Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Compression of morbidity, not prolongation of life, is the goal of Old Age preventive medicine
- Anthony Oke (10 August 2007)
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Prevention may not be benficial
- Tim M Reynolds (11 August 2007)
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Need for an individualized approach to preventive care in the elderly
- Paddy B Quail (11 August 2007)
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A patient's viewpoint
- Raymond G Holder (12 August 2007)
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More from a member of the public
- Bob Smith (13 August 2007)
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Not fair on the older patient.
- J THOMAS (13 August 2007)
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The complexity of later life needs a scalpel rather than an axe
- Desmond O'Neill (14 August 2007)
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Not all preventive interventions are equal
- Ashley R Bloomfield (14 August 2007)
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Preventive health care in elderly people needs rethinking
- Idris Williams (14 August 2007)
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Appropriate care of the elderly
- Lesley A M Evans (14 August 2007)
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Re: A patient's viewpoint
- Duane E. Graveline (14 August 2007)
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Evidence-Based Medicine in the Elderly
- Dean J Noimark (15 August 2007)
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Preventive health care in elderly
- Patricia E Price (15 August 2007)
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Saving Lives?
- Gina Johnson (16 August 2007)
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Primary Prevention- Ultimate Goal in Medicine??
- Heong Keong Goh (16 August 2007)
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Equitable health care
- Erik Buskens (16 August 2007)
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Saving Lives Versus Postponing Death
- Joseph I. Yikona (17 August 2007)
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Preventive health care in elderly people needs rethinking
- Martin J. Connolly (17 August 2007)
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Trade offs
- Joan McClusky (17 August 2007)
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Rethinking needed for each and every medication in elderly people
- Doron Garfinkel (20 August 2007)
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Challenging the QOF
- Dougal J. Jeffries (21 August 2007)
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Authors' response
- Dee Mangin, Kieran Sweeney, Iona Heath (23 August 2007)
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We lack reliable data on harms attributable to treatments
- Andrew Herxheimer (31 August 2007)
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Essential geriatric care
- Tamilmani A J (1 October 2007)
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Anthony Oke, Consultant Physician, Geriatric Medicine Mid-Staffordshire NHS Trust
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The public health benefit of preventive medicine in old age comes from the compression of the time spent in dependency to a minimum. Not just the prolongation of life. This also coincides with the majority view of what older people want. Older people identify successful ageing to include physical independence and an active mind. Cardiovascular disease prevention, including the aggressive use of statins from middle age, right into advanced age is a key component in the developed world. The incidence and the prevalence of most forms of dementia are influenced by the reduction of strokes, heart failure, and myocardial infarcts. I would therefore not be concerned that statin use in the elderly is not reducing overall mortality. Studies should be directed at looking at the time spent avoiding disability and dependency References 1. Roos NP, Havens B. Predictors of successful aging: a twelve year study of Manitoba elderly. Am J Public Health 1991;81: 63-8 2. Jick H, et al. Statins and the risk of dementia. Lancet November 11, 2000;356:1627-31. Competing interests: None declared |
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Tim M Reynolds, Consultant Chemical Pathologist Queen's Hospital, Burton-on-Trent, DE13 0RB
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Mangin et al argue that preventive health care in elderly people needs rethinking because it merely changes the mode of death [1]. Life is a sexually-transmitted terminal disease and the light at the end of everyone’s tunnel is the tax man with a torch and a demand for death duties. Since everyone dies at some point in their life, if preventive treatment is given that stops them dying of one thing (e.g. heart disease), it is inevitable that the likelihood of dying of another (e.g. cancer) is increased. The fact of dying (and therefore all-cause mortality) cannot be avoided and is therefore the wrong measure of success. What should be evaluated is the difference (hopefully, extension) in lifespan and the quality of life impact that results from the preventive measure. Many elderly patients are referred to my lipid clinic because they are intolerant of statins. Many others are referred because they do not meet the Government targets set in the QoF despite high doses of statin and the consequent myalgia that prevents further increases in dose. Many of these have high HDL levels and therefore their total cholesterol is high but their LDL cholesterol is not, so they did not need treating in the first place. In other patients the cholesterol was only mildly increased and the side effects of treatment make life unbearable. Frequently after a discussion of the meaning of risk, these patients opt not to be treated because the likely benefits are so small they do not outweigh the adverse side effects. The probability of being dead in the next 10 years obviously increases with age. The use of risk-based cut offs that set a probability at which treatment must be given means that there is an age-threshold where the prior probability of death is so high that treatment cannot be avoided by doctors who have been enslaved by the target culture. Evidence- based fascist solutions can result in the insistence that certain groups of patients must be treated regardless of their likely (minimal) extension of life. The main casualty of target-based medicine is therefore common sense. We do need to rethink our guideline-based culture of