Therapeutic Objectives in Older Adults

Therapeutic objectives for older adults should include not only successful treatment of a disease, but also consideration of how treatment or nontreatment may affect their quality of life. Before a major diagnostic test or treatment is administered, risks and benefits should be weighed in the context of the patient's individual preferences and goals.

Clinicians should consider the following:

• How will the results of the diagnostic test or treatment affect the patient's quality of life?

• Are the decisions being made based on these results consistent with the patient's goals of care?

Potential risks include the following:

• Inconvenience

• Cost

• Discomfort

• Need for additional tests or treatments

• Complications, including prolonged fatigue and disability

• Mortality

Potential benefits include the following:

• Symptom relief

• Functional improvement

• Prevention of complications

• Slowing of disease progression

• Prolongation of life

• Cure

When choosing whether to perform a diagnostic test, a patient should be counseled about what is involved in the test (eg, cost, inconvenience), risks, and how the results will be used to guide treatment decisions. Patients may choose not to do a test if they will not take action based on the results (eg, discontinuing routine screening for a disease if the result will not impact life expectancy or indicate follow-up tests or treatment the patient does not wish to do).

When treatments are very likely to achieve benefits and very unlikely to have adverse effects, decisions are relatively easy. However, assessing the relative importance of potential quality of life impacts to each patient is important when treatments may have discordant effects. For example, aggressive cancer therapy may prolong life but have severe adverse effects (eg, chronic nausea and vomiting, mouth ulcers) that greatly reduce quality of life. In this case, the patient’s preference for quality versus duration of life and tolerance for risk and uncertainty help guide the decision whether to attempt prolongation of life or palliation.

The patient’s perspective on quality of life may also affect treatment decisions when different treatments (eg, surgical versus pharmacological treatment of severe angina or osteoarthritis) may have different efficacies, toxicities, or both. Clinicians can help patients understand the expected consequences of various treatments, enabling patients to make more informed decisions. Discussions that help clarify alternatives should involve shared decision making that accounts for each patient's preferences, and language and concepts should be tailored to each patient's cognitive capacities.

When predicting adverse effects and benefits of various treatments, clinicians should use the patient’s individual clinical characteristics rather than age alone. In general, the patient’s age is irrelevant when deciding among different treatments or therapeutic goals. However, life expectancy may affect treatment choice. For example, patients with a limited life expectancy may not live long enough to benefit from aggressive treatment of a slowly progressive disorder (eg, radical prostatectomy for a localized, slow-growing prostate cancer).

Consideration of the impact of treatment on quality of life is important regardless of life expectancy. Thus, invasive treatments that may improve quality of life (eg, joint replacement, coronary artery bypass surgery) should not be automatically rejected for patients with a limited life expectancy. Similarly, discontinuing medications should be considered when treatment risks outweigh benefits because of changes in goals of care (eg, stopping a statin used to lower cholesterol levels for a patient in hospice).

As new methods of diagnosis and treatment emerge, the risks and benefits must be considered. Digital advances may contribute to enhanced independence in older adults through use of assistive technologies (eg, smart home devices, autonomous vehicles, artificial independence companions) that can compensate for physical or cognitive limitations (1, 2). However, consideration should be given to how digital interventions, telehealth services, and remote monitoring systems can support quality of life goals while respecting individual preferences for technology adoption and privacy concerns (3).