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Medical confusion - why a stress test?


Greta
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My husband is quite athletic:  he runs, he bikes, he hikes, he climbs, etc.  He was experiencing a mild arrhythmia during exercise, so (among other things) the doctor ordered a stress test.  This makes perfect sense:  the arrhythmia was happening during exercise, so they needed to see what's going on with his heart during exercise.  His resting heart rate was very low (athletic range), his blood pressure was perfect, his heart muscle was strong, and he was in very good overall health.  So, I get the need for a stress test in this situation.  It presents virtually no danger to do it, and the information is needed.

Here's what don't get.  My grandmother is 102 years old.  She is still ambulatory but has poor balance.  She must hold on to something while she walks (railings, furniture, a cane - but she refuses to use a walker.)  She has fallen a couple of times, but luckily only bruises and scrapes, no broken bones.  She's had high blood pressure for awhile.  And she was recently diagnosed with congestive heart failure.  And her doctor ordered a stress test.

WHY???  What possible good could come from putting a 102 year old woman with poor balance and a failing heart on a treadmill to stress her heart?!?  My uncle, who is not the only but the primary care giver to my grandmother, said "no way" to the doctor, so it's not happening (and all the other caregivers, like my mom, were in full agreement).  But I'm just dumbfounded that the doctor would even consider such a thing.  

This is not a JAWM, I really want to know. Is my grandmother's doctor the complete idiot that I think he is?  Or am I overreacting, and there really is some medically justifiable reason for putting her through such a difficult and risky test?  (My opinion is no doubt colored by the fact that I've known two people who had heart attacks during stress tests, one of whom died.)

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8 minutes ago, onelittlemonkey said:

That’s nuts.   I’m glad your uncle said no.   Like you, I’m flabbergasted.   I had an aunt die at age 50 at her stress test just a few years ago.   I would definitely not put the elderly on one at all. 

 

Oh, I am so sorry about your aunt.  And I appreciate your reply.  It does seem to me like sometimes doctors don't weigh out the potential benefits of the test against the risks.

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1 hour ago, kand said:

 Are you sure it was going to be a treadmill stress test? My understanding is that there’s another version that involves administering a drug to serve as the heart stressor. Although, I don’t really see what the point is with someone who is 102. 

 

Good point - I should have mentioned that.  My mom's understanding was that it was the treadmill test.  But she wasn't at this particular appointment, so that's second-hand information.  My other grandmother had the chemical stress test when she was in her late 60's or early 70's, and it was so horrible, she said she wanted no more tests, she'd rather just die.  So I'm not sure it would be any better!  

Edit:  this wasn't discussed at an appointment, but over the phone after her most recent appointment.  

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17 minutes ago, scholastica said:

Honestly, I think it's to avoid a malpractice lawsuit. So many doctors are doing unnecessary testing to cover their butts.

 

I hadn't thought of that -- doctors are probably more likely to get sued for not ordering a test than for ordering a test that harms or even kills you.

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12 minutes ago, happysmileylady said:

It may also be an insurance thing.  My BIL had to have surgery on his hip.  He and his docs knew he had to have the surgery.  He had multiple images taken over the years, (X-rays, scans, etc). But insurance wouldn’t PAY for the surgery without a particular “updated” scan.  Which was totally pointless because they already had all the previous scans.  This was a degenerative thing, (and I don’t remember what exactly, it was a while ago) and not something that ever just gets better/goes away.  Surgery was inevitable. But before insurance paid, they paid for him to do this useless scan basically so the doc could say to them “yep, still a problem.”

 

That's weird - seems more like a waste of their money than anything.  That could be the case here, and maybe I don't have all the details.  As far as I know, there is no other treatment he is recommending besides the medications that he's already prescribed.  So I'm not sure what the stress test would be proving.  But I'm 500+ miles away and getting all of my information second- and third- hand, so who knows!

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There is an increased push to treat elderly people the same as those under 70. I heard many times in nursing school that if the elderly were treated as aggressively as younger people are most people would live to around 120 years old. Whether that is a good choice for an individual or not probably has more to do with mental capacity and their own personal wishes than their physical health.  If your grandmother were young of heart and wanted to live as long as possible you may have cried age discrimination for not offering the test to her.  I recently got very upset when someone dismissed my grandmother's cancer scare because of her age - basically she's a widow whose mother died of cancer 20 years younger so why fight it?  And a cousin who is a physician rearranged her schedule to manage her care and make sure that didn't happen again.

Insurance probably is a factor.  More aggressive treatment options probably require a stress test.

