There are pros and cons of the new digital world. On the one hand for physicians the transmission of important medical information, especially about advances in medicine and concerns about well-established or novel treatments assists all of us in the world of health care to be as “up-to-date” as possible. Anyone in the field recognizes that there is an apparent constant Rocky Mountain avalanche or Hurricane Sandy flood of new information coming from endless sources ranging from the most respected- evidenced-based medical journals to free-wheeling, shoot-from-the-hip internet news sites that churn out information so quickly that there is often little time to attempt to verify the sources of the information and when it catches on the distribution is faster than a speeding bullet through the so-called “going-viral” process.

In reality, true, meaningful and reliable progress in medicine is usually slow and incremental; eventually there is what seems at times to be the slow tortoise-paced movement in positive and meaningful directions. Physicians and consumers of health care information (doctors call them “patients”) are routinely subjected to claims of “breakthroughs”, “major steps forward” and “almost miraculous” advances for one confounding medical condition or another. It is often claimed thatsomeone, which may mean the corporate pharmaceutical industry, the conservative “self-serving” medical profession and politicians who are “in the pay of” one of these mega-wealthy interest groups, that are repressing these breakthrough advances because of a threat to their financial interests or their “monopoly” on the health care industry. The current penchant for conspiracy theories promotes the suspicion held by many members of the public that if there is something missing in their health care, it is due to lack of useful information being purposely withheld or squelched by "vested interests."

When it comes to the categories of serious and often life altering or life-threatening illnesses, there is often an attraction to those for whom either intentionally or unintentionally misleading the public can be a major issue and for some can lead to devastating results. As a physician whose professional and academic interests have covered Alzheimer’s disease and other causes of dementia, end-of-life and palliative care and medical ethics, it is not hard to come across an array of individuals and situations in which it is hard to not consider the concept of mythology if not more accurately charlatanism. With all of such situations it is often the marketing of the product or procedure that becomes the goal of those for whom the potential for vast financial gain becomes a major issue—this can ultimately lead to at best misjudgement or excessive good intentions or naivety and at worst actual fraud.

A few examples to illustrate the history of mythology and marketing in medicine with a focus on aging and dementia and "incurable" illnesses is worth considering. Recently the son of one of my patients whose is living with fairly advanced dementia of the mixed-Alzheimer’s-vascular type wanted to know about my opinion of the use of coconut in its treatment. I admitted that I had not heard of that but he had his internet print out in his hand and right then and there  we logged on to the report including the YouTube depiction of the wife of the patient whose clinical condition of dementia was vastly improved by the eating of grated coconut and then the “medical”: commentaries that followed.  I could understand why a family member of someone with as serious condition as dementia would be mesmerized and hopeful that such a discovery would be beneficial for his suffering mother.  I did a further in depth review of the available literature which mainly referred back to the initial YouTube presentation. All the credible commentators agreed that although interesting there were no proper evidence-based studies that had been done to verify this one in essence case-report. A robust review of the claim and the medical supporting evidence can be found on the website snopes.

Another very popular “natural” purportedly natural preventative treatment for dementia that has been very popular for many years is Ginkgo Biloba, on which according to a 2009 Consumer Reports (CR) wrote that Americans spent in 2007 about $107 million according to the Nutrition Business Journal. They're probably hoping to enhance memory and increase mental focus, claims often made for Ginkgo.

According to the article in CR; “the results of a major trial published in a 2008 issue of the Journal of the American Medical Association suggest that taking Ginkgo Biloba to prevent cognitive impairment or dementia is probably a waste of money. Researchers followed more than 3,000 people age 75 or older for roughly six years—the largest Ginkgo-dementia trial ever. “The supplement did not decrease incidents of Alzheimer's disease or other dementias in people with normal cognition or in those with mild cognitive impairment. Bottom line : Ginkgo Biloba supplements can cost about $200 a year. Save your money. An accompanying editorial stated: "users of this extract should not expect it to be helpful. And while the supplement is widely considered to be safe, there is some concern about an increased risk of bruising, bleeding, and potential drug interactions . If you intend to take the supplement, discuss it with your doctor first.” The same negative results were reported in a more recent article : Ginkgo Biloba no better than placebo in preventing dementia published in the December 2012 edition ofMenopause International.