preventive medicine so that people who have the most to gain are treated whilst those who are unlikely to benefit do not have to take the risks. If instead of simply relying on risk we calculated the number-needed- to-treat to gain a minimum life increment (perhaps 2 years), this might allow more rational decisions. Then all that remains is the argument about what is the right NNT: Whilst it would clearly be reasonable to treat a particular group if the NNT was 10 [i.e. 1 of the 10 people would get 2 extra years], would it be sensible if the NNT was 100, or 200 etc? Defining cut offs is a political and medical decision. As doctors we believe our duty is to prolong the life of our patients. We are not trained to decide when a potentially useful treatment will provide so little benefit that it is merely a waste of scarce funds. It is up to our politicians to decide how far the public wants us to go in this respect; i.e. to decide what the public is prepared to pay for. The political solution to this was NICE: a body that advises when rationing should apply but that was designed to be at arms length from politicians because unpleasant decisions could lose them votes. Rethinking preventive medicine is therefore a very reasonable proposal; but it needs to be rethought at a political level as well as a medical one. REFERENCES 1) Mangin D, Sweeney K, Heath I. Preventive Health care in elderly people needs rethinking. BMJ 2007; 335: 285-7 Competing interests: I run a 'lipid' clinic |
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Paddy B Quail, Medical Leader Home Care Calgary Health Region, 10101 Southport Road SW, Calgary, AB Canada T2W 3N2
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Mangin and colleagues outline an argument in favour of benign neglect in regard to 'elderly people' as being in their best interest. That every older patient has a similar notion of a 'good way to go' presumes a sensibility not shared by many of my older patients. At no time are we provided with a definition of what is understood by 'elderly' and apart from the use of statins in the older patient no other preventive interventions are described. There are many preventive measures that are of clear benefit to the older patient eg influenza vaccination in residential care settings and blood pressure monitoring and treatment. Are we to discontinue these practices? To promote a preventive nihilism based on the use of statins in older patients is overly simplistic and runs counter to their own arguments. In fact to characterize the elderly as having 'many compounding diseases' is paternalistic when each patient requires our individual consideration and counsel to assist them in understanding the limits and potential of preventive health care towards the end of life. Competing interests: None declared |
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Raymond G Holder, Long retired engineer BH9 3NF
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It was so refreshing to read the article “Preventive health in elderly people needs rethinking” As one who has received a bonus to date of 23% over his allotted three score years and ten, very nearly cut short at half that value by the “life extending” statins, I feel that I am as well qualified as most others to offer an opinion. So much of today’s health advice output is in such terms as “More aggressive use of statins””-----“Extrapolation of statin treatment to all ages”----“give statins to all men over 50”, it comes as a great relief to find more articles from opposing views, particularly this one. Having been hit by the triple whammy of post polio, statin damage and finally a stroke, (probably caused by the stress of looking after my late wife with Alzheimer’s, in my statin weakened state) I know only too well that I cannot look forward to an extended future, but I have just sufficient mobility to live independently, with various amounts of help from family members, etc. I have several interests which my present state allows me to pursue, not the least of which is to campaign against the mindless extension of statin use, oblivious to the damage which they can and do cause to very many individuals, and in spite of the fact that cholesterol level is increasingly seen as irrelevant, other risk factors –smoking, blood pressure, deprivation, salt, etc are each quoted as having serious effects on heart health, without mentioning the effect of homocysteine level, a much more reliable marker of problems in store. The trials so far undertaken have not been really serious attempts to investigate its role, but the treatment of it has no golden eggs for industry to attract their financial backing. I read the PROSPER study, and my determination never to take another statin was vindicated when I read that they could possibly increase the chances of my demise from cancer. My heart must inevitably stop beating one day; I hope it does so without any accompanying malignant takeover of my remaining functions. Of course the authors said that the cancer problem was just a blip among its non-appearance in other studies, but the age group was so different. The great problem with statin use, unrecognised through the rosy spectacles of the statinators, is the throttling back of CoenzymeQ10 in step with cholesterol reduction. The University of St Louis website terms this effect “statin toxicity”, and that is no exaggeration. It quotes the many side effects and treatment, and also shows carnitine deficiency as a parallel event. Loss of CoQ10 over a lifetime is an inevitable process, and results in the deterioration of many bodily processes through their inability to receive the necessary energy to power them. The heart is the major user of energy, followed by liver, kidneys, and such things as hypothyroidism, insulin shortage, and possibly macular degeneration could result. Among the elderly users of statins, heart failure, and memory loss, simulating Alzheimer’s, are often seen, when and if recognised by their doctor as caused by the statin .The improvement of CoQ10 levels in such cases is a simple matter, virtually without side effects, controlling blood pressure at the same time, by improving heart pumping strength. The failing of so many drug treatments is that they interfere with normal body processes, rather than bolster up age related deficiencies, and unwanted effects occur. Statin use brings forward this CoQ10 reduction, especially in the elderly, whose supply is already naturally low, so worsening the ills of old age, by fostering and accelerating further degeneration. Many statin damage sufferers, mostly not senior citizens, have stated that they would rather have a