Elderly Fare Better When Included In Decisions On Treatment Trade-offs

About 65 percent of older Medicare beneficiaries have at least two chronic conditions, and 24 percent have four or more. The study highlights the complex care decisions these patients face when the treatment for one condition could worsen another — i.e., "competing outcomes." For example, a patient with high blood pressure, heart disease and osteoarthritis finds that the blood pressure medication he's on causes leg cramps to the point where he can't do the pool exercises that help keep his arthritis symptoms in check. While the medication lowers his cardiovascular risk, he decides, in consultation with his physician, to stop taking it because the leg cramps are unacceptable.

"Taking this kind of active role in treatment decisions means more customized outcomes for patients," said study author Terri Fried, M.D., professor in the Department of Internal Medicine at Yale School of Medicine. "Because of their experience with medication side effects, older patients with multiple conditions can understand the concept of competing outcomes. Prioritizing across all outcomes can help clarify what is most important to seniors who are faced with complex healthcare decisions."

Fried and her team conducted 13 focus groups with 66 people age 65 and older. Participants had an average of five chronic medical conditions and took an average of seven medications. They were asked to think about the goals for their care and to think about possible competing outcomes.

Participants initially thought about their goals of care in terms of disease-specific outcomes, such as lowering blood pressure or cholesterol levels. However, when faced with situations involving competing outcomes, they thought about more global outcomes that were applicable across diseases, such as length of life, functional status, and relief of symptoms. "Their prioritization of these outcomes revealed what was most important to them, and they chose the treatment option that would maximize the likelihood of their most desired outcome," said Fried.

Other authors on the study include Sarah McGraw, Joseph Agostini, M.D., and Mary Tinetti, M.D.

Citation: Journal of the American Geriatrics Society, Vo. 56, No. 10 (October 2008)