Geriatric Challenges: Age shouldn’t determine treatment, experts say

One of William Dale’s healthiest patients was working out three times a week, regularly walking two miles, lifting weights, maintaining a stable body weight of 120 pounds and not on any medications when she was diagnosed with a stage IV ovarian cancer. Dale, MD, PhD, section chief of geriatrics and palliative medicine at the University of Chicago, said the patient did fine with both surgery and chemotherapy. The fact that she was 89 years old, he said, shouldn’t necessarily come as a surprise.

“Sometimes I think people are dismissed as too old when they’re really pretty healthy,” Dr. Dale said. “If she was 65, what would you do? You’d treat her with standard therapy.”

Geriatricians are increasingly delivering that message to otolaryngologists, many of whom aren’t trained in geriatric issues but will be called upon to treat a rapidly aging population. By 2030, in fact, U.S. Census demographers project that one-fifth of the U.S. population will be over the age of 65, compared to 13 percent in 2010. Demand by seniors for otolaryngology-related surgeries, both elective and non-elective, will only continue to grow.

One of the primary directives emphasized by Dr. Dale and other experts is to pay little attention to age alone. “Usually we think of geriatrics as an age-specific specialty, but really our job is to think of people’s remaining life expectancy,” he said. A common misperception that good tools aren’t available for calculating life expectancy, he said, has too often spurred oncologists and surgeons to use age as a proxy.

As many otolaryngologists are finding, scrutinizing a patient’s other diseases and conditions, functional status, mental competency, and family support can offer much more accurate indicators of whether the person may benefit from surgery.

Dr. Dale said he first focuses on whether the patient will survive long enough for the surgery to matter. Then, based on life expectancy, he weighs the quality-of-life implications of doing something versus doing nothing.

David Eibling, MD, vice chair for education and professor of otolaryngology at the University of Pittsburgh Medical Center, agrees that surgeons shouldn’t rely on the calendar when assessing older patients. “A two-year-old child is very similar to another two-year-old child, but a 72-year-old woman may be extremely different than another 72-year-old woman,” he said. “There’s much more variability in elderly patients.”

Covering the Preoperative Bases

Some considerations are critical regardless of whether an otolaryngology-related surgery is elective or non-elective. For example, polypharmacy is often a major issue among seniors. “I tell all the patients not just, ‘Bring your list,’ but ‘Bring your bottles—just put them all in a bag and bring them all in so I can see everything you take, including your over-the-counter medications,’” Dr. Dale said.