Rethinking Health Care for the Elderly

When people visit their doctors, they will almost automatically get their cholesterol and blood pressure measured. There is nothing wrong with that, except committees of experts have, over time, been setting the “desirable” levels for these parameters lower and lower. Because of this, the elderly, even those who are currently healthy, are especially likely to be told that their health is at risk and they need to be put on drugs.

Three physicians have just written a provocative article in the August 7, 2007, issue of the British Medical Journal titled, “Preventive health care in elderly people needs rethinking.” They say that improved living conditions, immunizations and antibiotics have now allowed people to live long enough to face a new “epidemic: ” cardiovascular disease. Physicians now place much emphasis on prevention with the implication that their patients will escape death from cardiovascular disease. Left unsaid is the rest of the conversation: what will they die of instead? There is no mention of the fact that we all eventually do die. What is really happening is that people exchange one cause of death for another.

The example provided is the use of a popular group of drugs called statins, specifically pravastatin (PRAVACHOL). This drug was chosen because it is the only drug that has been tested in a large clinical trial designed exclusively for the elderly, in this case those 70 to 82 years of age. (Most other trials were either in younger people or had included some elderly people, but were not focused on this group.)

There was a 2 percent absolute reduction in various forms of cardiovascular disease in those using the drug (98 percent received no additional benefit from pravastatin). However, there was no benefit at all in elderly women, a conclusion not mentioned to elderly women when they are prescribed this or presumably other statins. Another striking outcome was that there was no difference in overall mortality for people being treated as opposed to those on placebo. In addition, the rate of cancer diagnosis was significantly increased (1.7 percent) in treated patients, as was the rate of cancer death, although the latter did not quite reach statistical significance.

This problem arises with any preventive disease approach: not everyone would get the disease, but by treating a large population, a significant number of people are put at risk for possible side effects from a treatment without any benefit to them individually. There is no doubt that certain people at high risk for cardiovascular disease can benefit from such drug treatments, but roping in more and more elderly people who are really at low risk is a poor public health approach.

At the base of all this is the powerful effect of the pharmaceutical industry: these industrial giants are the ones with the most to gain as drug use expands to ever more categories of people, a wider range of ages and more use in disease prevention. To this end, pharmaceutical companies spend billions on direct-to-consumer advertising; they employ thousands of salespeople to visit doctors, distributing free samples and slick promotional material; and they provide doctors with free meals, vacations and opportunities for paid speaking engagements, as well as research funds to conduct trials on drugs. These doctors then become the experts that sit on the committees that decide what the standards should be for treatment. This happened with the cholesterol drugs: eight of the nine members of the working group that decided on the latest cholesterol treatment goals had multiple ties to industry.

The authors of the recent British Medical Journal article plead for physicians to take a more global look at their patients, not to focus on individual diseases, and especially not to turn healthy patients into “sick” ones. Rather than putting people on drugs for prevention of a disease they might never have, they recommend using the available money to improve the quality of life of their patients (e.g., provide cataract operations, joint replacement surgery, and personal care of those with dementia). Physicians should not turn the elderly population into patients worried about disease. Instead, they should provide them with the care needed to increase their enjoyment of day-to-day life.

None of this, of course, refutes the need for prevention in the form of a healthy lifestyle, including a healthy diet (both in composition and quantity) and a reasonable amount of exercise. There are no downsides to this approach, as there are with pharmaceuticals.