shorter life without side effects, risking heart problems, than endure their intolerable statin side effects over a longer life. Older folk will already have enough problems of their own, without wanting to risk adding to them, as Malcolm Kendrick puts it, only to change what is written on their death certificate, without altering its date. As for my outlook for the future, I will continue to take my life essential Coenzyme Q10 and carnitine supplements to keep my poor statin- induced-energy-starved heart ticking for as long as I can, so that I may continue to campaign against the iniquitous statin/cholesterol dogma, and help those, neglected by official medicine, who suffer from the sinister damage resulting from statin use, keeping my strength up meanwhile with plenty of butter, cheese and red meat. But if something dreadful comes along, I shall only need to cease taking my Q10 to revert to the status of six years ago when my heart was close to failure, and depart this life gracefully, unless, of course, Father Time has called before my task is complete. I have had a very good and interesting life and the thought of just being kept alive to finish it in a home, losing all my independence and my interests bothers me much more than that of an earlier demise. Competing interests: Statin damaged patient |
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Bob Smith, Retired Home - SG17 5JH
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Like the previous response I welcome this Analysis paper. However, I am uncertain if much attention will be given to the potential improvements in healthcare. The PCT we work with is short of cash and time making decisions regarding treatments as simple/quick as possible across the age board. It is a luxury we have not seen generally for the NHS clinicians to take the time and trouble to listen to the individual patient. Despite this, we all feel that the future is in greater preventative care. Competing interests: Chairman of a Patient and Public Involvement Forum |
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J THOMAS, Consultant Geriatrician Nobles Hospital, Isle of Man IM4 4RJ
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The authors seem to have pre-conceived ideas regarding the longevity of the "elderly". The article seem to based on the principle "Our body seem to have a finite functional life...". Can the authors clarify what this finite number is? Can they say an 80 year old admitted with TIA will not live for another 15 years in fairly good health? Would they stop this patient from having secondary prevention which has been proven to be of benefit in older patients. I cannot help but think that there is an element of ageism coming out in this article. Competing interests: None declared |
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Desmond O'Neill, Associate Professor Medical Gerontology Centre for Ageing Neurosciences and the Humanities
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The key features of ageing are increased inter-individual variability, complexity and co-morbidity, which is why indicators of quality of care based on single disease models work less well among older than younger people. However, it is a far cry from this position to the nihilism of Mangin and colleagues. Individualized health promotion for older people is highly effective (1), and is likely to be among the reasons for falling disability among older Americans (2), to the point of stabilizing healthcare expenditure on older people. Health promotion among older people embraces a far wider repertoire of manoeuvres than the prescription of statins, and sadly, there is abundant evidence that old age is associated with a failure of doctors to provide health promotion to older people in a range of settings (3-5). Rather than systematically withholding preventive options for older people, clinicians should capitalize on other hallmarks of later life, wisdom and common sense, to develop a partnership approach whereby older people can choose whether or not to take up the different elements of an individualized health promotion programme. Using these gerontological principles effectively will help to ensure that health promotion in later life is sculpted with a scalpel rather than an axe. References 1) LIFE Study Investigators, Pahor M, Blair SN, Espeland M, Fielding R, Gill TM, Guralnik JM, Hadley EC, King AC, Kritchevsky SB, Maraldi C, Miller ME, Newman AB, Rejeski WJ, Romashkan S, Studenski S. Effects of a physical activity intervention on measures of physical performance: Results of the lifestyle interventions and independence for Elders Pilot (LIFE-P) study. J Gerontol A Biol Sci Med Sci. 2006;61:1157-65. 2) Manton KG, Gu X, Lamb VL. Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the U.S. elderly population. Proc Natl Acad Sci U S A. 2006;103:18374-9. 3) Arber S, McKinlay J, Adams A, Marceau L, Link C, O'Donnell A.Influence of patient characteristics on doctors' questioning and lifestyle advice for coronary heart disease: a UK/US video experiment. Br J Gen Pract. 2004;54:673-8: 4) Maguire CP, Ryan J, Kelly A, O'Neill D, Coakley D, Walsh JB. Do patient age and medical condition influence medical advice to stop smoking? Age Ageing. 2000;29:264-6. 5) Fairhead JF, Rothwell PM. Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study. BMJ. 2006 Sep 9;333(7567):525-7. Competing interests: None declared |
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Ashley R Bloomfield, Chief Advisor Public Health Ministry of Health, Wellington, New Zealand
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The article by Mangin et al has raised an important issue that merits further discussion. The example of statins is instructive, although not just in the elderly. One of the most important contributors to cardiovascular risk is smoking status - very often, successful quitting will reduce an individual's risk to a level where other pharmacological interventions may not be indicated. Presently, many smokers with an elevated cardiovascular risk have their smoking 'status' treated with statins (or antihypertensives). The wider use of effective pharmacological interventions for smoking could prevent unnecessary morbidity and mortality from cardiovascular disease and other chronic diseases - avoiding the trap of the single disease focus - including in the elderly. Support to quit smoking is arguably one preventive intervention that it is unethical to withhold at any stage of life. Competing interests: None declared |
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Idris Williams, Emeritus Prof of General Practice Barn Howe, Lyth, Kendal, Cumbria
