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A prejudice most commonly seen in workplace hiring practices-bias against the elderly, also known as ageism-apparently is alive and well in our nation's hospitals.

Numerous comprehensive studies, including one published in the Journal of the American Medical Association last year, suggest that rates of use of potentially life-saving and life-enhancing medical interventions decline as patients get older, often for no defensible clinical reason.

The JAMA study, published in March 2005, compared chemotherapy treatment given to 6,487 women with breast cancer in four clinical trials. It found that only 8 percent of them were age 65 or older, despite the fact that 44 percent of U.S. women with breast cancer are 65 or older and that chemotherapy has proven equally effective for both older and younger breast cancer patients.1

Health care in America "is shot through with ageism," declared Daniel Perry, executive director of the Alliance for Aging Research, a nonprofit organization based in Washington, DC.

"A pervasive prejudice against the old embraces assumptions we now know are clearly myths, such as the myth that older people can't respond to treatments used on younger people," Perry said. "Older patients are routinely excluded from clinical trials, and most physicians and other health care professionals have scant familiarity with the basic standards of geriatric care, which are left out of much of the curriculum."

A few providers, he added, "will pick up some values of geriatric care because many of their patients are older, but it's hit or miss; and this is pretty shocking when you stand back and look at the profile of most patients."

Risk/Benefit Ratios
For a variety of reasons, age influences the delivery of health services across the spectrum, particularly ICU care, according to several experts.

A retrospective examination of 1,108,000 Medicare beneficiaries presented at last year's American Thoracic Society conference found that use of critical care services declined in a step wise pattern from younger to older beneficiaries.2

Older Americans are "significantly less likely to use critical care services during the course of a serious disease," author Theodore J. Iwashyna, MD, PhD, of the division of pulmonary, allergy and critical care at the Hospital of the University of Pennsylvania, Philadelphia, commented. "This is a nationwide trend."

Iwashyna doesn't believe physicians engage in explicit ageism. Rather, he said, most share a belief that "the things we do don't work as well in older patients. ICU treatments have fairly tight risk/benefit ratios. Can a 95-year-old body tolerate them? There's a dearth of data on that in ICU settings."

In cardiac settings, he continued, "the thinking is generally that they can't tolerate it. There are higher side-effect profiles for acute MI."

However, the net positive result of cardiac interventions tends to be higher for older patients, researchers have found. Yes, elderly patients face bigger risks from cardiac interventions than do younger patients, but they realize bigger benefits. "And they really need that benefit," Iwashyna noted: Younger patients bounce back more readily on the strength of their own reserves.

Educated Guessing
Not many studies exist to guide clinicians and family members, and the data available are counter-intuitive. "If researchers ask healthy people what health care people want, they tend to say that older people would want less care," he pointed out. "While it is true that older people on average want slightly less aggressive care, healthy younger people dramatically overestimate the age effect. Older people, in general, want almost the same care as younger people. In the absence of knowing what people want, we may put too much emphasis on age."

Physicians will learn what geriatric patients want only by studying geriatrics. But that doesn't appear to be happening.

"There is reluctance on the part of young doctors to commit their careers to geriatric medicine," Perry noted. "It doesn't pay as well, and it takes longer to assess the health status of an older person. You are often dealing with not one, not two, but multiple conditions and multiple prescriptions." Sorting through an older patient's medical and social history takes more time than is needed for younger patients, time that is not reimbursable.

Given that reality, doctors' attitudes may be understandable, he said, "but that does not address the fact that elderly people will form the bulk of the patient population in the future."

Diverse Patient Attitudes
In some cases, a decision not to treat may make medical sense. For example, if a 75-year-old married man has a slow-growing form of prostate cancer and is still sexually active, it may be best not to surgically remove his prostate, subject him to radiation and end his sexual functioning.

"The classic cop-out is it's an individualized question," Iwahyna said. "But it is. Different people value states of health differently. My father hates hospitals. Unless a hospital can make him hugely better, he'd rather not be there. He'd rather stay home and suffer with it. At least he's in greater control than being in a hospital. Others want a few more days of life even with every type of machine hooked up to them. It's a very diverse country with diverse people."

What's needed is an honest conversation beforehand between physician and patient. "You need to say, 'Here is what is likely to happen with package A. Here's what is likely to happen with package B. Which do you prefer?'" he said. "That's a hard conversation to have, though."

The problem here is that doctors "are often bad at prognosticating," he added. "They overestimate how long patients will live. Doctors feel it's their job to provide hope to patients, so they tell researchers that they systematically tell patients they have longer to live than they really do."

Future Disaster?
Woe betides the country if things do not fundamentally change in the next 20 years, when most baby boomers are 65 and older, enrolled in Medicare and experiencing high rates of classic geriatric syndromes such as memory loss, cardiovascular deconditioning, type II diabetes, thinning bones, etc.

"That (would be) an economic and social disaster, because mismanagement of these chronic diseases is very costly and inefficient," Perry warned.

The health care system, he said, must "take a sharp turn" toward basic principles of geriatric medicine, including how to assess loss of function in elderly patients, how to establish a baseline of function and maintain it for as long as possible."

Too many health care professionals "have a tendency to write off these patients, not offer them treatment options, screenings or health promotion strategies that we offer younger people," he added.

Even older people themselves make "terrible assumptions" about their ability to rebound from disease, Perry added. "Our report cites many instances in which older people delay seeking care, thinking it won't do any good, or they don't want to be seen as complaining, or they think it's too late to help them," he said.

Boomers are better educated about health care and won't shortchange themselves, Iwashyna believes. "Boomers are a new cohort, more comfortable with physicians using the most extensive rescue therapies the ICU has to offer," he said. Not only that, they will be better prepared than previous generations to know when and how to handle their last days, because the country has seen a marked growth in hospice over the years. "Boomers care for their parents and, as a result, have become more savvy about their own terminal care needs," he said.

Michael Gibbons is an ADVANCE contributing editor.

References
1. Muss H, Woolf S, Berry D., et al. Adjuvant chemotherapy in older and younger women with lymph nodepositive breast cancer. JAMA. (2005;293:1073-1081).

2. Iwashyna T. Critical care use during the course of serious illness. AJRCCM. (2004; 170:981-986).




     

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