When to stop preventive medicine tests/treatment

[styphon]

Now I love EBM - I am a very strong advocate - but I think one of its weakest points involve when to stop treatment and testing.

There is very little to no evidence outside of PSA of when to stop screening.

Should you really screen a 89 year old for hyperlipidemia? Would it really extend her life? Or do the side effects of the medications negate any marginal benefit she would get?

Should permissive HTN (which is slightly touched on with the new guidelines) be allowed in the elderly? is the risks of falls and increased mortality from falls outweigh the benefits of controlling HTN strictly?

Would about hga1c? Stricter control leads to more hypoglycemic episodes in the elderly, who are also at risk for lacking the symptoms of hypoglycemia.

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[VA Hopeful Dr]

Now I love EBM - I am a very strong advocate - but I think one of its weakest points involve when to stop treatment and testing.

There is very little to no evidence outside of PSA of when to stop screening.

Should you really screen a 89 year old for hyperlipidemia? Would it really extend her life? Or do the side effects of the medications negate any marginal benefit she would get?

Should permissive HTN (which is slightly touched on with the new guidelines) be allowed in the elderly? is the risks of falls and increased mortality from falls outweigh the benefits of controlling HTN strictly?

Would about hga1c? Stricter control leads to more hypoglycemic episodes in the elderly, who are also at risk for lacking the symptoms of hypoglycemia.

Most USPSTF stuff I stop at around age 70 (colonoscopies and paps especially). Mammograms I'll go older if the person looks to be in good shape, but rarely past 80. DEXA scans I only stop when they either a) look like they have less than 2 years to live or b) are wheelchair/bed bound.

I also allow a1c's to hit 8 in my over 65-70 crowd as well, depending on how well they've been controlled and what on - I'm not going to cut down a 75 year old's metformin just because their a1c is 6.5.

I don't check lipids in 80+ who have never had any vascular events. In those who have, they likely are already on a statin anyway. I still will usually check, just to make sure they are on a potent enough one. If they are already on lipitor or crestor, often times I won't.

 

[deleted87716]

Where cardiovascular disease is concerned, risk increases with age. I'm not sure it's wise to pull your punches just because somebody's getting old. Maybe they'll get older.

In general, I tend to agree that hypotension and hypoglycemia are problematic in older folks if you try to control things too tightly, so I aim for BP <140/90 and HgbA1c <8.0 in most folks >70 y/o, and I won't be super-aggressive with lipid management at that point unless they're just incredibly high-risk. I follow current guidelines for PSA, mammography, colonoscopy, and Pap smears.

 

[Otto of the Silver-Hand]

End stage disease = consider ending preventive treatment/ tests
prognosis less than 2 years = stop preventive treatment/tests