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Editor BMJ I read with interest the paper by Mangin, Sweeney, and Heath (Ref1). I write this letter as someone well past an average lifespan. I do have my share of Long Term Conditions, each effectively treated, which allows me to lead an active & contributive life. The sophisticated arguments used against "preventive" health care in what is termed elderly (a pejorative term in itself) people, miss the point. What most people are interested in is something more positive: the achievement of high quality and effective ageing regardless of actual age. This means treating treatable illness at all ages. Most Long Term Conditions are treatable (Ref2). As a consequence it is likely that independence will be maintained or regained; so taking pressure off both Health and Social Services. Idris Williams References 1. Mangin D, Sweeney K, Heath I. Preventive health care in elderly people needs rethinking. BMJ, 11 August 2007. Vol335. 285-287 2. An Evidence Based approach to assessing older people in Primary Care. Eds. E.I.Williams et al. 2002. Occasional Paper No 82. Royal College of General Practitioners. London. Competing interests: None declared |
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Lesley A M Evans, Retired Consultant Geriatrician Taunton and Somerset Hospitals TA1 5DA
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I would like to congratulate the authors of this excellent paper on Preventive health care in the elderly, and agree whole-heartedly with them. When I was working, we used dedicated hospitals and staff for geriatric medical care, and this gave an environment which was far more conducive to appropriate care and a slower pace of recovery, which the elderly need. We had a separate acute hospital, where admittedly we did not have all the resuscitation equipment that a District General has, but we simply did not admit anyone who was likely to need intensive care, and we felt this would have been totally inappropriate for the patients we did admit. If the situation for individuals changed, we transferred them. We had 7 peripheral hospitals, where we ran clinics and Day Hospitals, and used those beds for rehabilitation or short term holiday relief or symptom control, and in the early days, long stay patients too. We worked with a team at all the hospitals, and had our own dedicated nurses, Physiotherapists, Occupational Therapists and Social Workers, the therapy staff coming on all ward rounds with the Consultant and the Social Worker meeting us afterwards. The essence of good care of the elderly is team work, which we were already doing 25 years ago, and which is not a new concept. But it does require that the staff are committed to that field, and not continually chopping and changing. The same applies to the nurses. Care of the elderly isn't everyone's cup of tea, after all. I am speaking of the 80s and 90s and even 100 year olds. I fear that now that the elderly are put onto general wards, and offered all available interventions, and preventive medication, in the desperate fear by the management of being seen to be "ageist", they are almost certainly no longer being treated as different in terms of their physiology, recovery rates, and frequently multiple pathology. The elderly ARE different, and their homeostatic mechanisms are often not as efficient as younger patients, they can become dehydrated so quickly, and they often need longer courses of antibiotics. Elderly skin breaks down easily. Just as Paediatrics is a distinct specialty, so is Geriatrics. They need far more time and patience when history taking - the most important part of any examination is the history, which will give you the diagnosis in most cases, but it takes time and patience when the person is confused and slow. Only staff used to dealing with such patients will treat them appropriately. This is not ageist, simply a fact. Often old people are being screened unnecessarily, and given drugs which they cannot remember to take or take wrongly, when they might be much happier left with some minor pathology which is an inevitable part of age. After all, we have to die of something!! Patients should not be made to feel they must have every available test, or for example take hypotensive medication which will make them faint and ruin the quality of what life they have left. It would be far, far better to accept that medical care of the very elderly is a compromise, and to increase the personal care available, to enable people to stay in their own homes, even if they are at some risk of falling, and to provide good terminal care for all conditions, not just malignant ones. This can be done, as I found in my own practice. We need less emphasis on statistics and targets, and more on human beings! We used to have homely little hospitals, with a hospital cat, and lovely gardens. That in itself helped patients to get better quicker. And we never sent them home until we were sure they could cope, however long it took - bed blocking is a very perjorative term, and sending a person home too soon only results in their bouncing back in. The managers need an injection of common sense - which they always seem to lack, in my experience. Lesley A M Evans Competing interests: None declared |
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Duane E. Graveline, retired MD, research scientist 4414 Cormorant Ln. Merritt Island, Florida 32953
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I know this patient, Ray Holder, very well and concur with everything he has said about statin side effects and wish to add just a bit more so the reader gets a more complete picture of the consequences of mevalonate blockade, the action of all reductase inhibitors. Think of the mevalonate pathway as a tree with multiple branches and then think of the effect of our statins drugs as “girding” this tree at the base. This is what “Big Pharma” has done in its efforts to block cholesterol using reductase inhibitor. We threw caution to the winds 15 years ago when our national priority to lower cholesterol so fogged our minds that we (medical, pharmaceutical and food industry) focused just on the cholesterol branch of the mevalonate “tree” and completely disregarded the important consequences of collateral damage to the other main branches of this tree from our statin drugs. The predictable result of all this has been our bizarre spectrum of statin associated side effects ranging from cognitive, to myotoxic, neurotoxic, neurodegenerative and even behavioral. Mr Holder has well described the consequences of CoQ10 inhibition. I wish to focus on the dolichol branch of our