Cheers for the ‘Age-Adjusted’ Cutoff Making
Pulmonary Embolism Test Work for Senior Citizens
Is this a break-through in health care adjusting to
meet the demands of an aging society that is different than the one we
grew up in?
By Tucker Sutherland, editor, SeniorJournal.com
March 18, 2014 – Probably more common sense should
be applied to the medical care of older people. A study released today
by the prestigious Journal of the American Medical Association (JAMA)
lauds the accomplishment of international doctors who solved the problem
of a blood test for pulmonary embolism (blood clot in lungs) that was no
longer working for senior citizens. Seniors seem to find themselves
increasingly excluded from certain medical testing due to their advanced
In this particular case, measuring D-dimer - a
breakdown product of a blood clot - levels is one way doctors exclude a
diagnosis of pulmonary embolism (PE). The problem was that several
studies had revealed that D-dimer levels increase with age. So, it was
becoming increasingly difficult to use this blood test for older people
to determine if they had suffered a blood clot in their lungs.
For most commercial tests and abnormal reading of
above 500 µg/L for D-dimer was supposed to indicate a PE problem. But,
with increasing numbers of old people in the world, the results were
increasingly above the 500 level. The test was becoming less useful for
seniors, as more and more healthy seniors were testing positive.
It took Marc Righini, M.D., of Geneva University
Hospital, Geneva, Switzerland, and his colleagues to decide that maybe
there needed to be an “age-adjusted” D-dimer threshold for a positive
Their solution to accommodate the increasing scores
by older people was to multiply the patient’s age by ten in patients 50
years or older. So, if the patient was age 60, the test reading to
determine if the patient scored abnormal of normal became 600, rather
They found it seemed to safely exclude the
diagnosis of PE in elderly patients who had been suspected of PE.
The study was expanded to include 19 centers in
Belgium, France, the Netherlands, and Switzerland between January 2010
and February 2013. To be assured of their results, the outpatients in
the study underwent a clinical probability assessment (measured by one
of two scoring systems based on risk factors and clinical findings), D-dimer
measurement, and computed tomography pulmonary angiography (CTPA; image
Of the 3,346 patients with suspected PE included in
the analysis, the prevalence of PE was 19 percent. The researchers found
that combining the probability assessment with adjustment of the D-dimer
cutoff for the patient’s age safely excluded the diagnosis of PE and was
associated with a low likelihood of subsequent PE or other venous blood
As suspected, and logic would indicate, among
elderly patients, there was an increase in the proportion of patients in
whom PE could be excluded without further imaging.
“Future studies should assess the utility of the
age-adjusted cutoff in clinical practice. Whether the age-adjusted
cutoff can result in improved cost-effectiveness or quality of care
remains to be demonstrated,” the authors conclude.
It doesn’t sound like the greatest challenge in
medical science, but it has to be encouraging to senior citizens and
their advocates that the medical world is taking the time to consider
the differences in people as we age. Too often the scenario seems to be
one where the health care establishment had rather just exclude senior
citizens from test that made adjustments to meet the needs of a
changing, aging society.
“Longer life spans and aging baby boomers will
combine to double the population of Americans aged 65 years or older
during the next 25 years to about 72 million. By 2030, older adults will
account for roughly 20% of the U.S. population,” according to Aging &
Health in America 2013, published by the Centers for Disease Control and
The diseases that claimed our ancestors, like
tuberculosis, diarrhea and syphilis, are no longer our biggest worries.
They have been replaced, primarily by the two big killers, heart disease
But, the risk of developing chronic diseases
increases as a person ages, and with more older people, this problem
grows. Two of three older Americans have multiple chronic conditions,
and treatment for this population accounts for 66% of the country’s
health care budget.
The nation’s health care system is largely designed
to treat one disease or condition at a time, but many Americans have
more than one, and often several, chronic conditions. For example, just
9.3% of adults with diabetes have only diabetes. Other common conditions
include arthritis, asthma, chronic respiratory disease, heart disease,
and high blood pressure.
“As more and more Americans reach the age of 65,
society is increasingly challenged to help them grow older with dignity
and comfort. Meeting these challenges is critical to ensuring that baby
boomers can look forward to their later years,” says the CDC.
Hopefully, the term “age-adjusted cutoff” is one we
will hear more often.
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