Are All These Doctor Visits Necessary?
Deciding which medical procedures you can omit depends on your health and your goals
While telling my mom about the next medical procedure I scheduled for her, she replied, "Enough with the doctor visits."
She has a point. In the previous six months, I had arranged for her to be questioned and examined by an army of medical professionals, including an audiologist, a geriatrician, a physical therapist and several specialists at Montefiore Medical Hospital's Center for the Aging Brain in Yonkers, New York. She wants these appointments to stop.
In my defense, I hoped for solutions to the aging-related problems she suffers from. In her defense, the geriatrician said my mom was relatively healthy for a 90-year-old woman and recommended she take a daily vitamin with iron, vitamin D and calcium.
"You have to talk to your doctor and ask, 'Why are these tests being ordered?'"
Getting hearing aids was necessary, too. So were more trips to the Center for the Aging Brain. The last doctor who examined her at the Center nixed medication because the side effects were harmful. He said he believed her lack of hearing contributed to her mild cognitive decline.
That doctor noticed my mom shuffled her feet when she walked and recommended I take her to a physical therapist. The physical therapist gave her the option of walking on her own every day or coming to the therapist's office three times a week and exercising daily at home. My mom chose walking.
Do You Really Need a Colonoscopy at 80 or 90?
"This is not a one-size-fits-all yes or no answer," says Dr. Suneet Singh, an emergency department physician, assistant professor at the University of Texas Austin Dell Medical School, and medical director at CareHive. "You have to look at your age, your health, and your life's goals. You have to talk to your doctor and ask, 'Why are these tests being ordered?'"
"Do you have a history of cancer?" he continued. "A colonoscopy can screen for polyps. Most are benign, but some can eventually become cancerous, and early detection is when cancer treatments work best."
Like other doctors, Singh discusses with his patients the risks and benefits of surgeries and other medical procedures. "I also talk to them about their goals in life," he says. "If you're in your eighties and nineties, in good health and want to see your granddaughter walk down the aisle, then yes, maybe you do get that colonoscopy."
Look at your age. "For example, current research shows colonoscopies could prevent death from colon cancer in patients with life expectancy of greater than ten years," says Dr. Eric Chyn, geriatrician, assistant professor and director of the geriatric medicine fellowship program at Rutgers Health New Jersey Medical School and University Health/Ambulatory Care Clinic.
For older patients in excellent health who are expected to live 10 years or longer, Chyn said he believes a colonoscopy "will likely bring more benefit than harm."
If a patient is in fair health and expected to live another five years, "then the benefit of colonoscopy is unclear," he says. "Therefore, a shared decision is particularly important. If the patient is in poor health and has less than five years, then prioritizing care that improves a patient's quality of life would have more benefit than a colonoscopy."
"However, this is not an overall statement that a colonoscopy is never appropriate for older adults living with poor health," he says. "If there are concerns of life threatening internal bleeding, a colonoscopy would still be offered for the purpose of diagnosis and treatment."
Roll Back or Stick With It?
Chyn and Singh point to the U.S. Preventive Services Task Force (USPSTF), which keeps an up-to-date list of recommendations for different medical procedures for people of all ages. For example, the Task Force recommends biennial screening mammography for women aged 50 to 74 years. After age 75, the USPSTF sees little evidence for women to have mammograms.
"An older patient in excellent health may choose to stop proton pump inhibitors to avoid lung infection and weakened bones."
"We consider the patients' medical comorbidities and prognoses," Chyn says. "We explore the patients' goals of care. We enable patients by explaining the likelihood of benefits versus harms within the context of their personalized health profiles so they can arrive at decisions that align with their goals of care."
The USPSTF recommends against PSA (prostate-specific antigen) screening for prostate cancer in men 70 years and older because of potential harms, such as false-positive results that lead to more testing, overdiagnosis, overtreatment, and treatment effects such as incontinence and erectile dysfunction. "This again comes down to talking to your physician and making an informed decision," Singh says.
Do the Positives Outweigh the Negatives?
A good example is a proton pump inhibitor, which is great at controlling heartburn. It's also associated with increased risk of bone weakening and lung infections. "An older patient in excellent health may choose to stop proton pump inhibitors to avoid lung infection and weakened bones," Chyn says. "On the other hand, a nursing home resident in poor health may value heartburn symptom control as the top priority."
Women, ages 65 and up, and men, ages 70 plus, should schedule routine bone density scans for osteoporosis. Symptoms for osteoporosis are often undetected until a bone fracture occurs. According to the American College of Obstetricians and Gynecologists, osteoporosis occurs five times more often in women than in men.
Men, ages 65 to 75 with a history of smoking, should schedule an abdominal aortic aneurysm screening. The screening can detect an aneurysm before it ruptures.
Too Many Meds?
"Many older adults take five or more medications each day," Singh says. "It's called a polypharmacy. Is it too much? Again, you have to look at the benefits and the risks by talking about them with your doctor."
Chyn asks his patients what bothers them the most and then focuses on improving his patients' quality of life. "After establishing if it's important to my patients, I then prescribe or deprescribe accordingly," he says. "It's another example of shared decision-making and personalized health profiles to guide treatment plans."
To find out about drug side effects and if your new prescription interferes with an old one, keep all of the doctors you see in the loop. You can also check out the American Geriatrics Society's Beers list, which posts inappropriate medications for older adults.