mevalonate pathway, for recently I have learned much about the role of dolichols and it is time to share it with you. I have been talking of the consequences of excessive dolichol inhibition for years now, thinking that this substance contributed solely to neuropeptide formation and our functions of thought, sensation and emotion. More recently I have learned that this assembly of peptide fragments within the endoplasmic reticulum of every cell in our body is only a small part of dolichol’s contribution for it is here that our sacharrides (sugars) are attached to proteins and lipids to give a far broader range of diversity and information transfer than either protein or lipid alone. No longer do we consider our sugars as just simple fuel. The effects of just eight vital sugars on the resulting peptide structure being created constantly in each of our bodies cells, is just short of miraculous. And this attachment of sugars is completely dependent on dolichol’s orchestration. Throw in a statin and what do you have – inevitable inhibition of dolichol synthesis, roughly comparable to the degree of cholesterol inhibition. The resulting effect upon our body of this dolichol theft is completely unpredictable for this is the very center of cell communication and immunodefense. We now know that dolichol inhibition is fully as important as CoQ10 in this game of statin roulette with a range of side effect that we are only just beginning to know. And mind you, CoQ10 and dolichols are just a part of statin's biochemical effect. Competing interests: None declared |
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Dean J Noimark, SpR in General and Geriatric Medicine Charing Cross Hospital, Fulham Palace Road, London, W6 8RF
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Mangin et al (1) present an interesting perspective on treatment strategies in the elderly. Although, they make the point that the PROSPER trial (2) demonstrates no benefit in the elderly, the more worrying point is that there is a lack of randomised controlled trials (RCTs) including the elderly (3-4)in order for treatment options to be guided by an evidence-based approach. Only last week it was reported that the international Hypertension in the Very Elderly Trial (HYVET) was being halted due to a significant reduction in strokes and cardiovascular mortality in those receiving the active treatment (5). A common sense approach to treating the elderly is paramount. Clearly, one does not want to label the well with a disease they do not have. Society has to weigh up the costs of prevention versus more immediate beneficial treatments. The debate however will continue to rage as long as there is a lack of RCTs. 1. Mangin D, Sweeney K, Heath I. Preventive health care in elderly people needs rethinking. BMJ 2007; 335: 285-287 2. Shepherd J, Blauw G, Murphy M, Bollen E, Buckley B, Cobbe S, Ford I, Gaw A, Hyland M, Jukema J. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. The Lancet 2002; 360:1623-1630 3. Trimble EL, Carter CL, Cain D, Freidlin B, Ungerleider RS, Friedman MA.Representation of older patients in cancer treatment trials. Cancer. 1994 Oct 1;74(7 Suppl):2208-14. 4. Heiat A, Gross CP, Krumholz HM,Representation of the Elderly, Women, and Minorities in Heart Failure Clinical Trials. Arch Intern Med. 2002;162:1682-1688 5. BBC Health Competing interests: None declared |
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Patricia E Price, retired GP NA
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The article by Mangin, Sweeney and Heath is a breath of fresh air! All doctors dealing with the elderly should reconsider their present practice. A retired GP in my eightieth year I have personal experience of "over prevention" About three years ago I was persuaded that I was hypertensive (150-160/90-95)and I reluctantly agreed to start treatment with the aim of preventing stroke and /or myocardial infarct.I was prescribed a calcium channel blocker. Cholesterol level was 6.3 and, again reluctantly, I agreed to take a statin. I was also taking meloxicam . I was not immediately aware of any side effects, but on two subsequent occasions I experienced severe nightmares, acute anxiety and very frequent extrasystoles (apex beat 120+,radial pulse 70-80). The first occasion was when I had a viral illness, the second when I sustained a Colles fracture. On this second occasion the nightmares were so bad I was frightened to go to sleep, the anxiety so bad that I wondered how I could go on coping. I then aquired a British National Formulary and, having looked up the possible side effects of my medication decided to stop these three. The nightmares reduced then ceased,the acute anxiety settled, the extrasystoles became only occasional (as they have been since I was in my late twenties). Initially I checked my BP daily. As my pulse normalised so my BP reduced. It has now stabilised at 135-140/80-85. I now check monthly. Cholesterol had reduced on the statins now returned to 6.3. In general I feel better than I have done for some years. Life is certainly worth living! I have, of course, informed my GPs and my decision has been accepted. I feel that I am now in charge of my own health again. For most elderly people it is more important to be able to enjoy life than to have (possibly) a few more years which have been made miserable. The view of the individual patient needs to be considered. Competing interests: None declared |
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Gina Johnson, General Practitioner Churchfield Medical Centre, Luton LU2 9SB
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Thank you, thank you, for introducing a rare element of common sense into the debate on preventative interventions for older people. We doctors have become intoxicated by the pharmaceutical power with which we can apparently transform our patients' futures. Yet we cannot achieve immortality, much less eternal youth, and the drugs are much less powerful than we like to imagine. With older patients we must stop deluding ourselves that we are saving lives, and start a more honest debate about the morality of changing deaths. Competing interests: None declared |
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Heong Keong Goh, Registrar Malaysia