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12 minutes ago, Katy said:

There is an increased push to treat elderly people the same as those under 70. I heard many times in nursing school that if the elderly were treated as aggressively as younger people are most people would live to around 120 years old. Whether that is a good choice for an individual or not probably has more to do with mental capacity and their own personal wishes than their physical health.  If your grandmother were young of heart and wanted to live as long as possible you may have cried age discrimination for not offering the test to her.  I recently got very upset when someone dismissed my grandmother's cancer scare because of her age - basically she's a widow whose mother died of cancer 20 years younger so why fight it?  And a cousin who is a physician rearranged her schedule to manage her care and make sure that didn't happen again.

Insurance probably is a factor.  More aggressive treatment options probably require a stress test.

 

Thank you, Katy - that does make sense that medical providers would want to avoid discriminating against the elderly, and I certainly honor that intention.  But I would hope that would usually take the form of carefully discussing all of the increased risks associated with age, and not just giving the same blanket recommendations to everyone regardless of age.  But again, since I wasn't the one involved in the conversation, I can't really know for sure what was discussed.  But this gives me hope that the doctor was at least trying to do right by her, so thank you for that.

I must say I'm extremely skeptical (to put it mildly) of that claim that people would live to 120 if the elderly were given the same medical care as those under 70.  First of all, that seems to be ignoring the fact that medical mistakes are a leading cause of death in the US.  And secondly, while medical care is important, very important, there's only so much that medicine can do to counteract an unhealthy lifestyle, which is the leading cause of death.  If doctors really want people to live to 120, they need to focus more on educating people about nutrition, exercise, stress relief, etc. and not just prescribe drugs and surgery.  But I know I'm getting off on a tangent here, and that's not really where you were trying to take the conversation!

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33 minutes ago, Greta said:

 

Thank you, Katy - that does make sense that medical providers would want to avoid discriminating against the elderly, and I certainly honor that intention.  But I would hope that would usually take the form of carefully discussing all of the increased risks associated with age, and not just giving the same blanket recommendations to everyone regardless of age.  But again, since I wasn't the one involved in the conversation, I can't really know for sure what was discussed.  But this gives me hope that the doctor was at least trying to do right by her, so thank you for that.

I must say I'm extremely skeptical (to put it mildly) of that claim that people would live to 120 if the elderly were given the same medical care as those under 70.  First of all, that seems to be ignoring the fact that medical mistakes are a leading cause of death in the US.  And secondly, while medical care is important, very important, there's only so much that medicine can do to counteract an unhealthy lifestyle, which is the leading cause of death.  If doctors really want people to live to 120, they need to focus more on educating people about nutrition, exercise, stress relief, etc. and not just prescribe drugs and surgery.  But I know I'm getting off on a tangent here, and that's not really where you were trying to take the conversation!

 

Well you're probably right, and in 20 or so years when we know more about genetics and why what is healthy for some people is unhealthy for others, I'm sure lifestyle choices will be more frequently addressed. But for many people it's often not as simple as following a better diet.  Several of my family members say they're healthier when they eat junk. When they try to eat healthy they always get sick.  We didn't previously know about histamine intolerance, or exactly why foods that are healthy for some people make others ill immediately, but it's always been a factor.  There's a lot we still don't know about many lifestyle factors. I'm pretty sure in the near future they're going to discover that fortifying every food with folic acid might reduce neural tube defects, but increases things that worsen with inflammation - like miscarriages and autism. When something approaching 30% of the population has increased inflammation from synthetic folic acid, which is added to everything, that's a problem.

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4 hours ago, scholastica said:

Honestly, I think it's to avoid a malpractice lawsuit. So many doctors are doing unnecessary testing to cover their butts.

 

Malpractice suits can be filed for subjecting someone to an unnecessary test that kills them, too. And either way, the way that wrongful death awards are calculated, malpractice CYA for a 102-yo patient should simply not be as big a factor in how the doctor does things.

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4 hours ago, Greta said:

 

I hadn't thought of that -- doctors are probably more likely to get sued for not ordering a test than for ordering a test that harms or even kills you.

 

Presenting it as an option should be enough to avoid a serious settlement--and in these circumstances, probably with further advice that the risks outweigh the benefits.

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3 hours ago, Ravin said:

 

Presenting it as an option should be enough to avoid a serious settlement--and in these circumstances, probably with further advice that the risks outweigh the benefits.

 

Yes, that's a good point.

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Did the doctor actually order the test or just bring it up as a possibility? A lot of times doctors will review every option available for investigating an issue, or at a well check, will go through tests that are recommended at a particular person's age. That doesn't mean they ordered it, though, it just means they discussed it.

 

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46 minutes ago, TechWife said:

Did the doctor actually order the test or just bring it up as a possibility? A lot of times doctors will review every option available for investigating an issue, or at a well check, will go through tests that are recommended at a particular person's age. That doesn't mean they ordered it, though, it just means they discussed it.

