You've Won The Game

MONDAY, June 15, 2026 (HealthDay News) — When a patient has made it to 85 years old in reasonable health, their instinct — and often their physician’s — is to redouble prevention efforts, optimize every number and close every gap. I want to argue the opposite. 

If you have made it to 85 and are healthy and living independently, you have won the game of life. The appropriate response is not more medicine. It is recognizing what got you there and being very careful not to break it. We have precious few interventions that can reliably extend an 85-year-old’s lifespan (let alone their health span) but an infinite number of ways we can mess it up.

What Winning The Game Actually Means

Average life expectancy at birth in the United States is roughly 78 years. A healthy 85-year-old has outlived that mark by nearly a decade, and someone born in 1940, when life expectancy at birth was closer to 63 years, has outlived what the actuarial tables of their birth year would have predicted by more than two decades. 

Something is working, likely their genetics and lifestyle behaviors, acting together with a huge dose of good fortune, none of which we fully understand. That humility should inform everything that follows. This is a patient who succeeded at survival — not one who failed prevention — and interventions calibrated for a 58-year-old in a randomized clinical trial do not apply to them in any straightforward way.

It also helps to remember what we know about how treatments work. 

Most interventions benefit a small number of people substantially and a moderate number modestly. The averages obscure that distribution. We cannot predict who is in which group, and in someone who has already beaten the actuarial tables, the odds that any given preventive intervention will be the thing that helps them, rather than one of the many things that gets in the way, are not what they were at age 55. 

Treatments that transform outcomes in high-risk middle-aged patients often offer marginal benefit and real potential harms to someone who reached their mid-80s in good health.

Time-To-Benefit And Who Was In The Trials

Most of the landmark prevention trials that underpin our guidelines enrolled patients with median ages in the late 50s or early 60s, often with explicit upper age cutoffs. We then apply those findings to patients a decade or two older, with more comorbidities, more medications and shorter time horizons. This is a foundational problem.

Time-to-benefit illustrates the problem. Statins in primary prevention take two to three years to show cardiovascular disease (CVD) risk benefits and longer to show the full effect, including survival improvement. For a healthy 87-year-old without established CVD, those numbers may still favor treatment. For someone with lung disease, mild cognitive impairment or metastatic cancer, they almost certainly do not. That needs to be discussed explicitly with our patients.

Where We Can Hurt You

The ways medicine can harm someone who has won the game are numerous, and they do not always even seem like harm in the moment. Here are some examples:

1. Dietary obsession. The relentless pursuit of a heart-healthy diet in someone already lean and functional can drive protein restriction, loss of muscle mass, impaired balance and falls. In older people, falls can start a spiral of injury, debility and complications that lead to death. The intervention meant to extend life shortens it. Among older adults who sustain a serious fall (that is, one requiring emergency transport or resulting in a fracture) roughly 20% to 33% die within the following year.

2. Tight control of blood sugar. In older adults with diabetes, aggressive targets increase hypoglycemia risk substantially. Hypoglycemia is associated with CVD events, falls, cognitive decline and death. The ACCORD trial demonstrated this directly, showing that intensive glycemic control (target HbA1c below 6.0%) increased all-cause mortality compared with standard therapy, leading to early termination of the intensive arm. Any long-term microvascular benefit from the lower number is almost certainly offset well before it accrues.

3. Polypharmacy. Add an antihypertensive, a sleep aid or even a simple antihistamine to someone already on five medications and you have created a fall waiting to happen, not a prevention success.

4. Aggressive screening. Particularly in older patients, more screening often generates incidental findings, which can lead to anxiety and downstream costs, including procedures whose harms are real and whose benefits, at that age and life expectancy, are theoretical.

None of this is inevitable, but it happens regularly because the clinical impulse is to act, which decision scientists call “action bias.”

Action Bias

Ironically, many patients complain that their doctor just listened and “did nothing.” That “nothing” often demonstrates evidence-based and humanistic restraint and listening often is the best “something” they could have done. 

Physicians feel pressure to act. So do patients and their families. Inaction in medicine can be read as neglect or indifference, even when watchful waiting is the correct and evidence-based choice. It is the same tendency that makes goalkeepers dive on penalty kicks even though staying in the center of the goal is statistically the better choice. Diving looks like effort. Standing still looks like giving up. One of my most impactful mentors, Dr. Jesse Hall, then director of the Medical ICU at University of Chicago Hospitals, often said, “Don’t just do something, stand there.”

Indeed, there is a specific harm in converting a healthy older adult into a medical project. They have to get the pill, pay for the pill, take the pill each day at the right time, have follow-up doctor visits, blood draws, imaging tests and check their blood pressure twice a day and weight each morning, consulting the guidance each time. Each one seems reasonable and takes only a few minutes a day. But when you are older, those minutes feel like they matter even more. They collectively medicalize what should be healthy years and increase the work of living them.

The decision rule I try to apply is straightforward: Will this test result change management in a way that meaningfully improves prognosis or quality of life? If yes, order it. If we are optimizing something that is already good enough, we should leave it alone. Time spent in waiting rooms is time taken from a life.

Careful Medicine Is Not Nihilism

I hope you know I am not advocating for nihilism or abandoning health care for older patients. There are interventions that work at advanced age. Blood pressure reduction improves CVD outcomes and reduces risk of cognitive impairment. But both findings require the same caveat: The SPRINT study that guided our recommendations excluded patients with prior stroke, heart failure, diabetes mellitus and severely reduced kidney function, as well as institutionalized patients, patients with significant alcohol use and those already on complex medication regimens (precisely the patients who populate the oldest-old in clinical practice). The trial population was healthier, more independent and less medicated than most 85-year-olds seen in practice, so applying its targets without that context is a form of evidence misuse rather than evidence-based care. 

Patients with established CVD benefit from treatments like lipid-lowering therapy regardless of age, but personal preference and goals of care always reign supreme, especially in dealing with people who have won the game and hope to stay on the winning side as long as possible. For those patients, another medical aphorism applies: “The enemy of good is better.” In the context of an older adult who is doing well, the hardest prescription can be doing nothing additional medically and suggesting that they go live their life.

More information

Johns Hopkins Medicine discusses the role of geriatricians, specialists in aging.

About the author

James H. Stein, MD, is the Robert Turell Professor of Cardiovascular Research in the Department of Medicine at University of Wisconsin. He is a preventive cardiologist and professor with over 35 years caring for patients and researching cardiovascular disease who aims to make health and science clearer and more approachable. The opinions in his writings are his, not his employers'.  You can follow his Substack at   https://substack.com/@jamesstein18