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I once heard this old Chinese saying- the best doctor is the one who try to prevent his patients getting sick in the first place. However, as we are trying to pursue this ultimate goal in modern medicine, we have to consider various factors affecting our judgement in implementing this preventive health care system. We are bombarded with various clinical trials everyday and we tend to forget the primary end point and the targeted population group of the trial. Some of us may be too eager to help our patients and try to extrapolate certain benefits in certain trials to other population group. This blind approach not only harms our patients but also indirectly burdens our health care system. I certainly welcome this article and I hope that we should always bear in mind the evidence behind before taking any action in patient management. Hopefully, future healthcare system in any country in this world is affordable and accessible! Competing interests: None declared |
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Erik Buskens, Professor of Medical Technology Assessment University Medical Center Groningen, PO box 30.001, 9700 RB Groningen, The Netherlands
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Dear sir, Reading that someone had answered a question that seemed critical to the future of health care, and had kept me thinking (and applying for research grants) for several years now, was both encouraging and disappointing. Initially disappointed that this intriguing issue might have been resolved, I do, however, admire the work by Mangin et al. who recognise that one needs to take into account much more than preventing cardiovascular events at old age. [1] Their publication questions the hardly evidence based cholesterol and other targets for the elderly set in various guidelines. In fact they put prevention at older age high on the research agenda, which lifted my spirits again. Most of the responses to the paper by patients, and practitioners (having been) involved in preventive and curative treatment alike, underscore the importance of the issue further. In the doctor’s office are we really conveying the full picture when prescribing statins, blood pressure lowering drugs, insist on exercise and quitting tobacco use in the middle aged and elderly? The fact that most patients either quit taking the drugs soon after picking it up at the pharmacy or refuse preventive treatment altogether somehow seems to convey a common sense value judgement that all the effort and resources required may not be worth their while. It would appear that what is badly needed is full picture of what cardiovascular risk management might actually accomplish. Are stroke and MI related morbidity and mortality merely replaced by other possibly more gruesome outcomes? Once this information would be available we could set out to obtain an appropriate value judgement on these altered life courses, and only then could we attain a considered policy decision or clinical guideline. Suggesting that this would be a political issue as stated in one response seems to evade the broad responsibility medical professionals have or should take on together with other relevant stakeholders. With an ageing population and ever new treatment possibilities comes an ever increasing demand for resources. These resources both in terms of financial demands and actual health care capacity ultimately will have to be distributed equitably. The responsibility and challenge is huge and to me seems a noble mission for medical professionals too. Erik Buskens MD, PhD
1) Mangin D, Sweeney K, Heath I. Preventive health care in the elderly needs rethinking. BMJ 2007;335:285-7. Competing interests: None declared |
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Joseph I. Yikona, Specialist Registrar-Internal Medicine and Geriatrics Elderly Medicine, Box 135, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2QQ, UK
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Dee Mangin and colleagues discuss the ethics and morality of extrapolation of cardiovascular epidemiological data from the young to the older patient populations. I do agree with their analysis and reminder. We must accept that there is no cure for ischaemic heart disease. My concern is the paucity of future expertise in caring for these patients whose deaths are in fact being POSTPONED. Most of these patients will have the less sexy chronic heart failure. Worldwide, the majority of the current and possibly future cohort of Cardiologists have repeatedly shown more interest in interventional cardiology. Medical training curricula should now prepare for acceptable general expertise in caring for these heart failure patients from acute-on-chronic presentations upto the inevitable palliative phase. Within the general vocabulary of "saving lives" we probably should be thinking about the philosophical concepts of "postponement of death". Competing interests: None declared |
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Martin J. Connolly, Freemasons' Professor of Geriatric Medicine, University of Auckland , New Zealand University Department of Geriatric Medicine, North Shore Hospital, , PO Box 93 503, Auckland
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Whilst agreeing of course that informed consent for any intervention should be as complete as possible, I assume that Drs. Mangin, Sweeney and Heath, had they been writing in the 19th century, would not have advocated a rethink of the installation of sewerage systems on the basis that the application of such expensive technology to the poor would merely allow them to survive in order to die of malnutrition, TB or coal-worker's pneumoconiosis. Competing interests: None |
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Joan McClusky, Medical writer New York, NY 10003
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This article raises the important point that we constantly make trade offs that affect our health--some of our own choosing and some made for us. What is interesting is the idea of others choosing how we will die, while we choose how we will live. Someone decides we should not die of heart disease, and that taking statins will reduce that likelihood. A person takes statins, experiences side effects, and stops taking them. Perhaps a lot of the "compliance" problems seen today regarding lifestyle issues such weight, diet, smoking, etc have more to do with this split than is recognized. Advice is often tempered as "stop living this way because we don't want you to die of thus and such." To those controlling the death of others, this often appears to be a numbers game as much as anything else, especially when population risk data are extrapolated to individuals. But each person gets only one life that inevitably leads toward one death. In the end, the question might be, "what kind of life do you want to have?" rather than "what kind of death do you want to have?" Competing interests: None declared |
