Editorials

The medicalisation of old age

Should be encouraged

The Oxford English Dictionary describes medicalisation as pejorative, initially applied to the over-investigation and treatment of sexually active teenage girls. Since Ivan Illich's popularisation of the term, its use has spread to conditions such as pregnancy and childbirth, sexual orientation, mental illness, and the menopause. There is legitimate concern about the medicalisation of dying,¹ and because old people die, it is tempting to extend such concern to old age.

In the 1930s, Marjory Warren showed that old people in workhouse wards had treatable diseases and could be rehabilitated and discharged. Apparent social problems were in fact a result of patients being poorly served by health services. With the realisation that something could be done for elderly patients and that such care would make hospitals run more efficiently, geriatric medicine has grown dramatically in the United Kingdom, but less so elsewhere.² However, in the past decade the problems of elderly people have been "de-medicalised" by the movement of patients from hospitals into nursing homes, where their health care has been substituted by social care.³ The warehousing of frail elderly people in nursing homes is a result of medical disinterest and of political ideology, and has led to a social model of care in which medicine is denied a role.⁴ At a less extreme level, evidence of benefit from social interventions in the form of aids and appliances for mobility problems in old age has been reported.⁵ But how many of these people would benefit from medical treatment?

With the increase in life expectancy over the past century, people in their 90s are commonplace, and questions are raised about the wisdom of using invasive and expensive treatments for their illnesses.⁶ Chronological age is a poor marker of vitality and ability to benefit from treatment. Variability in the physiological reserves of very old people and the limited evidence base of treatment efficacy at ages over 80 years makes it difficult to generalise about the value of intervention at older ages. Here clinical judgment and patients' viewsincluding living willsare important in making treatment decisions. Diagnosing "dying" and providing palliative care rather than making futile attempts to cure is essential but difficult because of limited prognostic information about the probability of dying, and the training of doctors that emphasises cures.⁷

"A fair innings?"

"The years of our life are threescore and ten, or even by reason of strength fourscore; yet their span is but toil and trouble; they are soon gone, and we fly away" (Psalms 90, 10). Traditionally the biblical threescore and ten years have been misinterpreted as a natural limit, but the psalm is concerned with the nature of life and not its span. For example, Williams states, "Anyone who achieves or exceeds this is reckoned to have had a fair innings . . ."⁶ However, the fair innings argument as a means of rationing healthcare resources has limitations. Without compulsory euthanasia at the end of the innings, palliative care may prove more expensive than therapeutic treatments.⁶ Concerns about medicalisation of old age may hide a desire to reduce costs.⁸ It is dying in hospitalnot an ageing populationthat costs money. If people die later the costs of health care will fall later, but this is the cost of dying, not of ageing.⁹

As Skrabanek commented, "Since life itself is a universally fatal sexually transmitted disease, living it to the full demands a balance between reasonable and unreasonable risk."¹⁰ Even among individuals who indulge in risky lifestyles a minority succeed in exceeding the age of 70 years.¹¹ Elderly people today are probably fitter than those of two decades ago, but old age still covers a wide range of conditions and needs, from the fit to the frail. Although ageing is a natural process, it would be wrong to conclude that the diseases that accompany it are also natural and should be excluded from medical attention. Myriad trials have shown the benefits of treating rather than ignoring the health problems of older people.¹² Evidence from trials of blood pressure lowering and statins shows us that old people are no different from younger people in their response to treatment, but because of their higher levels of risk, gain greater absolute benefits from effective treatments. Effective treatments for cataract, hearing impairments, angina, osteoarthritis, impotence, depression, and other common conditions exist and should be used.

Keep young and beautiful

The growing population of affluent older people may have greater expectations of medical care, fuelled both by greater consumerism and the promotion of new medical technologies by doctors and the pharmaceutical industry. Are older people likely to demand cures for wrinkles, baldness, yellow teeth, and relief from symptoms of the menopause and andropause? You bet! "Keep young and beautiful if you want to be loved" is the message these days. We have botulinum toxin for the treatment of wrinkles, minoxidil for male pattern baldness, tooth whitening treatments; hormone replacement therapy for women (but not men, yet). But medicalisation of the two commonest social scourges of old agepoverty and lonelinesshas not occurred, suggesting that medicine does recognise some limits.

Arie comments, "it is much more society's convenience that `medicalises' complex problems than the avidity of doctors to take responsibility for them."¹³ Hollywood and the media promote positive images of older people, but it would be surprising if society's stereotypes of beauty were to be reoriented towards images of old age. So demands for medical fixes for ageing are likely to grow. Only a few of these discretionary treatments are likely to be funded in a national healthcare system. Extension of the general principles of evidence based medicine to providers of these treatments will be needed but may be resisted. Consumer and retired people's associations may be in the best position to lobby policy makers for such extension.

Medicalisation can be dangerous. Legitimate concerns exist about the risks of infection during hospitalisation, over-prescribing, inappropriate use of tranquillisers for restraint, and the hazards of pressure sores. But many of these problems occur in social care and represent poor standards of practice. Hazards associated with medical care exist at any age and are not valid reasons for forgoing the potential benefits of treatment. Furthermore, many dangers of medical care are avoidable.¹⁴

In summary, the medicalisation of old age is not to be repudiated, but should be encouraged. Greater access to medical care for older people will result in reductions in mortality and disability. Attempts to ration such care on the grounds of the fair innings argument or by chronological age are flawed. Treatments to combat the ageing process itself should be subject to the same regulatory framework as any new medical technology. In wealthy countries there is no excuse for ignoring the medical problems of older people or attempting to redefine them as social problems, and therefore outside the remit of medicine.

Shah Ebrahim, professor of epidemiology of ageing. 

(shah.ebrahim{at}bristol.ac.uk)Department of Social Medicine, University of Bristol, Canynge Hall, Bristol BS8 2PR