Spare No Efforts in Cardiopulmonary Resuscitation Following Cardiac Arrest in the Elderly -- Though Doomed to Fail

"It's a common scenario. And it's not going to have a good outcome."
"She was trying to die, and it was only a matter of time before she arrested again."
"Should CPR even have been started for this patient?"
Dr.Kei Ouchi, emergency physician, researcher, Brigham and Women's Hospital

"Many of us in daily practice have the perception that we regularly do resuscitations that are futile from the inception."
"We wanted to examine that."
Dr.Patrick Druwe, physician, Ghent University Hospital, Belgium

"The big ethics discussion has been around, 'When do we stop'?"
"Only recently have there been discussions about, 'When do we start it'?"
Dr.Monique Starks, cardiologist, Duke University School of Medicine, North Carolina

James Steinberg

Recently, an international network was organized by a team led by Dr.Patrick Druwe at Ghent University, for the purpose of surveying health care professionals in Europe, Japan, Israel and the United States. A study, published in The Journal of the American Geriatrics Society considered CPR for adults over 80 who had experienced out-of-hospital cardiac arrest.

The results of the study shone a spotlight on a number of issues, none very favourable, respecting physician reaction to elderly patients in cardiac arrest. The survival rates were dismal; an outcome reported previously in the medical literature. What the study pointed out was how frequently health care professionals automatically support resuscitation, despite knowing beforehand through experience that the outcome will have poor results. Results though well known to the health community are not shared with the general public.

Roughly 600 clinicians, half of whom were paramedics and emergency technicians, the remainder representing emergency physicians and nurses, were tasked with recalling their most recent patient    aged 80 or more who had undergone CPR. The question put to them was whether they were in agreement with beginning cardiopulmonary resuscitation, and did they feel certain that resuscitation should not have been started, or were they uncertain?

Of the patients in the specific age category suffering cardiac arrest and immediately subjected to CPR,  a mere two percent survived and were able to leave hospital. Despite which over half the clinicians felt CPR was appropriate in those instances, while only 18.5 percent felt it inappropriate. A minority of patients have a 'shockable' rhythm in cardiac arrest, where the heart is moving but abnormally and it is not pumping blood effectively.

With the use of CPR, along with a defibrillator to shock the heart, circulation can be restored and the patient's life saved. Most patients, however, have non-shockable rhythms; their hearts show electrical activity, despite which they aren't pumping at all, and in these instances survival rates tend to fall sharply.  Age increases the proportion of cardiac arrests involving non-shockable rhythms.

Over 40 percent of the cases of cardiac arrest followed by CPR had been 'unwitnessed', which is to say rescuers had no idea how long the patients had been in arrest -- when reality is that the odds of successful resuscitation become increasingly diminished ten percent with each minute that passes while in cardiac arrest. Of the elderly patients with non-shockable rhythms and unwitnessed arrests, none survived hospitalization.

Irrespective of which, 44 percent of the clinicians taking part in the study felt those efforts under those circumstances, to be appropriate. Bleak outcomes following CPR for out-of-hospital cardiac arrest at advanced ages has been documented by other research, even though improvements have been seen in resuscitation results where hospitalized patients have better rates of survival.

Bruce Ayres / Getty Images

Type 2 Diabetes Risk Reduction

"We found that eating plant-based diets was associated with, on average, 23% reduction in diabetes risk."
"We further showed that individuals who consumed a healthy version of the plant-based diet by emphasizing the intake of fresh fruits, vegetables, whole grains, nuts and legumes, and minimizing intake of sugar-sweetened beverages and refined carbohydrates, had a further 30% reduction in their risk of developing type 2 diabetes."
"I would describe these risk reductions as being quite significant." 
"Plant-based diets can promote metabolic health and reduce diabetes risk through many pathways, including preventing excess weight gain, improving insulin sensitivity, reducing inflammation and other mechanisms."
"It does matter what veggies people eat and how the veggies are processed. Therefore, consuming healthy plant foods that are not or minimally processed, such as fresh fruits and vegetables, legumes, nuts, and whole grains, should be emphasized."
Dr. Qi Sun, associate professor, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston 

Healthy plant-based diets can help prevent type 2 diabetes, new analysis suggests.

