Caring for health
A paper just published in the British Medical Journal has received no media attention here, but its messages were so thought-provoking, they are worthy of our own reflection. Three well respected doctors and medical school lecturers looked at preventive health care of the elderly and found that it needs rethinking. Right now, they said, it is failing elderly: “Rather than prolonging life, preventive treatments in elderly people may simply change the cause of death and the manner of our dying.”
Preventive health care aims to delay the onset of illness and disease and to prevent untimely and premature deaths. But the theory and rhetoric of prevention do not deal with the problem of how such health care applies to people who have already exceeded an average lifespan.... In the richer countries of the world, improved social conditions combined with immunisations and antibiotics have rapidly reduced the rates of death from infectious diseases. People saved from these epidemics now live long enough to face the new “epidemic" of cardiovascular disease, which is the focus of huge investment and endeavour in health promotion.
By using preventive treatments to reduce the risk of a particular cause of death in elderly people are we simply changing the cause of death rather than prolonging life? Three factors fuel this possibility. Firstly, single disease perspectives lure researchers and guideline groups into assuming that improved outcomes for the index condition mean that everybody with that condition should be treated, irrespective of the overall effect on population mortality and morbidity. Secondly, sensitivity about age discrimination prevents us from looking at things differently when dealing with an elderly population. Finally, drug companies make huge financial gains if effective interventions in relatively small populations become standard care for all people at risk of that condition.
The doctors were specifically concerned that: “Currently, we use evidence from younger populations and extrapolate this to elderly ones.” We’ve seen a number of preventive health guidelines aren’t in the best interests of people as they age, such as BMI, low-salt diets and low-fat diets.
As an example, they examined the evidence behind new practice guidelines calling for lipid lowering treatments. This paper has received media attention in Britain, where statins are being heavily debated. The doctors said:
However, evidence for the effects of prevention of heart disease with drugs is scant in elderly people. The largest study in this group is the pravastatin in elderly individuals at risk of vascular disease (PROSPER) trial. In this trial more than 5000 participants, aged 70-82 years, were followed up for an average of 3.2 years. Pravastatin had a clear but small effect on mortality and morbidity from cardiovascular disease... (absolute risk reduction 2.1%)... However, examination of all mortality and morbidity data is revealing. Pravastatin showed no benefit over placebo for any outcome in elderly women and despite a change in composite cardiovascular outcomes, all cause mortality stayed the same, inferring that mortality and morbidity from other causes must have increased. Rates of cancer diagnosis and death were higher in the treatment group than in the placebo group. The difference was significant for a new diagnosis of cancer and almost significant for mortality from cancer....
The doctors noted not only the financial incentives behind the guidelines themselves, but in the pay for performance measures coercing doctors to persuade patients to comply with preventive treatments. But “whether it improves health care is not always so clear,” they said, adding:
The best interests of elderly people, who have paid a lifetime of taxes, might lie in investing that money in health care that will genuinely relieve suffering. Cataract operations, joint replacement surgery, and personal care of people with dementia are obvious examples. This may explain why general practitioners are not comfortable about applying the national service framework for heart disease in elderly people and their reluctance to follow guidelines for cholesterol measurement and lipid lowering agents in people over 75.
We should not carry on extrapolating data from younger populations and using linear models that use absolute risks of disease specific mortality and morbidity rather than all cause mortality and morbidity. If we do, the only ones to benefit will be drug companies, with increasing profits from an ageing population consumed by epidemics rather than enjoying their long life.