Preventive health care in elderly people needs Rethinking

Preventive health care aims to delay the onset of illness and disease and to prevent untimely and premature deaths. But the theory and rhetoric of prevention do not deal with the problem of how such health care applies to people who have already exceeded an average lifespan. In recent years, concerns about equity of access to treatments have focused on ageism. As a result, preventive interventions are 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.

The epidemic of cardiovascular disease

In the richer countries of the world, improved social conditions combined with immunisations and antibiotics have rapidly reduced the rates of death from infectious diseases. People saved from these epidemics now live long enough to face the new “epidemic” of cardiovascular disease, which is the focus of huge investment and endeavour in health promotion. The national service framework for cardiovascular disease aims to reduce the number of people dying from coronary heart disease by 40% by the year 2010 with advice that standards set out in this framework apply to all people, irrespective of age. But what will be the next most common cause of death—the next epidemic? Our bodies have a finite functional life and age is a fundamental cause of disease.By using preventive treatments to reduce the risk of a particular cause of death in elderly people are we simply changing the cause of death rather than prolonging life?

Three factors fuel this possibility. Firstly, single disease perspectives lure researchers and guideline groups into assuming that improved outcomes for the index condition mean that everybody with that condition should be treated, irrespective of the overall effect on population mortality and morbidity. Secondly, sensitivity about age discrimination prevents us from looking at things differently when dealing with an elderly population. Finally, drug companies make huge financial gains if effective interventions in relatively small populations become standard care for all people at risk of that condition.

Research estimates of differences in the absolute risk of an adverse outcome enable us to assess the potential benefits of treatments. The number needed to treat is calculated from the reduction in absolute risk and can help clinicians assess the balance between the burden of treatment and possible benefit. This measure is most useful for younger people in whom a single disease is more likely to have a significant effect on mortality and morbidity. The number needed to treat works best with acute conditions and less well with chronic conditions. In older people, the likelihood of many compounding diseases increases, and the absolute risk of dying is higher because they are nearer the end of their life. This may magnify the apparent effect of a single intervention for a specific condition while overall survival is only minimally affected. The use of statins to prevent cardiovascular disease provides a case study for examining these issues further.

Evidence for lipid lowering treatments in elderly people

Currently, we use evidence from younger populations and extrapolate this to elderly ones. Anxiety about age discrimination means that no upper age limit exists for assessing cardiovascular risk. However, evidence for the effects of prevention of heart disease with drugs is scant in elderly people. The largest study in this group is the pravastatin in elderly individuals at risk of vascular disease (PROSPER) trial. In this trial more than 5000 participants, aged 70-82 years, were followed up for an average of 3.2 years.

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