Submitted by Dr T on November 20, 2010 – 6:09pm
Treatment of the elderly has been a subject on my list of to-do’s for a while. Elderly patients often have a laundry list of problems with their associated treatments and live a life centered on when to take the next pill.
At such an advanced age there is little data (if any) to show how much benefit these treatments offer, while there is considerable evidence of deleterious side effects. No information is available showing meaningful prolongation of life: at that age loneliness is a major factor as most contemporaries have died, while in this modern society children often live too far away for frequent social contact.
The oldest patient I have ever operated upon was 99 years old and needed a heart valve replacement. He was totally disabled from his heart condition and completely unconcerned about his risk of dying. He was lucky that there were plenty of children and their offspring nearby. After a totally uneventful recovery, he went back to the one passion that made life worth living. The operation rid him of one of the other major nuisances in his life: all those damn pills!
As an example, hypertension treatment of the elderly protects against stroke, exposes patients to dizziness but also promotes death from myocardial infarction. In part due to those types of side effects, plus forgetfulness and sometimes dementia, adherence to prescription instructions is often poor. A patient who has been living to that age with a blood pressure of 180 or higher may actually become more confused with a lower BP, or have episodes of dizziness (and thus the risk of falling and injuries such as a broken hip).
Another disease of the elderly, atrial fibrillation, an arrhythmia that requires anti-coagulation therapy with Coumadin to protect against stroke, often causes as many complications from too much or too little (bleeding or clotting), as the disease it is meant to protect against.
Life quickly becomes very complicated, especially if there is not enough help or supervision available. I am sure, most nonagenarians as well as their younger colleagues, are very much alike to my patient, happy to undergo a procedure if it will improve the quality of their lives, but no longer afraid to stop living.
My advice, concentrate on optimizing quality of life issues and don’t worry too much on fine tuning the care of someone who has already outlived most if not all of their contemporaries. Patients themselves, their family and caretakers should all play an active role in the decision in regard to how much treatment to give!
Tell me what you think,