A clear-eyed look at treating the elderly with medicine

A recent case taught me a lot about how people perceive their medicines.

I was trying to help a 92-year-old man get off some of his medicine. I can’t go into the details, but suffice to say, there was much opportunity to trim a long list of drugs, many of which were threatening his existence and impairing his quality of life.

As I was discussing stopping many of the meds, the patient said (with a quite sincere tone):

“You doctors these days just want us old people to go off and die.”

That was a zinger, a real punch in the gut. I was trying to do the opposite–allow him to live a longer and better life–but the patient perceived me as a mini-death panel.

I’ve been thinking a lot about this case. Why was this man “attached” to his meds? Why had he associated his longevity with chemicals that now threatened his existence?

The answer, I believe, is a knowledge gap. He, like many people, doctors included, fell into the trap of association and causation. He associated his health with his medicines; he overestimated their benefits. He thought the pills were keeping him alive. They were not. He lived despite his medicines.

What I tried to explain to this patient was that benefits from medicines do not continue indefinitely. Things change in the elderly, and, what is for younger patients may not be in the aged.

Take the case of preventing stroke in the elderly. Simple drugs, such as high blood pressure medicines and statins, may no longer offer a net benefit to the patient over the age of 80. Really. It is true.

Let me tell you about a recent commentary in the journal Evidence Based Medicine (from BMJ).

Dr Kit Byatt is a doctor in the UK who specializes in Geriatric Medicine. He wrote this refreshingly concise summary outlining four reasons why the medical community should reconsider its overenthusiastic views of stroke reduction in patients over the age of 80. In the title, Dr. Byatt asks whether we are being disingenuous to ourselves and to our elderly patients.

The answer is yes.

Dr Byatt makes four arguments:

First, he points out that population studies (like Framingham) of the elderly show that high blood pressure ceases to be a significant risk factor for stroke in patients over the age 80. In fact, in this study of 4000 veterans, mortality was higher in those with lower blood pressure. Likewise, the utility of cholesterol as a predictor of stroke in the elderly is dubious. Researchers put together this systematic review involving 900,000 patients and found no independent positive association of cholesterol levels with stroke mortality, especially at older ages or higher blood pressures.

Second, Dr. Byatt goes onto refute the evidence that treating high blood pressure in the elderly effectively reduces the risk of stroke. Here, he reviews the actual data from the 2008 HYVET trial (NEJM), which was a comparison of blood pressure medicine v. placebo in 3845 elderly patients followed for 2 years. The primary outcome was the combination of any stroke (nonfatal plus fatal.) Unlike the authors of the paper, Dr. Byatt emphasizes the actual not relative results: for the reduction of stroke in the elderly, treatment and placebo performed 99% the same. (and this did not reach statistical significance.)

Third, Dr. Byatt moves on to the use of statins in the elderly. He uses the PROSPER trial, which looked at 6000 high-risk patients (age 72-80) who took either pravastatin or placebo over 3 years. Although the composite endpoint (all fatal or non-fatal strokes or cardiac events) was statistically lower with statins, the absolute difference was just 1.7%. This means statins and placebo performed 98.3% the same. What’s more, when one looks at Table 2 from that Lancet paper, there were no differences in non-fatal or fatal strokes.

Finally, Dr Byatt asks doctors to consider the goals of care of the elder person. He points out that patients’ values and preferences relating to stroke vary a lot, and, importantly, differ from physicians. He says, “deciding what to focus on in frail older patients with multiple pathology is much more challenging than these ‘single problem’ cases, and a complex interaction of factors influence these decisions.” That’s an understatement.

My summary:

This is really important stuff. The elderly are different. They develop other diseases and take other drugs. The human body gets worse with age, not just our bones and muscles, but also our ability to clear drugs from our system. It is always important to treat the person rather than his or her diseases, but never more so than in the elderly.

Dr. Byatt reminds us that even “simple” drugs, such as anti-hypertensives and statins, have marginal benefits in the elderly. His essay is persuasive because he uses the actual data from major trials. This view of science often leads to a more truthful outlook on things.

The message here is simple: Doctors should “rethink our priorities and beliefs about stroke prevention, and actively inform and involve the views of the key person, the patient.”

Hear-hear.

JMM

P.S. Dr Leslie Kernasin, a practicing geriatrician, writes an excellent post on this matter over at the Health Care Blog. It’s titled: A Cautionary Note About the Risks of Treating High Blood Pressure in the Elderly

6 comments

  1. Hello Dr. John,

    Some excellent questions – and answers – here. Thanks so much for that link to the BMJ report.

    “Why was this man ‘attached’ to his meds?”

    That’s an easy one. It’s because his doctors have no doubt spent decades clobbering the NEED for all of these pharmaceuticals into his noggin, that’s why.

    Being COMPLIANT (the dreaded C-word that so many of us patients despise) is the imposed goal of every “good” patient. “My doctor says…” is the mantra of every “good” patient. Recording treatment target numbers at every doctor visit is what this man and every other “good” patient dutifully watches our physicians do – observing, assessing and adjusting more and more or newer and newer meds year after year after year when those target numbers are not reached. Leaving the office with yet another prescription is the familiar role of the “good” patient.

    That is why he’s so “attached” to his meds.

    Is it any surprise, really, that after decades of being well-trained by his physicians to “associate his longevity with chemicals”, this old man believes what his docs have likely been telling him for decades?

    regards,
    C.

  2. Good post. Dr. Byatt’s article is important & I’m glad to see you bringing attention to it.

    Will add that when I was a geriatrician PCP, I felt that patients often gave quite a lot of weight to what the specialist was telling them. The heart specialists were usually very gung-ho about statins, lots of BP meds, etc. The endocrine specialists were very gung-ho about tight glucose control. And so forth…all approaches that are unlikely to be beneficial to the elderly.

    It was frankly rather awkward for me to try to explain to the patient why I thought it might help them to cut back on meds that were being recommended by their specialists…patients were uncomfortable with the idea that their specialist wasn’t recommending ideal care, and also tended to assume that the specialist must obviously know more than I did.

    I often had to spend time getting another doc on the phone, trying to explain to them why I think a different approach might be a better fit in terms of benefit/burden, or for the patient’s preferences. Some specialists were congenial about discussing this by phone (I am sure you would be!); others were not.

    I say this just to highlight that PCPs — and geriatricians, for that matter — often face an uphill battle if they decide to help an older person better understand the benefits/burdens of various medication approaches.

    Thxs again for this post.
    PS: The issue of aging adults feeling that clinicians are giving up on them is important, deserves its own conversation!

    1. Thank you Dr K for the excellent comment. Your description of undoing expectations of therapy are one of the main reasons for writing these kinds of posts. It’s why I tell doctors to participate online. Maybe this is naive but I believe the “good” doctoring could made easier if the expectations of both patients and doctors more closely aligned with the actual evidence.

      1. Dr. M: I don’t think you’re naive at all! Agree that we need patients and doctors to reconsider expectations in light of the best evidence available.

        I think it’s especially powerful for a specialist like you to be sharing this take on cardiovascular medications in aging adults.

        And thank you for adding a link to my recent THCB post!

  3. This is an increasing area of frustration with Quality Measures coming into the picture and no upper age limits (among other problems) with HEDIS and similar programs. Getting paid less for taking EXCELLENT care of patients is jaw-dropping in its stupidity.

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