One only has to wander around any pharmacy’s health supplements section or shopping mall’s health and nutrition outlet or to one of the “big box” stores like COSTCO® and you will see bottle after bottle of nutritional brain enhancing supplement being bought by the truckload. As physicians I think we have a duty to inform our patients that there is no evidence for any benefit of these products rather than take a very common posture which is, “if it can’t hurt, what’s the difference?”

Money saved on useless and heavily marketed supplements can be used for more beneficial purposes, even if to support a worthy charitable cause.

This article was originally published online at www.clinicalgeriatrics.com.

The Clinical Scenario
It was one of those unusual clinics where I saw three similar cases in which the exact same issue surfaced and I was able to demonstrate in “real time” to residents in training with me in the care of the elderly. The first of the encounters was with a couple accompanied by two family members; the couple lived at home with some personal care help and each had some degree of cognitive impairment but not enough to completely interfere with reasonably safe functioning when under some supervision. I was interviewing and examining one member of the couple and my resident was doing the same to the other.

Denial or Hearing Impairment: A common scenario
As I embarked on my interview with the patient it became clear that as noted in previous visits, he was quite hard of hearing. According to the son who was with him, his father refused to wear his hearing aids because “they bothered him” and he often stated that he had, “no problem with hearing”. Each time I spoke to him, he leaned into me to hear my question or answer and turning to the son to repeat the question.  With his wife the resident also noted in addition to some degree of cognitive impairment a significant degree of hearing impairment.

Low cost, effective hearing enhancement: very dramatic at times
I retrieved my Pocket Talker® which I keep in the office for such cases. I put the simple earphones first on him and gradually turned the volume and suddenly his face lit up as I asked if he could hear me and he said, “very well”. We practiced a bit with the device until it was clear that he could engage in a three way conversation with his son and me.  The resident was now ready to review the wife’s issues with me and the son entered the room with us as did his father. They had already learned from me that during the discussion, while I asked questions they were to sit quietly despite a desire to “help with answers” unless I asked them specifically to comment on something said to me by the patient. The resident had reiterated the story to me of mild dementia he mentioned and emphasized that she was quite hard of hearing; she had refused hearing aids although the family was planning on acquiring them. I retrieved the Pocket Talker® that I had just used with her husband, put on the head phones and as I increased the volume, like her husband her face lit up when she heard my questions and I looked at the son and husband and said to them, “maybe you can get a deal if you get two of these”.

A hearing augmentation “Hat trick”
Later in the clinic, a different resident saw another patient. This resident had not been apprised of the experience that I and my other resident had with the couple. She recounted a history of progressive cognitive decline and also mentioned an issue with hearing that the accompanying daughter raised. Like the previous couple the daughter said her mother absolutely refused to go for a hearing assessment and said that she did not want “hearing aids” as she “did not need them” and they were in any event “a waste of money”.  I carried out the same manoeuvre that I had used with the previous couple. Although less dramatic than the previous cases, the way she responded to my repeated questions clearly indicated that she could hear better with the device.  In this particular case,  I was not convinced yet that some of the apparent cognitive impairment may have been perceived as such due to her hearing impairment or at least aggravated by it.  I explained to the daughter when I said I was not yet sure of the degree of cognitive impairment, “if you can’t hear it, you can’t remember it”.

Don’t overlook Hearing as part of the Cognitive Assessment
In these three situations during one clinic session the young residents who in their careers would see many elderly people with cognitive impairment or dementia, the message of the importance in hearing was clearly demonstrated.  It can be hard to convince older people to utilize hearing aids or pay for them. For many a simple and inexpensive Pocket Talker® may be a device that can be used  as an introduction to the benefits of hearing enhancement or may on its own solve the hearing deficiency problem for the purpose of social communication.