ISTOCK/LISOVSKAYA

"Plant-based dietary patterns, especially when they are enriched with healthful plant-based foods, may be beneficial for the primary prevention of type 2 diabetes."
"Multiple interventional and observational studies have indicated that increased consumption of plant-based foods can lead to short-term weight loss or prevention of long-term weight gain."
"In turn, it is likely that a considerable proportion of the protective association between plant-based diets and risk of type 2 diabetes can be attributable to weight control."
"Moreover, refined grains, starches, and sugars can also be characterized as plant-based, although they are independently associated with a higher risk of type 2 diabetes." 
Study report, published in JAMA Internal Medicine

"People truly have to understand that what they put in their mouth affects their health. You’re gonna have to commit to yourselves and acknowledge that your current diet is hurting you."
"What if we had a world without processed food in it?" 
"We wouldn’t have the weight problems we have now if it weren’t for processed food. It would be very difficult to become obese while eating a whole-food, plant-based diet."
"By eating the wrong foods, we increase our insulin levels. Increased insulin levels actually block the production of leptin [a hormone that works to regulate appetite by signalling to the brain that enough has been consumed].”
Mara Schwartz, CDE, RN, coordinator, Diabetes Prevention Program, Self Regional Healthcare, Greenwood, South Carolina

Ms. Schwartz, while well-credentialled as a dietitian, knows the issues of controlling diabetes from the inside-out, since she is herself a Type 1 diabetic; completely insulin-dependent. Her body does not produce insulin and to compensate she must take multiple daily doses of insulin injections to maintain life-saving balance controlling her diabetes, enabling her body to process glucose for energy. Most Type 1 diabetics are diagnosed at a young age; diabetes-onset having a large genetic component. Diet management is critical to the health of people with Type 1 diabetes.

Unless diabetes is under control, avoiding both high- and low-blood-sugars through constant monitoring of blood sugar levels, the potential for acquiring further chronic diseases is high, from neuropathy to blindness; kidney failure to amputations, and not least, heart conditions. In contrast it is not some disturbing event that causes the body's immune system to attack its insulin-producing beta cells that causes Type 2 diabetes. This type of mostly non-insulin-dependent diabetes is viewed largely as a middle-age-overweight-sedentary problem leading to the condition.

Type 2 diabetes is generally controlled by a regimen of lifestyle changes including diet, exercise and medications in pill form meant to enable the efficient use of the insulin the body produces through body cells' uptake. In some instances, insulin must be resorted to as therapy when the drugs fail to work. All of the potential incidence of heart and kidney disease, nerve damage, blindness that can assail Type 1 diabetics, are issues that Type 2 diabetics are also susceptible to, requiring careful blood sugar monitoring as part of therapy.

While Type 1 diabetes cannot be avoided until more is known about its onset-provoking mechanisms, Type 2 diabetes is avoidable with a change of lifestyle. And that, critically, includes diet and weight loss. Researchers have produced a new study that categorically validates plant-based diets as a deterrent to weight gain and Type 2 diabetes onset. It was found that those people who adhered to a vegan, a vegetarian or other kind of plant-based diet were 23 percent less susceptible to developing Type 2 diabetes.

Those people who consume a wide variety of meals based on plants are able to reduce risk of diabetes without being strict vegetarians avoiding meat, poultry and fish. On the other hand, white rice, white bread, pastas and other types of highly processed grains vastly reduce the inherent benefits of including grains alongside fresh fruits and vegetables. Those who took part in the study following this kind of nutritional dietary advice were 30 percent less likely to develop Type 2 diabetes than others who ignored the advice.

Undertaking the study, the researchers studied data from nine published studies which totalled 307,099 participants, among them 23,544 people who developed Type 2 diabetes. The studies' timelines ranged from two to 28 years and all of the studies made use of food frequency questionnaires in assessing participants' diets.  The conclusion was that those who most carefully followed a vegan, vegetarian or plant-based diet were more successful in protecting themselves from diabetes onset as opposed to those consuming a lesser amount of plant-based meals.

