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Therapeutic Objectives in the Elderly

By Richard W. Besdine, MD, Professor of Medicine, Greer Professor of Geriatric Medicine, and Director, Division of Geriatrics and Palliative Medicine and of the Center for Gerontology and Healthcare Research, Warren Alpert Medical School of Brown University

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Patient Education

Before a treatment or major diagnostic test is used, potential adverse effects should be weighed against potential benefits in the context of the patient's individual desires and goals.

Potential adverse effects include the following:

  • Complications, including prolonged fatigue and disability

  • Discomfort

  • Inconvenience

  • Cost

  • Need for additional tests or treatments

Potential benefits include the following:

  • Cure

  • Prolongation of life

  • Slowing of disease progression

  • Functional improvement

  • Symptom relief

  • Prevention of complications

When treatments are very likely to achieve benefits and very unlikely to have adverse effects, decisions are relatively easy. However, assessing the relative importance of these quality of life factors to each patient is important when treatments may have discordant effects. For example, aggressive cancer therapy may prolong life but have severe adverse effects (eg, chronic nausea and vomiting, mouth ulcers) that greatly reduce quality of life. In this case, the patient’s preference for quality vs duration of life and tolerance for risk and uncertainty help guide the decision whether to attempt cure, prolongation of life, or palliation.

The patient’s perspective on quality of life may also affect treatment decisions when different treatments (eg, surgical vs drug treatment of severe angina or osteoarthritis) may have different efficacies, toxicities, or both. Practitioners can help patients understand the expected consequences of various treatments, enabling patients to make more informed decisions.

When predicting toxicities and benefits of various treatments, practitioners should use the patient’s individual clinical characteristics, rather than chronologic age alone. In general, the patient’s chronologic age is irrelevant when deciding among different treatments or therapeutic goals. However, life expectancy may affect treatment choice. For example, patients with a limited life expectancy may not live long enough to benefit from aggressive treatment of a slowly progressive disorder (eg, radical prostatectomy for a localized, slow-growing prostate cancer). Nevertheless, quality of life is important regardless of life expectancy. Thus, invasive treatments that may improve quality of life (eg, joint replacement, coronary artery bypass surgery) should not be automatically rejected for patients with a limited life expectancy.

Regardless of the overall therapeutic goal, symptom relief should always be offered.