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Doron Garfinkel, Head, Dept. of Evaluation & Rehabilitation and Palliative unit Shoham Geriatric Medical Center, Pardes - Hana, Israel 37000
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To the Editor, Mangin et al. argue against current trends in medicine that encourages preventing interventions regardless of age, and warn that this approach can be harmful to patients and expensive for the health services.1 As an example, they note that in the elderly Pravastatin had no beneficial effect on all cause mortality, inferring that mortality and morbidity from other causes must have increased. I would like to take this perception further suggesting that in the elderly, the Mangin et al. call for “rethinking” should be expanded to include not only preventive treatments, but also medications classified as curative and in some cases even those used for palliative care and symptom relief. Mangin et al. stress that in older people, the likelihood of compounding diseases increases, but they do not relate to other medications consumed. However, the more diseases one has, the more medications prescribed, thus increasing the risk of inappropriate medication use and adverse drug effects. With incresed age, comorbidity and the number of drugs consumed, the usually unmeasurable but obviously negative impact of polypharmacy should be weighed as a significant risk factor in itself, against all possible benefits of each and every medication added to the patient’s drug pool. In a recently published manuscript entitled “The war against polypharmacy”, 2 we used a new algorithm to discontinue a total of 332 different drugs in 119 disabled elders patients in nursing departments (range 1-7 drugs/patient). The control group included patients of the same departments with compareable demographic and comorbidity characteristics, in whom no drugs were discontinued. The overall rate of discontinuation success was 82% of all patients and 90% of all drugs and it was not associated with significant adverse effects. The one year mortality rate decreased from 45% in the control group to only 21% in the study group (p<0.001); the annual referral rate to acute care facilities also decreased from 30% in the controls to 11.8% in the study group (p< 0.002). So, not only the increased risk of cancer and other life threatening or “Quality of life threatening” diseases but also polypharmacy, should be included among what Mangin et al. refer to as “mortality and morbidity from other causes”. We have proven our hypothesis claiming that the sum total of negative impacts of polypharmacy may outweigh the sum total of the potential beneficial effects of all specific drugs. This assumption seems even more likely when considering preventing treatments. Most guidelines for treating human maladies represent good evidence-based medicine and have been proven effective by decreased mortality and morbidity rates (eg. hypertension, diabetes mellitus and hyperlipidemia) in middle age patients. In the elderly however, particularly in institutionalised patients and/or in those with limited life expectancy, the same medications may be inappropriate having greater risks and unproven or at least questionable beneficial impact on longevity, with probably no beneficial effect on life quality. I completely agree with Mangin et al. regarding the ethical principle of respect for autonomy. We should share our evidence-based knowledge (limited as it is) with either the elderly themselves or their guardians/families. They should be informed about the pros and cons of each medication prescribed and its possible impact on longevity and life quality, keeping in mind that for frail older adults and persons with limited life expectancy, more room should be given to issues such as symptom control, quality of life and patient / family preferences. As for Mangin et al. concern of being accused of ageism – no one would dream of accusing pediatricians of discrimination when they use decreased dosage or not prescribe at all certain drugs to children. It is our task to first convince ourselves then teach the public that just like babies, elderly people being much more vulnerable to adverse medication effects, also need individualisation of drug therapy as well as professional physicians (preferably geriatricians) to achieve the best care possible. Furthermore, as evidence-based data is scant in elderly people, extrapolating data from youger population in the name of equality can do more harm than benefit and severely damage phycisians’ most fundamental ethical rule of “primum non nocera”. References: 1. Mangin D, Sweeney K, Heath I. Preventive health care in elderly people needs rethinking. Brit Med J 2007: 335:285-287 (11 August). 2. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: A new, cost effective, Geriatric - Palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J 2007; 9: 430-4. Correspondence to: Doron Garfinkel, M.D. Head, Department of Evaluation & Rehabilitation and Palliative unit, Shoham Geriatric Medical Center Pardes - Hana Israel 37000 e-mail: dorong@shoham.health.gov.il Competing interests: None declared |
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Dougal J. Jeffries, general practitioner St Mary's Health Centre, Isles of Scilly TR21 0NE
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As a British GP who has disliked and mistrusted the Quality and Outcomes Framework from its first appearance, I applaud this paper by Mangin, Sweeney and Heath. I am pleased to see that the majority of rapid responses have supported their arguments, and would like to point out one or two apparent misunderstandings in some of the other responses. First, the charge of 'ageism' in whatever guise is clearly false. The authors are, on the contrary, trying to prevent unneccesary harms to older patients (and why the term 'elderly' should be regarded as pejorative rather than merely descriptive eludes me). What should be regarded as abusive is to apply guidelines whose evidence base is derived from generally much younger and fitter populations to older and frailer ones. Secondly, the analogy of the introduction of a sewerage system being rejected on the gounds that the poor would still die of other poverty related illness is also false. In that situation, the overall morbidity and age-specific mortality would fall with the introduction of safe sewerage. In the case of witholding statin treatment in the elderly (and we have to admit that we do not have the evidence to be precise about what age or degree of comorbidity we are talking about), the point is that life expectancy is not extended at all. The logical inference therefore must be that widespread statin treatment actually increases mortality from other causes, rather than being neutral in its effects. Similar arguments may be applied to other interventions. The message of the article is that we should be much more circumspect in applying the targets set by the QOF (and in non-QOF related areas of care as well), pay more attention to patients' feelings and preferences, and continue to assess what evidence comes to light. Younger GPs in particular need to be reassured that their intuitive reservations - I hope they have them! - about the blanket application of QOF targets are often wholly justifiable, and that they should not be afraid of making use of the 'exceptions' facility when it is in their patients' best interests. Competing interests: None declared |