Fresh vegetables are a good choice. Some processed plant-based foods aren’t always the best option. Getty Images

 

You Are How Old?

"For most people, chronological age corresponds well with emotional and biological age and thus it is often unproblematic that legal age equals chronological age. But this is not always the case."
"Psychologists and medical doctors should be consulted to find out how serious an age change candidate is [along with establishing motivation for the amendment in the birth date]."
"While we can stop whisky from aging by bottling it, we cannot stop humans from aging [but genes, epigenetic changes, lifestyle can influence outcomes], so why should legal age match how long a person has existed for? Why not match legal age with how able and functioning the person actually is?"
"We live in a time when you can change your name and change your gender. Why can't I decide my own age?"
"These are questions that I think biologists and medical doctors should consider together with philosophers and bioethicists."
"Chronological age does not always matter. So why are we so obsessed with it?"
Joona Rasanen, Finnish bioethicist, University of Oslo

In Green / Shutterstock

According to this doctoral research fellow at the University of Oslo, there are moral arguments of a compelling nature to be made permitting people to turn back their age legally, where three set conditions are met:

• The individual feels unreservedly that his/her "felt" age has a meaningful difference from his/her chronological age;
• The person's biological (physiological) age -- the age that person's body and mind by objective measures -- actually differs from legally documented age;
• The individual may be risking ageism such as workplace age discrimination.

The recently released study, published in the Journal of Medical Ethics boosts the belief that 'you are as old as you feel' could be carried forward to a legal recognition of a person's choice to alter their documented age. Legal age, argues this philosopher, need not match chronological age. How swiftly our arteries clog, our bones decay and our cells and organs become health-compromised with age can be attributable in part to the choices we make in life, as well as environmental influences and exposures, beyond diet and exercise.

His argument reflects an experience by Emile Ratelband who sought a legal ruling in his bid to alter his age by reducing it from his actual 60s to his proposed 40s. In so doing, he was willing to forgo the $1,500 Euro monthly pension allotted the elderly in exchange for the legal right to alter his birth date. Having worked as a fashion retailer, tour guide, pancake baker, real estate developer and politician, he states: "My feeling about my body and about my mind is that I'm about 40 or 45". A Dutch court turned him down.

Mr. Rasanen pointed to ageism in society and at the workplace, using as an example that employees at Google, Intel, and IBM, along with a number of other high-tech companies sued for age discrimination. "Young people are just smarter", Mark Zuckerberg was once heard to say in an unguarded moment of communication. As a 'young person', it is unsurprising given the attitude of the young toward the more mature among them, that he would express such an opinion, which facts often belie.

There is always the critical issue of when age in and of its effects on the human body make a truly aged individual inappropriate to hope to be employed in some critical positions that impinge on the safety of others; pilot comes to mind. With an age alteration, each candidate, stresses Mr. Rasanen, would ideally require testing and evaluation.And with the message that an entire new bureaucracy would of necessity have to arise out of what seems like an egotistical whim, one must ask: 'why bother'?

The new method to determine biological ageing could help researchers discover what keeps some people looking and feeling younger   123RF.com

"[The law likes] bright lines and ease of application. It's why we decide that most people, roughly speaking, are mature enough at 18 to do things like get married. It's also fine to call you 70, because it triggers privileges to social programs and ticket discounts, some of it awarded just because you've been on the globe for a certain period of time, not because of your biology."
"If you went from 62 to 25, literally, in all aspects of biology ... it might even require the creation of a new person, meaning a new identity."
"If I reversed myself to 25-years-old, it's not like it's me any more. I have a history, but most of that is irrelevant. I may want to start again and declare myself Arthur Caplan, part two, or Arthur Caplan, beta."                                Bioethicist Arthur Caplan, New York University

Thinking Young, Extending Life

"Children as young as three or four have already taken in the age stereotypes of their culture."
"These age stereotypes are communicated to children through many sources, ranging from stories to social media. Individuals of all ages can benefit from bolstering their positive images of aging."
"We found those who expressed more positive age beliefs at baseline were less likely to develop dementia ... than those who expressed more negative age beliefs."
"We know ... that exposing older individuals to negative age stereotypes exacerbates stress, whereas exposing them to positive age stereotypes can act as a buffer against experiencing stress."
Becca Levy, professor of psychology, Yale University

