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Preventive treatments in elderly people needs rethinking

August 10, 2007

Rather than prolonging life, preventive treatments in elderly people may simply change the cause of death - the manner of our dying, say doctors in this week's BMJ.

They call for a more sophisticated way of assessing the benefits and harms of preventive treatment in elderly people.

Preventive health care aims to delay the onset of illness and disease and to prevent untimely and premature deaths, say Dr Dee Mangin and colleagues. But concerns about equity of access to treatments have led to preventive interventions being encouraged regardless of age, and this can be harmful to the patient and expensive for the health service.

In rapidly ageing populations, we urgently need to reappraise the complex and uncomfortable relations between age discrimination, distributive justice, quality, and length of life, they argue.

For example, preventive use of statins shows no overall benefit in elderly people as cardiovascular mortality and morbidity are replaced by cancer.

Is it possible, they ask, that by introducing preventive treatments in the elderly aimed at reducing the risk of a particular cause of death, we are simply changing the cause of death without the patient's informed consent"

This is fundamentally unethical, undermining the principle of respect for autonomy.

Financial incentives for doctors that are linked to guidelines and targets may coerce doctors into persuading patients to accept such preventive treatments, they add, but the best interests of elderly people might lie in investing the money in health care that will genuinely relieve suffering, such as cataract operations, joint replacement surgery, and personal care of people with dementia.

They believe that a more sophisticated model is needed to assess preventive treatment in the elderly that takes a wider perspective when balancing potential harms against putative benefits.

We should not carry on extrapolating data from younger populations and using linear models that use absolute risks of disease 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, they conclude.

BMJ-British Medical Journal