3 medical routines that older people may not need

Enough time had passed since the patient’s last colonoscopy that she met the criteria for another colonoscopy, Dr. Steven Itzkowitz, a gastroenterologist at the Icahn School of Medicine at Mount Sinai in New York.

She was in “fairly good health” and the risks of the procedure – bleeding, reactions to anesthesia, perforation of her colon – were relatively low. But she was 85. And she had to briefly stop the blood thinners she was taking because the heart stents were keeping her arteries open; This could increase the risks.

If Dr. If Itzkowitz and his patient had faced this decision five years ago, he might have scheduled the screening “without thinking about it,” he said. However, recent research has again shown that the benefits of repeat colonoscopy after age 75 are small.

Now he said, “I ask myself, ‘What are we accomplishing here?'”

He’s not the only doctor – or patient – to change his mind. The risks and benefits of common tests, procedures, and medications add up differently as we age, and research continues to point to new examples of some that may become unnecessary.

Recently, researchers addressed questions about common skin lesions that probably don’t need to be removed, a widely used thyroid drug that many older patients can safely stop, and colonoscopies that reduce mortality from colorectal cancer so slightly that the risks may outweigh the benefits.

Ugly, but probably harmless

The reddened or rough areas on the skin are called actinic keratoses in medical terminology. Since they are caused by long-term exposure to the sun, they usually appear on the face, scalp, forearms and the backs of the hands.

Such lesions most commonly occur in elderly patients. A large study of traditional Medicare recipients found that over a five-year period, nearly 30 percent were diagnosed with actinic keratosis. What then?

“In the vast majority of cases they are removed,” said Dr. Allison Billi, a dermatologist at the University of Michigan and author of a recent commentary on the topic in JAMA Internal Medicine. These typically include cryosurgery (liquid nitrogen freezing), topical creams, or laser therapy.

The reason: The plasters could become cancerous. But “the average patient with no history of skin cancer has a less than 1 in 1,000 chance of developing skin cancer,” Dr. Billi and cited a 2013 meta-analysis. It is far more likely that the lesions will go away on their own.

“Treatment can be more stressful than the disease itself,” she added. Removal “is actually extremely painful, both during and after.” Swelling, irritation and permanent discoloration may occur.

In addition, actinic keratosis is likely to recur or new ones appear. “This is a chronic disease,” said Dr. Billie.

Instead, she suggests active surveillance: Family doctors could examine the lesions annually for warning signs, such as bleeding, pain or rapid growth, that might warrant removal. But “in many cases it’s not necessary,” she said. “We don’t always have to do everything we can.”

However, she recommends using sunscreen.

Questionable treatment

Patients take levothyroxine, one of the most commonly prescribed medications worldwide, when their thyroid cannot produce enough thyroid hormone.

With this condition, called hypothyroidism, “people gain weight. They have less energy. Their hair and skin are dry,” explains Dr. Jacobijn Gussekloo, family doctor and researcher at the Leiden University Medical Center in the Netherlands. “Everything is slowing down.”

Doctors are also increasingly prescribing it for a borderline condition called subclinical hypothyroidism, which usually causes no symptoms but can progress to hypothyroidism.

Most patients take the medication for life – but do they have to? Gussekloo’s team found that hormone levels normalize on their own in many older adults with subclinical hypothyroidism.

Researchers also reported that levothyroxine had no effect on symptoms and “no apparent benefit” in older people with the condition.

Like any medication, it can also be harmful. It may interact with other medications that older patients normally take. In addition, “it requires frequent laboratory tests and follow-ups, more visits and costs,” said Dr. Maria Papaleontiou, an endocrinologist at the University of Michigan and author of an editorial in JAMA on the latest Dutch study.

“In high doses it can cause hyperthyroidism, which can lead to cardiac arrhythmias and bone loss,” she added. Patients taking it also need to adjust their diet and meal plans.

To determine whether some patients might stop taking levothyroxine, the Dutch researchers developed a protocol that gradually reduced doses over 30 weeks, with ongoing laboratory testing and consultations with doctors.

After one year, a quarter of the 370 participants, all over 60, had discontinued the drug while maintaining healthy thyroid function. Most had received lower doses from the start.

Patients should not stop levothyroxine on their own, warned Dr. Papaleontiou. Discontinuation requires gradual tapering with testing and monitoring. Some patients will always need the medication.

But it appears that “a select group of adults over 60 may not need this treatment for life,” Dr. Papaleontiou.

A screening with risks

The question of when older patients can safely stop screening for colorectal cancer has sparked years of debate. The influential United States Preventive Services Task Force gives screening after age 76 a moderate rating of C and describes the benefit as “marginal.”

Nevertheless, according to a 2023 study, almost 60 percent of older patients who have already undergone a colonoscopy and whose life expectancy is limited (less than five years) are advised to undergo further screening.

As a gastroenterologist at the University of California, San Diego, Dr. Samir Gupta regularly addresses this problem in older patients. “I know their risk of colon cancer is really low, and I’m putting them at higher risk,” he said.

The risk of complications after a colonoscopy increases with age. A recent study found that nearly 7 percent of patients over 75 had to go to the hospital or emergency room within a month of the procedure.

Is it worth it? Dr. Gupta is the lead author of a new study of nearly 92,000 Veterans Affairs patients over 75 who had already undergone colonoscopies. About 28 percent were found to have an adenoma, a type of polyp that can become cancerous, during the procedure. Although this only occurs in a small proportion, they are generally removed by gastroenterologists.

The researchers found that veterans with a previous adenoma were more likely to develop colorectal cancer after 10 years than those without an adenoma, although the rate was extremely low in both groups.

But only 0.5 percent — yes, half of 1 percent — of people with a previous adenoma died of colon cancer, compared with 0.4 percent of those without an adenoma: “a tiny difference,” Dr. Gupta.

Both groups were dwarfed by the number of veterans — nearly half — who died of other causes within the decade.

“Even if the procedure goes well, you’re either not going to find anything or you’re going to find something that has no real impact on your longevity,” Dr. Itzkowitz, author of an editorial published alongside the study.

Still, he has found that many patients who have had polyps removed want to continue colonoscopies.

It is difficult to change established medical norms. Efforts to “write off” medications can be met with resistance from both patients and healthcare professionals.

Many older women continue to have mammograms beyond the documented benefit, and older men often undergo prostate cancer screening beyond the recommended age.

Colonoscopies are less comfortable, so older patients may prefer to avoid them. “Even with polyps, the chance of dying from colon cancer is very small compared to anything else that can happen to you,” said Dr. Itzkowitz.

So he told his 85-year-old patient that she could forgo another colonoscopy. She seemed satisfied.