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Age: Sometimes a Good Reason to Discriminate

 |  By cclark@healthleadersmedia.com  
   August 14, 2014

As evidence grows that the risks of harm outweigh the chance of benefit for some procedures on older patients, thoughtful providers are putting the brakes on overly aggressive care for their senior patients.

Three months before my 92-year-old father died, his family doctor diagnosed an occluded popliteal artery in his leg. Dad was cachectic and skeletally thin, barely spoke, and was too weak to move without help.

On top of congestive heart failure and dementia. He also seemed so very, very sad.

Though it wasn't in his best interest, I watched medicine's referral network take over his care. He should see a surgeon, his doctor said. An operation could restore blood flow to his leg and foot. His hopeful wife got dad dressed, maneuvered him gingerly into the car and into the surgeon's office—a very difficult undertaking—one very slow and scary step at a time.

Just say yes, and surgery would be done, they were told. Another perilous trip to the cardiologist to make sure his heart was strong enough. He'd need expensive drugs that promised to rekindle his desire for food. $100 each for tiny tubes of silver medicine for the pressure sores on his feet.

None of it worked.

Thank goodness reason prevailed to avoid a surgical procedure. It surely would have killed him sooner, amid much pain, probably in a confusing and noisy ICU. He couldn't speak, but I remember the look he gave me in the kitchen. It said "Please, no more."

The Start of a Conversation

In the four years since my father died, I've seen some encouraging signs. Thoughtful providers are putting the brakes on overly aggressive care, not just for those at the end of life like my dad.

Evidence is getting stronger that, at least for some procedures, the risks of harm probably outweigh the chance of any benefit, even for seniors at much younger ages. And providers are starting to have those discussions among themselves, and with their patients.

Daniel Wolfson, executive vice president and COO of the American Board of Internal Medicine Foundation, agrees. The ABIMF fosters the Choosing Wisely campaign which now has some 300 guidelines from 58 physician specialty societies on what care practices, once considered routine, patients and their doctors should question, many of which reference age as the point at which pro-forma care should be replaced by an honest conversation about benefits versus risks.

Wolfson started to list a few, and I found some others.

  • Avoid using medications to achieve hemoglobin A1c less than 7.5% in most adults age 65 and older; moderate control is generally better. There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults.
  • Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. Large-scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics.
  • Don't recommend screening for breast, colorectal, or prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment. Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms.
  • Don't routinely prescribe lipid-lowering medications in individuals with a limited life expectancy. There is no evidence that hypercholesterolemia, or low HDL-C is an important risk factor for all-cause mortality, coronary heart disease mortality, or hospitalization for myocardial infarction or unstable angina in persons older than 70 years.
  • Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary diseases in patients older than age 70 who has not had chest radiography within six months.

More to Come
Wolfson thinks more of these kinds of recommendations based on age will be added to the Choosing Wisely list.

"Particularly with the geriatric recommendations, I think you are seeing age as a factor in some of the recommendations. It's the start of a conversation," Wolfson says. One that used to be a lot more difficult to have.

Like me, Wolfson thinks an arbitrary age cutoff, particularly for people still in their 60s, is not necessarily a sound strategy. But it should be a weighted decision, to consider overall health and life expectancy.

"It's all about the conversation the patient has with the doctor," Wolfson says. "You have to be rational about this."

In his own experience, he has family members' whose doctors were not. His dying mother-in-law, who had a stroke at age 95 and suffered from dementia, " had a pacemaker implanted. Why? It hurt her, agitated her, and she died two months later. That doesn't make any sense."

Five years ago, doctors wanted to perform a colonoscopy on his then 88-year-old mother. That wasn't right. "The risk of perforation of her colon is so much greater than her dying of colon cancer," Wolfson says.

That's the point of a study published in Monday's online edition of JAMA Internal Medicine. ResearchersatKaiser Permanente in Southern California found that for people over age 74, surveillance colonoscopy — procedures performed in people who have a history of polyps or colorectal cancer finding from a prior colonoscopy — might have a higher risk of a hospital admission due to adverse events from the procedure combined with their frailty and comorbidities, than a similar cohort of patients ages 50–74.


In Cancer Survivors, Colonoscopy Risks Rise with Age


An Hong Tran, MD, a Kaiser geriatrician and the paper's first author, says the finding was a surprise, and provides even more evidence to justify those conversations between doctors and their older patients.

I'm not saying that there should be automatic cutoffs. That sounds like rationing and brings back the ugly specter of "death panels." But we need intelligent research, like that performed at Kaiser, to know when to give care, and when to say, as did my dad: Please. No more.

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