The landscape of healthcare for aging populations is undergoing a significant re-evaluation, as recent research increasingly challenges long-standing medical practices. For many older adults, the benefits of common screenings, procedures, and medications, once taken for granted, are being re-examined against the backdrop of age-related risks and evolving life expectancies. This shift is prompting physicians and patients alike to question whether established medical interventions remain as beneficial as they once were, or if they might even introduce unnecessary burdens.
A prime example of this evolving medical perspective can be seen in the case of an 85-year-old patient who, according to Dr. Steven Itzkowitz, a gastroenterologist at the Icahn School of Medicine at Mount Sinai in New York, met the standard criteria for a repeat colonoscopy. The patient was described as being in "reasonably good health," and the inherent risks associated with the procedure—such as bleeding, adverse reactions to anesthesia, or perforation of the colon—were considered relatively low. However, her age presented a critical factor. Furthermore, she was on blood thinners to manage cardiac stents that kept her arteries open, necessitating a temporary cessation of these medications, which itself carried an increased risk of clotting.
Dr. Itzkowitz reflected that had this decision been made just five years prior, the colonoscopy likely would have been scheduled with minimal hesitation. However, a growing body of research has underscored that the benefits of repeat colonoscopies diminish significantly after the age of 75. This empirical evidence has led to a crucial recalibration of clinical judgment. "Now," Dr. Itzkowitz stated, "I’m saying to myself, ‘What are we accomplishing here?’" This sentiment is not isolated; a growing number of physicians and patients are experiencing similar second thoughts about routine medical interventions as they age.
The recalibration of risk-benefit analyses in older adults is a complex but necessary evolution in geriatric medicine. As individuals age, their physiological resilience changes, and the potential for complications from medical procedures and treatments can increase. Simultaneously, their remaining life expectancy may shorten, altering the timeframe over which the long-term benefits of certain interventions can be realized. This has led researchers to scrutinize a range of common medical practices.
Examining Common Skin Lesions: Actinic Keratoses Under New Scrutiny
Among the areas undergoing re-evaluation are common skin lesions known as actinic keratoses. These reddish or rough patches, a consequence of prolonged sun exposure, typically appear on sun-exposed areas like the face, scalp, forearms, and the backs of hands. They are particularly prevalent in older individuals. Data from a large study of traditional Medicare beneficiaries revealed that nearly 30% of these individuals were diagnosed with an actinic keratosis over a five-year period.
Traditionally, the standard medical response has been to remove these lesions, a practice that often involves cryosurgery (freezing with liquid nitrogen), topical creams, or laser therapy. The rationale behind this approach is the potential for these lesions to develop into skin cancer. However, current research suggests this concern may be overstated for the average patient. According to dermatologist Dr. Allison Billi of the University of Michigan, and an author of a recent commentary in JAMA Internal Medicine, the risk of an actinic keratosis progressing to skin cancer for an individual with no prior history of skin cancer is less than 1 in 1,000. This statistic is supported by a 2013 meta-analysis. More often, these lesions resolve on their own.
Dr. Billi highlights that the treatments themselves can be more burdensome than the condition. The removal procedures are often described as extremely painful, both during and after the intervention, and can lead to side effects such as swelling, irritation, and persistent discoloration. Furthermore, actinic keratoses are a chronic condition; even after removal, they are likely to reappear, or new ones may emerge.
In light of this, Dr. Billi advocates for a strategy of active surveillance. This approach would involve primary care physicians annually observing the lesions for any warning signs, such as bleeding, pain, or rapid growth, which might then warrant removal. However, for many, this intensive intervention is unnecessary. "We don’t always need to do everything we can do," she emphasizes. While she strongly recommends the consistent use of sunscreen as a preventative measure, the aggressive treatment of every actinic keratosis is being questioned.
Levothyroxine Use in Older Adults: Reassessing the Need for Lifelong Treatment
Another area of significant re-evaluation concerns levothyroxine, a medication widely prescribed for hypothyroidism, a condition where the thyroid gland fails to produce sufficient thyroid hormone. This condition can lead to symptoms such as weight gain, fatigue, dry skin, and a general slowing of bodily functions, as explained by Dr. Jacobijn Gussekloo, a primary care physician and researcher at Leiden University Medical Center in the Netherlands. Levothyroxine is also frequently prescribed for subclinical hypothyroidism, a milder, often asymptomatic form that can potentially progress to overt hypothyroidism.
Historically, levothyroxine treatment has been considered lifelong for most patients. However, new research from Dr. Gussekloo’s team suggests that this may not be the case for all older adults. Their studies have found that in many older individuals diagnosed with subclinical hypothyroidism, thyroid hormone levels can normalize spontaneously. Crucially, the research also indicated that for older patients with this condition, levothyroxine did not appear to improve symptoms or provide any discernible benefit.
