after 10-14 years, the researchers wrote in their discussion of the findings, and smoking cessation of 10 years or more resulted in risk for death from pneumonia similar to that of never-smokers.

“To our knowledge, no previous studies have examined the association between years of smoking cessation and pneumonia in a general population,” they added.

The study findings were limited by several factors, including the use of data on smoking and smoking cessation at baseline as well as a lack of data on the use of tobacco products other than cigarettes, although alternative tobacco products are rarely used in Japan, the researchers noted. Other limitations include the use of pneumonia mortality as an endpoint, which could have ignored the impact of smoking cessation on less severe pneumonia, and the inability to clarify the association between smoking cessation and pneumonia mortality by sex because of the small number of female former smokers. However, the results were strengthened by the large sample size and long observation period, they said.

“The present study provides empirical evidence that smoking cessation may lead to a decline in the risk of mortality from pneumonia,” and supports smoking cessation as a preventive measure, the researchers concluded.

The study was supported by the Japanese Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare, Health and Labor Sciences; and an Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center. The researchers had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.

Adults who quit smoking significantly reduced their risk for mortality from pneumonia; the risk decreased even more with added years of not smoking, according to data from nearly 95,000 individuals.

Smoking is associated with an increased risk for pneumonia, but the extent to which smoking cessation reduces this risk long-term has not been explored, wrote Tomomi Kihara, MD, PhD, of the University of Tsukuba, Japan, and colleagues on behalf of the Japan Collaborative Cohort.

In the Japan Collaborative Cohort Study for Evaluation of Cancer Risk, known as the JACC Study, a community-based cohort of 110,585 individuals aged 40-79 years participated in health screening exams and self-administered questionnaires that included information about smoking. Other findings from the study have been previously published.

In the current study published in Preventive Medicine, the researchers reviewed data from 94,972 JACC participants who provided data about smoking status, including 59,514 never-smokers, 10,554 former smokers, and 24,904 current smokers. The mean age of the participants was 57 years; 57% were women.

The respondents were divided into groups based on years of smoking cessation: 0-1 year, 2-4 years, 5-9 years, 10-14 years, and 15 or more years. The primary endpoint was an underlying cause of death from pneumonia.

Over a median follow-up period of 19 years, 1,806 participants (1,115 men and 691 women) died of pneumonia.

In a multivariate analysis, the hazard ratio for those who quit smoking, compared with current smokers, was 1.02 for 0-1 year of smoking cessation, 0.92 for 2-4 years, 0.95 for 5-9 years, 0.71 for 10-14 years, and 0.63 (0.48-0.83) for 15 or more years. The HR for never smokers was 0.50. The analysis adjusted for competing risk for death without pneumonia in the study population.

Most of the benefits of smoking cessation occurred after 10-14 years, the researchers wrote in their discussion of the findings, and smoking cessation of 10 years or more resulted in risk for death from pneumonia similar to that of never-smokers.

“To our knowledge, no previous studies have examined the association between years of smoking cessation and pneumonia in a general population,” they added.

The study findings were limited by several factors, including the use of data on smoking and smoking cessation at baseline as well as a lack of data on the use of tobacco products other than cigarettes, although alternative tobacco products are rarely used in Japan, the researchers noted. Other limitations include the use of pneumonia mortality as an endpoint, which could have ignored the impact of smoking cessation on less severe pneumonia, and the inability to clarify the association between smoking cessation and pneumonia mortality by sex because of the small number of female former smokers. However, the results were strengthened by the large sample size and long observation period, they said.

“The present study provides empirical evidence that smoking cessation may lead to a decline in the risk of mortality from pneumonia,” and supports smoking cessation as a preventive measure, the researchers concluded.

The study was supported by the Japanese Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare, Health and Labor Sciences; and an Intramural Research Fund for Cardiovascular Diseases of National Cerebral and Cardiovascular Center. The researchers had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

A version of this article first appeared on Medscape.com.

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

A version of this article first appeared on Medscape.com.

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

A version of this article first appeared on Medscape.com.

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

A version of this article first appeared on Medscape.com.

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

A version of this article first appeared on Medscape.com.

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

A version of this article first appeared on Medscape.com.