Happiness is a direction, not a place. 

                                                   Sydney J. Harris

FRIDAY, Oct. 7 (HealthDay News) -- A patient's ability to ride a bicycle can help doctors determine whether the patient has Parkinson's disease or atypical parkinsonism, regardless of the terrain or riding situation, a new study indicates.

Atypical parkinsonism includes disorders that appear similar to Parkinson's disease but respond differently to treatment. It was already known that patients with atypical parkinsonism lose the ability to cycle early in their illness, while Parkinson's patients can still ride well.

But it wasn't known if this "bicycle sign" was universally applicable across the varieties of riding environments or situations in different countries.

In this study, Japanese researchers assessed the reliability of the "bicycle sign" in their country, which has hilly, narrow roads crowded with cars. They found that 88.9 percent of Japanese patients with atypical parkinsonism stopped cycling during the first few years of their illness, compared with 9.8 percent of Parkinson's patients.

They compared this to the bicycle-friendly Netherlands, where 51.5 percent of patients with atypical parkinsonism stopped cycling early in their illness. The difference may be due to the fact that cycling is much more difficult in Japan.

The study was published Oct. 6 in the Journal of Parkinson's Disease.

"Although bicycling cultures may differ between countries, it is possible that the 'bicycle sign' could contribute to earlier and better differential diagnosis of parkinsonism during the diagnostic interview. When we see patients with parkinsonism without a definitive diagnosis, it is a simple thing to ask the question, 'Can you still ride a bicycle?'" Hideto Miwa, of the neurology department at Wakayama Medical University, said in a journal news release.

More information

The U.S.-based National Parkinson Foundation outlines the different types of atypical parkinsonism  .

THURSDAY, Oct. 6 (HealthDay News) -- As many as one-third of Medicare beneficiaries in fee-for-service plans have inpatient surgery in the last year of their life, a new Harvard study finds.

But the issue of whether such surgery is necessary or not is a tricky one that can only be decided by the doctor, the patient and patient's family, said Dr. Frank Opelka, an associate medical director at the American College of Surgeons.

Nor is there any good way to predict when an elderly patient is going to die.

"There's no way possible to know ... if it's the person's last year of life," said Jane Bolin, an associate professor of health policy and management at Texas A&M Health Science Center School of Rural Public Health in College Station. "The doctor doesn't know. The patient doesn't know."

Dr. Alvin Kwok and colleagues published their findings in the Oct. 6 online edition of The Lancet.

It's been well-noted that treatment intensity tends to step up at the end of a person's life, often involving intensive-care stays, ventilators and pulmonary resuscitation in the days before someone dies.

Less is known about surgery at this vulnerable period of life.

By analyzing Medicare claims data the study authors found that, in a group of almost 2 million elderly beneficiaries, all of whom died in 2008, almost one-third had inpatient surgery in the year before they died, almost one in five in the last month of their lives and almost one in 10 in the week before they took their last breath.

As participants progressed in age, the proportion of people undergoing surgery declined: 38.4 percent among 65-year-olds, 35.3 percent at age 80 and 23.6 percent for those between 80 and 90.

The most surgeries were performed in Munster, Ind., and the fewest were done in Honolulu; surgeries tended to be more common in hospitals with more beds available.

An accompanying commentary from Dr. Amy S. Kelley of Mount Sinai School of Medicine in New York City pointed out that Medicare reimbursement rates for surgery are highly lucrative, suggesting that "surgeons and hospitals are often financially motivated to operate, regardless of the patient's preferences or goals."

But other experts disagreed that this might be the case.

"I do not know a single surgeon who says, 'We're going to do this because there's a financial incentive,'" Opelka said. "These patients are absolutely facing the most difficult time in their life, and the profession just doesn't act that way."

Instead, the issue might be one of how the medical community and the larger community might start discussing the inevitability of death.

"We want to do everything we can when we have the opportunity but when we reach a point of futility, we have to have a mature conversation," Opelka said. "It's no longer about getting past an acute, life-threatening situation but the inappropriate prolonging of the dying process, giving the patient dignity and control of a God-given process," he noted.

