Are Seniors Getting Enough Medical Care or Too Much?
Choosing the right treatment plan at the right time means weighing several factors.
By Dr. Sanjay Gupta
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For years, Sarah Beville’s doctors were able to effectively treat her for heart and kidney disease, even into her nineties. But when Beville’s one remaining kidney began to fail, she decided to move into a hospice. It was a difficult transition for Beville, who passed away this month at age 94. She had been extremely active in her community in Dinwiddie, Virginia, and was socializing regularly with friends until just a few weeks ago.
The increasing number of older Americans living with chronic health conditions raises difficult questions about appropriate medical treatment for seniors. Some older patients receive aggressive treatments that may cause more harm than good. Others may be undertreated because treatment risks are perceived to outweigh potential benefits. “Balance is really important,” says Eve Kerr, MD, director of the VA Center for Clinical Management Research and Louis Newburgh research professor of internal medicine at the University of Michigan, both in Ann Arbor.
“Overtreatment in seniors is a real concern,” says Dr. Kerr. In a December 2015 study published inJAMA Internal Medicine, Kerr and a team of researchers found that many seniors with diabetes are being treated too aggressively, which is a problem because not scaling back their medications can lead to low blood sugar (hypoglycemia) and put older patients at risk for falls, cognitive problems, and even death. “Evidence is accumulating that older individuals with diabetes mellitus have little to gain from the treatment burdens of stringent blood glucose control,” according to the study.
Kerr adds that many drugs that may be effective for younger adults, such as pain or high blood pressure medications, can be dangerous for older patients if used incorrectly.
Assessing Functional Age
“The best medical decisions are personalized,” says oncologist Arti Hurria, MD, director of the cancer and aging research program at the City of Hope cancer center in Duarte, California. Dr. Hurria stresses that cancer treatment decisions should be based on an assessment of patients’ functional age, which factors in their health status, life expectancy, goals, personal values, and healthcare preferences. “We want to make treatment decisions in the context of this [assessment],” she says.
Hurria has developed an assessment to help identify patients who may not respond well to chemotherapy. “[Some] older adults are at risk for side effects, but not all older adults,” she says. Hurria led a study at several cancer centers to determine who was at risk and identified 11 predictive questions to help oncologists make individualized treatment recommendations.
Kerr and Hurria agree that patients should play an active role in treatment decisions — a principal known as shared decision making. When doctors suggest new treatments, tests, or medications, patients should ask: What is the likelihood it will benefit me? What are the specific side effects or downsides? Are there alternatives? Beville’s son Don says that his mother always asked questions when she was unclear about her doctors’ recommendations.
Kerr suggests older patients regularly review with their doctors whether to continue taking medications at the same doses. “Patients get used to a certain set of goals and medications,” she says. “Sometimes it’s okay to change [medications] as our body changes when we age.” Kerr says that medications for conditions like osteoporosis, depression, and diabetes should be re-evaluated periodically.
Health Literacy Is Key
According to the Agency for Healthcare Research and Quality (AHRQ), roughly one-third of U.S. adults, particularly among the elderly, have limited health literacy, which is “the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.”
Regardless of the patient’s age, there are tools available to help them make informed treatment choices. Known as decision aids, these tools combine printed materials, video demonstrations, and risk calculators. According to a 2015 report in theBritish Medical Journal (BMJ), over 500 decision aids have been developed so far. Many are available on websites such as the .
Choosing Wisely, an initiative of the American Board of Internal Medicine, offers condition-specific, evidence-based guides to help patients and their loved ones discuss treatment options with their doctors. One of these resources, Treatments and Tests for Seniors, reviews medical information and tips for conditions common in older adults, such as dementia and chronic pain.
“It’s important that patients make sure their doctor really knows them,” Hurria says. Patients who have a constellation of medical problems often have to balance quantity versus quality of life concerns. “It’s critical patients understand [treatment] risks and benefits, and are not just signing a consent form.”
Kerr and Hurria encourage patients to bring a family member along to doctors’ visits. “Having someone by their side, to be a second set of ears, can really help decision-making,” Hurria says. “That way the patient can also hear family members’ concerns,” Kerr adds.
Beville’s son believes aggressive treatment was the right approach for his mother. “I think the doctors saw my mother asking what she could do to stay healthy, and they were willing to work with her.”
The key, Kerr says, is “delivering the right care at the right time for the right patient.”
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