Letter: When overtreating the elderly is just unfair

Dear Editor 

Dr Donal O'Donaghue, chairman of the DoH's Renal Advisory Group, misses my point on exception reporting entirely (GP, 26 May). I agree wholeheartedly that it would be unethical to exception report people aged over 70 even though the eGFR is unreliable after this age.

The point I am making is that GPs have a large number of hypertensive patients in their 80s and 90s. My late mother would have been one of them, had she survived vascular dementia and a stroke at 83.

I can well remember - when I was a student in the 1970s - her telling me, while faithfully taking her Aldomet, that her BP was good at 160 systolic.

Our predecessors, of course, did not have the wonderful ABCD and the options of more antihypertensives or statins that we have now.

These very elderly people who have survived decades of uncontrolled hypertension, no doubt now have 'pin hole' renal arteries and hence a degree of renovascular hypertension.

Every medical student knows, if he/she has learned the pathophysiology of the renin/ angiotensen system, how dangerous it can be to suddenly switch this off with an A drug - catastrophic hypotension, falls, acute renal failure, and so on.

What do we say to these 'hardy' survivors when their eGFR comes back at 59 or less? Do we tell them that their kidneys are 'packing in' and they have to take yet another drug, warning them that the drug might make them fall and might worsen their kidney function; that they will have to attend much more frequently so that we can keep an eye on them with more frequent BP checks and blood tests?

If we cause them problems with an ACE inhibitor, do we then try them with an angiotensin II antagonist to see if they can tolerate this?

Do we present them with a fact sheet about the dangers of this A drug in their age group and ask them to sign a disclaimer? I don't think so.

Or do we simply abandon good clinical care and just not check their U&Es to avoid coding them as CKD3 or worse?

I could list dozens of cases of very elderly patients I have watched over the past 30 years, whose BPs are much less than 140/85mmHg; many of them are on warfarin, many are already unsteady on their feet and many are already confused by their multiple medications.

If I suddenly find them to have the wonderful 'new' diagnosis of CKD stage three, I know what I will be doing. My computer keys '9hE1.' will be worn out by the end of the year.

Dr James Kenny, Ballymena, County Antrim.

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