"We've grown up believing we can get anything and buy anything," Opelka added. "We can't buy eternity."

More information

The U.S. National Cancer Institute has more on end-of-life care.

TUESDAY, Oct. 4 (HealthDay News) -- Depending on where you live, having an advance directive may raise the odds that you'll receive hospice services and reduce the overall cost of your end-of-life care, a new study indicates.

An advance directive, sometimes called a living will, is a legal document that expresses your wishes for the type of care you would like to receive should you become unable to make such decisions yourself.

"The most important finding from our study is the evidence that advance directives can be very important in shaping the care that's provided to patients," said study author Lauren Hersch Nicholas, a health economist at the Institute for Social Research at the University of Michigan, in Ann Arbor.

The findings are published in the Oct. 5 issue of the Journal of the American Medical Association.

End-of-life care is often a controversial subject, and when policymakers are looking for ways to control Medicare costs, such care typically comes up in the discussion. That's not surprising, because end-of-life care accounted for more than one-quarter of Medicare spending last year, according to background information in the study. One concern is that this spending may be largely earmarked for aggressive care that's not necessarily what the patient might have wanted.

And, that's where advance directives can be useful. They allow patients to document their wishes, whether they want all life-sustaining measures to be taken or if they'd prefer to avoid such procedures.

The study authors noted that there's also a wide variation in the amount spent on end-of-life care, depending on the area you live in the United States. For example, according to 2003-2007 data from the Dartmouth Atlas of Health Care, regions such as the more densely populated areas of the Northeast, Texas and California spend much more on caring for people in their last 2 years of life than do areas such as the rural Midwest.

So, the Michigan researchers wanted to see what effect advance directives might have on end-of-life treatments and costs by region.

Their study included information on more than 3,300 Medicare beneficiaries from the Health and Retirement Study. The data was gathered prospectively between 1998 and 2007, and it was linked to Medicare claims information and the National Death Index.

The researchers found that in areas where end-of-life care costs were normally high, having an advance directive significantly lowered the cost of care. On average, end-of-life care spending was $5,585 less per person in the high-spending regions when someone had an advance directive.

Having an advance directive didn't change end-of-life care costs in regions that were already considered low- or medium-spending areas for end-of-life care.

"We found that for people in some parts of the country -- those who live in regions classified by more aggressive, expensive end-of-life care -- there was a very pronounced difference in outcomes for those who had a living will," said Hersch Nicholas. "They were much more likely to receive palliative care, much less likely to die in the hospital, and Medicare spending on these patients was about $5,000 lower than on patients who didn't have an advance directive."

As to why an advance directive didn't appear to change much about end-of-life care in lower-spending regions, Hersch Nicholas said these areas may have come up with ways to rein in more aggressive end-of-life care.

Another important finding, she said, was that having an advance directive didn't necessarily limit the initiation of aggressive treatments, but seemed to lead to their earlier withdrawal.

Hersch Nicholas said this finding was particularly important because some people make the argument that having an advance directive might limit all of the care you receive at the end of your life. But, this finding shows that while treatments are often started, for "patients with an advance directive, there's an earlier recognition of when treatments aren't working and when it's time to go to hospice."

"Advance directives do serve as a helpful tool, but they're not a perfect tool. What you say you want today might be different from what you want another day. But, an advance directive gives permission for family members to withhold care when there's no reason to think that more medical treatments might help, and to do what will make this person more comfortable," said Dr. Tia Powell, director of the Montefiore-Einstein Center for Bioethics, and director of the Einstein-Cardozo Masters of Science in Bioethics in New York City.

"There remains a disconnect between practice patterns regarding [end-of-life care] in different parts of the country. We still have a lot of distance to cover in terms of providing the level of sensitive, individualized care for the elderly and the ill in the U.S.," Powell said. "There can be benefits from advance directives, and also from providing appropriate care and not wasting money."

More information

Learn more about advance directives from the American Academy of Family Physicians  .