Overtreatment in elderly care: ethical considerations

To the Editor,

One of the biggest challenges facing Western societies is demographic change and the rapid growth of the population over 65. This increase in average life expectancy, associated with improved health care delivery, has resulted in an increase in the prevalence of various chronic pathologies and the consequent need to use medicines to control these same pathologies (1). This multimorbility situation leads to concomitant use of several medicinal products, i.e. polymedication. Polymedication is considered a global public health problem, assuming a particular dimension in the elderly, where the consumption of medicines is more prevalent (2, 3).

The administration of medication is not at all an innocuous process, especially in the elderly due to the structural and functional physiological changes specific to aging that lead to pharmacokinetic and pharmacodynamic changes that compromise the efficacy and safety of medicines (4). In this context, the American Geriatrics Society (2019) recently updated the list of drugs considered inappropriate for the elderly, incorporating new scientific evidence on the drugs most used by the elderly, supported by more information around geriatric care and specific pharmacotherapy (5).

Due to the presence of multimorbilities, polymedication, increased use of inappropriate medications for the elderly, the elderly person is exposed to an increased risk of adverse drug events, with harmful effects on the health and quality of life of the elderly. In these circumstances, where the damage of intensive control of pathologies probably exceeds the benefits, we speak in the notion of “overtreatment” (6). Overtreatment is not a new concept, it is used to mean unnecessary medical or surgical interventions. However, it has recently become a public health problem, whose reasons most commonly pointed out by clinicians as a cause of this over-prescription are fear, neglect and pressure of the patient (7).

In addition to these reasons, we also highlight a certain “dictatorship” of the treatment guidelines for the various chronic pathologies, which do not discriminate the old person with various diseases of the young adult patient (8). In this sense, the individualized approach in the practice of care to the old person, with regard to pharmacological treatment, imposes an ethical reflection and deliberation. To the extent that drugs are substances with proven biological activity, they are therefore at higher risk for the older person. In view of the physiological weaknesses common in the elderly, the use of medicines should be based on the ethical principles of caution and non-maleficence. This means conducting a clinical trial with the responsibility of weighing the risks and benefits of medicines and making a choice.

This choice can have two possible paths. It can go through a decision based on the rigidity of the guidelines directed to the pathology and less to the person. Instead, it can go through a decision based on clinical experience, adjusting doses and dosages against the specific pathological condition of the old person. In this context, applying the principles of prudence and non-maleficence consists of making reasonable and balanced decisions for a specific person.

By embodying good professional practice in a relationship of closeness and respect for the dignity of the person, the prescription of medicines to the elderly citizen must consider the right of the person to participate in this decision-making. Looking at the needs, interests and values of the person and full respect for the autonomy of the old person, the prescription of medicines constitutes a shared responsibility for a good that both have the duty to care for and protect - health. In this regard, the various studies suggest that the development of a relationship of trust between the physician-elderly is an important and decisive factor to reduce the excess prescription (9). We know that the present time does not favor or promote communication and interpersonal relationships between health professionals and patients to ask questions about the medication that is prescribed. This situation ends up exposing the elderly to an unnecessary risk, related to the side effects and adverse reactions of the medicines, which often cause them harm.

Thus, the increased vulnerability of people of geriatric age justifies that the counseling and use of drugs in this group be carried out in a personalized way, considering the interests and will of the patient, so that the final choice complies with all the precepts of a correct deliberation from the clinical point of view, but also ethical.