 

 

Yes, that is an important distinction!  My mom has taken my grandma to several of her appointments, and she said this doctor doesn't discuss anything, doesn't look anyone else in the eye, doesn't spend more than five minutes with you.  He rushes in, taps away on the computer, says "this is what we're doing" and rushes out again.  My Mom was the one who took my grandma to the appointment that resulted in her diagnosis.  Grandma had swelling of her hands and feet, and a rattle sound in her lungs.  The doctor didn't even bother to listen to her breathing.  He just ordered some blood tests and left.  (My mom has tried very hard to get my grandma to change doctors, but she doesn't want to.)  This time it was my uncle that spoke to him, so I can't be sure (because I haven't talked to him directly).  But from what my mom said, I got the distinct impression that it was an order not a discussion, and my uncle put his foot down and said no.  

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1 hour ago, Greta said:

 

Yes, that is an important distinction!  My mom has taken my grandma to several of her appointments, and she said this doctor doesn't discuss anything, doesn't look anyone else in the eye, doesn't spend more than five minutes with you.  He rushes in, taps away on the computer, says "this is what we're doing" and rushes out again.  My Mom was the one who took my grandma to the appointment that resulted in her diagnosis.  Grandma had swelling of her hands and feet, and a rattle sound in her lungs.  The doctor didn't even bother to listen to her breathing.  He just ordered some blood tests and left.  (My mom has tried very hard to get my grandma to change doctors, but she doesn't want to.)  This time it was my uncle that spoke to him, so I can't be sure (because I haven't talked to him directly).  But from what my mom said, I got the distinct impression that it was an order not a discussion, and my uncle put his foot down and said no.  

 

Good for your uncle!

I think I could write a book on doctor interactions with patients and families. It can be very crazy making.

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25 minutes ago, vonfirmath said:

This makes me very nervous. I had no idea a stress test could cause death!

I think the incidence of that is probably quite low. Risks and benefits need to be looked at closely but there are occasions when not having a stress test might mean something is missed and cause death. Now, I don't think the benefits outweigh the risks for a 102 year old, and for what it's worth, I'm fairly certain it would have been a chemical stress test not a treadmill one. Still a crazy idea in my opinion because what will they do differently once they have the results? Surely treating symptoms is the better option.

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6 hours ago, vonfirmath said:

This makes me very nervous. I had no idea a stress test could cause death!

 

Hopefully that's exceptionally rare.  It just doesn't "feel" rare when you know someone that it happened to.

5 hours ago, TCB said:

I think the incidence of that is probably quite low. Risks and benefits need to be looked at closely but there are occasions when not having a stress test might mean something is missed and cause death. Now, I don't think the benefits outweigh the risks for a 102 year old, and for what it's worth, I'm fairly certain it would have been a chemical stress test not a treadmill one. Still a crazy idea in my opinion because what will they do differently once they have the results? Surely treating symptoms is the better option.

 

I haven't had a chance to talk to my mom the last couple of days, but the more I think about it, the more I think you're right and she probably misunderstood.  Surely no one would order a treadmill stress test for someone who has trouble walking, right?

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6 hours ago, Greta said:

 

Hopefully that's exceptionally rare.  It just doesn't "feel" rare when you know someone that it happened to.

 

I haven't had a chance to talk to my mom the last couple of days, but the more I think about it, the more I think you're right and she probably misunderstood.  Surely no one would order a treadmill stress test for someone who has trouble walking, right?

 

Well, I agree it sounds nuts for someone that is 102.

That said, I walk with a cane and can not walk far.  (I sometimes use a walker now, but didn't at this time)  I had a stress test.  They said to try the treadmill... if that didn't work they had an exersize bike.  If that didn't work they would just have me wakk the track, but that wouldn't give nearly as much info.   I was shocked, I can walk a treadmill (holding on) much much better than I can walk.  I can't get on or off without help either, which stops me from exercising on one.....

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9 hours ago, scoutingmom said:

 

Well, I agree it sounds nuts for someone that is 102.

That said, I walk with a cane and can not walk far.  (I sometimes use a walker now, but didn't at this time)  I had a stress test.  They said to try the treadmill... if that didn't work they had an exersize bike.  If that didn't work they would just have me wakk the track, but that wouldn't give nearly as much info.   I was shocked, I can walk a treadmill (holding on) much much better than I can walk.  I can't get on or off without help either, which stops me from exercising on one.....

 

I didn't realize they had so many accommodations - that's good.  Maybe they would have put her on a stationery bike, so that she wouldn't have had to trust to her own balance.  I'm glad that your test worked out well.

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