Precision medicine in the elderly care

Marco Inzitari

One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

In the face of this almost mathematical "precision medicine" perspective, and with regard to care for the elderly, often with multi-factorial complexity (due to multi-morbidity, physical and cognitive frailty and psychological, social and environmental factors), we should be even more ambitious: the interventions, also multi-component, should be individualized, planned and modulated based on multiple parameters. I detail the main ones below:

• The biological and clinical aspects, with the added complication of adapting evidence often derived from studies done with highly selected "prototype patients"
• The vulnerability of the person and the prognosis, which are often related to frailty, which is nowadays quantifiable with more or less simple assessments
• Social and environmental factors
• The preferences of the person, who, if we have been able to do a good job, should come from a former assessment in a situation of stable health status

In addition, all this should be adapted to each one understating (or “literacy”) so we can share the decisions with people and their caregivers.

This paradigm should be applied systematically in decision-making when facing advanced chronic diseases. Also when dealing with cancer, which in 75% of cases will affect older adults by 2030, this will be key. It should be added that different highly promising complex interventions, both in prevention and treatment, are based on a high level of individualization, such as:

• The "Frailty Intervention Trial", targeting pre-disabled frail older adults, proposes an "à la carte" multi-component intervention based on altered areas
• The DICE (describe, investigate, create, and evaluate) approach to the management of neuropsychiatric or "behaviour" disorders associated with dementia is based on an individual "co-design" process with the patient’ caregivers

I have the clear aim that bright medical students become passionate about geriatrics, because our society needs this. Often, knowing that they aspire to excellence or that their “measurement unit” can be series like Dr. House, I point out to them that treating older people can be more complex than “simply” working as a physician, given that it requires a deep and updated knowledge of  medicine, knowing and contextualizing the scientific evidence, knowing how to assess frailty, mastering non-technical skills (communicative, etc.), and often being flexible in decisions. If they succeed, no machine can replace them in diagnosing or treating, in the short term. But for those who aspire to make lots of money, they better opt for another path!

Photo: Kasparov Vs Deep Blue