The potential for harm associated with levothyroxine, like any medication, must also be considered. In older patients, who often take multiple medications, interactions are a concern. Furthermore, the management of levothyroxine therapy necessitates frequent laboratory tests and follow-up appointments, increasing healthcare utilization and associated costs. Dr. Maria Papaleontiou, an endocrinologist at the University of Michigan and an author of an editorial in JAMA accompanying the Dutch study, notes that high doses of levothyroxine can lead to hyperthyroidism, which carries risks of cardiac arrhythmias and bone loss. Patients also need to adhere to specific dietary and meal schedule adjustments.
To explore the possibility of discontinuing levothyroxine, the Dutch researchers implemented a protocol involving gradual dose reduction over 30 weeks, coupled with ongoing laboratory monitoring and physician consultations. The results were compelling: after one year, approximately a quarter of the 370 participants, all over the age of 60, were able to discontinue the drug while maintaining healthy thyroid function. This success was most pronounced in individuals who had been on lower doses.
Dr. Papaleontiou cautions that patients should not attempt to stop levothyroxine independently. The process requires a carefully managed tapering schedule, consistent monitoring, and medical supervision. It is acknowledged that some patients will always require the medication. Nevertheless, the findings suggest that a specific subset of adults over 60 may no longer need lifelong levothyroxine therapy.
Colon Cancer Screening in Older Adults: Weighing Benefits Against Risks
The debate surrounding the appropriate age to cease colon cancer screening has been ongoing for years. The U.S. Preventive Services Task Force, a leading authority, assigns a "C" rating to colonoscopy screening after age 76, indicating a "small" benefit. Despite this, a 2023 study revealed that nearly 60% of older patients who had previously undergone colonoscopies and had limited life expectancies (less than five years) were still advised to have another screening.
Dr. Samir Gupta, a gastroenterologist at the University of California-San Diego, frequently encounters this dilemma. He observes that many older patients have a low risk of developing colon cancer, yet they are still subjected to a procedure that carries its own set of risks. The likelihood of complications following a colonoscopy increases with age. One study indicated that almost 7% of patients over 75 experienced a hospitalization or emergency room visit within a month of the procedure.
Dr. Gupta led a new study involving nearly 92,000 Veterans Affairs patients over the age of 75 who had prior colonoscopies. The study found that while approximately 28% had adenomas (polyps that can become cancerous) detected and removed, the long-term impact on mortality was minimal. After 10 years, veterans with a history of adenoma were more likely to develop colon cancer than those without one, but the rate remained extremely low in both groups. The critical finding was that only 0.5% of those with a previous adenoma died of colon cancer, compared to 0.4% of those without one—a difference described as "tiny" by Dr. Gupta.
The mortality rates from colon cancer in both groups were significantly dwarfed by the number of veterans—almost half—who died from other causes within the same decade. Dr. Itzkowitz, who co-authored an editorial accompanying the study, commented, "Even if the procedure goes well, you’ll either find nothing or you’ll find something that’s not going to have real impact on your longevity."
Interestingly, Dr. Itzkowitz has noted that many patients who have had polyps removed express a desire to continue colonoscopies. This highlights the challenge of shifting established medical norms and patient expectations. Efforts to "deprescribe" medications, for example, often face resistance from both patients and healthcare professionals, as evidenced by the continued practice of mammograms in many older women past the point of documented benefit, and prostate cancer screenings in older men beyond recommended ages.
Given that colonoscopies are generally considered less pleasant than mammograms or prostate screenings, there may be a greater willingness among older patients to forgo them. As Dr. Itzkowitz puts it, "Even with polyps, the chance of dying from colon cancer is so low compared to everything else that can get you." He recently advised his 85-year-old patient that she could skip her next colonoscopy, a recommendation that was met with apparent relief.
Broader Implications and the Future of Geriatric Care
The ongoing re-evaluation of these common medical practices has profound implications for the future of geriatric care. It signals a move towards more personalized medicine, where treatment decisions are not solely based on standardized guidelines but are tailored to the individual’s overall health, life expectancy, and personal values. This approach, often referred to as "high-value care," aims to maximize patient well-being while minimizing unnecessary interventions and their associated risks and costs.
The shift requires open communication between physicians and patients, fostering a shared decision-making process. Physicians must be equipped to discuss the nuanced risks and benefits of various interventions for older adults, and patients must feel empowered to express their preferences and concerns. The success of these efforts can lead to improved quality of life for older individuals, allowing them to avoid potentially harmful or burdensome treatments and focus on aspects of health and well-being that are most meaningful to them. The evidence suggests that for many, a more judicious approach to medical interventions, particularly as they age, can lead to better outcomes and a more fulfilling later life.
This article was produced in partnership with The New York Times.
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