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Dee Mangin, Senior Lecturer in General Practice University of Otago, Christchurch, Kieran Sweeney, Iona Heath
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We were very encouraged by the level of interest and agreement about the importance of exploring this issue. It is clear there is discomfort across a range of disciplines and we hope the thoughtful responses will spark wider discussion and commonsense approaches to polypharmacy like the one proposed by Garfinkel.1 A few responses suggest a framework that better assesses the balance of harms and benefits is ageist or nihilstic. It is no more ageist nor nihilistic to state what is clear from these data than it is sexist to point out the reduced efficacy of statins in women or racist to suggest greater harms from a medicine in particular ethnic groups. 2 The PROSPER study has been acknowledged as the best available evidence for the effects of statins for prevention of cardio- and cerebrovascular disease in the elderly. 3 We cannot then ignore these data. The increased risks of adverse effects and polypharmacy in the elderly are vividly described in the patient accounts. It is suggested we need a scalpel not an axe. The current approach resembles a sledgehammer. Discussion and debate about a different way of assessing the merits of preventive and other treatments is not the same as systematically withholding them - some preventive interventions will likely be of benefit using this model (flu vaccination, exercise, smoking cessation). Some, like statins, will fail these criteria. Patients and physicians are entitled to all the information they require to make decisions with such profound consequences. The current models of guidance, guidelines and incentive-linked indicators make this unlikely. There is no evidence that there is any benefit from statins in the studied age range for primary prevention, for stroke prevention or in women. 3 One response asserts that statins are important in dementia prevention and that overall mortality is not as important as compression of morbidity. The referenced case control study on dementia has the same potential biases as the HRT studies that suggested similar effects. 4 There was no evidence that using statins improved cognitive outcomes in this more recent RCT. 3 Assessing the real benefits and harms of interventions in terms of compression of overall morbidity - relief of suffering - is exactly what we are suggesting, however statins fail this test. In the treated group, life is neither longer nor is it healthier. The elderly deserve better than to be squeezed uncomfortably into a single disease model designed to best assess the benefits and harms of treatment in younger populations. Equity is not equality in this instance. 1 Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: A new, cost effective, Geriatric - Palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J 2007; 9: 430-4. 2 Kendrick M. Should women be offered cholesterol lowering drugs to prevent cardiovascular disease? No. BMJ 2007;334;983- 3 Shepherd J, Blauw G, Murphy M, Bollen E, Buckley B, Cobbe S, Ford I, Gaw A, Hyland M, Jukema J. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. The Lancet 2002; 360:1623-1630 4 Jick H, et al. Statins and the risk of dementia. Lancet November 11, 2000;356:1627-31. Competing interests: None declared |
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Andrew Herxheimer, emeritus fellow, UK Cochrane Centre London N3 2NL
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A major underlying point that is implicit in the important and excellent paper by Mangin, Sweeney and Heath, and which must be made explicit is that we have quite inadequate data on harms attributable to treatment. There is no proper or coherent effort - let alone a programme or plan - for identifying, analysing, investigating or quantifying harms. That means qualitative as well as quantitative research, and when appropriate, decent meta-analyses. Lack of data has led to widespread ignorance and lack of awareness of harms, and systematic underestimation, with benefits estimated from optimistic RCTs which tip the balance towards many treatments that we should often hesitate to use. The Cochrane Collaboration has just inaugurated a Cochrane Adverse Effects Methods Group (www.aemg.cochrane.org), with the primary aim of getting adverse effects justly represented in systematic reviews. In most such reviews they are not, and that has led to a widespread bias in their conclusions, which we must try to correct. Competing interests: None declared |
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Tamilmani A J, Medical Officer, Indian Inst Of Technology- Madras Chennai-600036
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Dear Sir, Congrats to the Author first. I have a different opinion about the need for Preventive Geriatric Care for old age related diseases. Most of the chronic illnesses start in middle age between 30 and 50 because of poor knowledge about HEALTH AND PREVENTIVE CARE. Sedentary lifestyle, Inadequate exercise, Improper food habits, frequent travels, late working hours, excessive physical and mental stress and ignorance atlast are the presumptive factors for the late onset geriatric disabilities like Osteoarthritis , Alzeimers and Dementia... I did not include diabetes, Hypertension , IHD , Bronchial Asthma or Tuberculosis as the geriatric diseases since the onset of the above nowadays maximum in middle age. It's highly mandatory to educate the middle aged population about the life style modifications and preventive aspects of Geriatric Diseases. Thereby we can extend the lifespan of a human without any deadly diseases in his old age too. With sincere Regards,
Competing interests: None declared |
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