"Sixty-year-olds felt like they were 46. Seventy-year-olds felt like they were 53. Eighty-year-olds felt like they were 65. It looks like this is pretty consistent across age groups."
"People know that they are aging, but they are evaluating themselves and their lives and reporting feeling about 20 percent younger than their current age."
"Negative views about aging are communicated to us early in life, through media, books and movies, and what our friends and family tell us. These attitudes are present and pervasive already in childhood, so naturally it's hard to enact meaningful change to these attitudes -- but that's what we're trying to do at the moment."
"Part of that [thinking younger by seniors] might arise from not wanting to be considered an older adult. As a result, people could be perpetually pushing what is considered an older adult into the future."
William Chopik, assistant professor of psychology, Michigan State University

"Aging well is not only escaping or delaying disease."
"Feeling good about your life is important and should be considered an important aspect of healthy aging."
Paola Sebastiani, professor of biostatistics, Boston University School of Public Health

One study on attitudes to aging concluded that as people become older they express the opinion that they find it strange to contemplate how old they actually are, because they feel much younger than their chronological age. And then there was the study that took to examining the attitudes of children of centenarians, making the discovery that those children, if they were healthy and long-lived like their parents share a sense of purpose, finding meaning in their lives, in comparison with the thoughts of the general population.


Evidence exists that positive attitudes about aging may even be the cause of a reduction in the risk of acquiring dementia, arguably among the most apprehensively-viewed consequences of aging. The elderly endowed with their own positive sense of time, place and person share a sense of serenity and pleasure in life. Balanced against the public onslaught of negative messaging about aging in the media, the workplace and pervasive throughout popular culture.

So what makes it fascinating for researchers to study is the elderly who firmly grasp their personal sense of confidence as opposed to the general public firmly entrenched in the belief that to be elderly is to be inconsequential generally. Those who can blithely rise about such widespread cultural views and in fact remain steadfastly oblivious to them, firm in their own beliefs of self-value are healthier both psychologically and physically.

Research shows that older people who have positive outlooks on aging eat healthier, exercise more and recover more quickly from illnesses. Credit Fred R. Conrad/The New York Times

Dr. Chopik's study incorporates a survey of over a half million Americans through the Internet, finding that irrespective of people aging, they continue to feel themselves younger than their true age. Subjects from the ages of ten to 89 were questioned to determine that as people grow older their views undergo a change in perception. Teens and young adults equate becoming 50 with old age, an attitude that persists into old age. The elderly on the other hand view 80 as old when they are just 70, and when they become 80, it is 90 that appears to them to be 'old'.


Data from the New England Centenarian Study was used in the study of centenarians' offspring, following close to four thousand centenarians, some of their siblings and children, since 1994. Healthy, long-lived children of centenarians with an average age of 82 were compared by researchers from the Boston University School of Public Health. The study subjects were separated into three groups; their 'birth cohort' (a group who lived only to their early 70s); the study subjects' spouses; and those included in the Health and Retirement Study, a U.S.-wide study of over 30,000 people older than 50.


Respondents were asked their opinion, whether to agree or disagree with statements such as: "I enjoy making plans for the future and working to make them a reality", and "My daily activities often seem trivial and unimportant to me", to measure psychological well-being. Children of centenarians were found to express greater purpose in life than any other of the three groups. For her part, Dr. Levy evaluated 4,765 older people with an average age of 72, free of dementia when the study began, and followed them for a succeeding four years. A series of questions were posed to the participants relating to their aging beliefs.

A protective effect was found for all participants inclusive of those carrying the E4 variant of the gene APOE known to raise the risk of dementia and carried by about a quarter of all Americans, though dementia develops in only 47 percent of this group. It is unknown why the remaining 53 percent never develop dementia, but the APOE E4 carriers with positive beliefs on aging had a 2.7 percent risk of developing dementia while carriers with negative beliefs had a 6.1 percent risk of acquiring dementia.