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

Some patients may appear cognitively impaired because they’re depressed and may require a psychiatric or psychological assessment. Even if a true cognitive issue is uncovered, physicians should first ask whether it is correctable before ruling out surgery, said Karen Kost, MD, FRCSC, director of the McGill University Voice and Dysphagia Laboratory in Montreal, Quebec. “Sometimes, it could be something as simple as a metabolic imbalance or an issue with their medication: It’s underdosed or overdosed or interacting with other medications, as in polypharmacy,” Dr. Kost said.

A patient’s social circumstances, including the presence or absence of a good family support system, can provide further guidance. A patient with mild cognitive impairment but a strong support system, Dr. Dale said, will likely do much better than a patient with a broken family situation that makes it difficult to keep up with complicated post-op recommendations. “You need to figure out how you’re going to handle that before you do a big surgery that’s then likely to fail or end up in re-hospitalization,” he said.

Elective Surgeries

Assessing a patient’s medical, functional, cognitive and social status can uncover clear warning signs ahead of a potential surgery. But Dr. Kost said a thorough analysis can also counteract the tendency of a patient’s age to negatively bias physicians on treatment options, particularly for elective surgeries. “It’s very easy to overlook treatable issues on the basis of age,” she said. Doctors may assume that a weak voice is age-related, for example. “But when you look, you find that there’s something very treatable,” she said.

A primary question for such patients is the degree to which surgery may improve their quality of life, said Michael Johns, III, MD, associate professor of otolaryngology-head and neck surgery and director of the Emory Voice Center at Emory University in Atlanta. “Individuals are living longer and longer, they’re staying engaged occupationally and socially and they want to live quality years in addition to quantity,” he said.

Unless patients have severe complications, most sinus surgeries are likely quality-of-life elective operations. As with any procedure, geriatricians say doctors should discuss all non-surgical alternatives. The University of Kentucky’s Dr. Archer, however, said many of his patients considering an operation to open up their sinuses have already taken multiple medications and antibiotics, with X-rays revealing lingering evidence of disease despite all medical efforts.

Even so, Dr. Archer said the prospect of surgery can unnerve patients of all ages and interfere with their ability to fully comprehend a surgeon’s explanations and directives. “I’m a firm believer that the physician is the one that needs to be the caregiver giving information, holding their hand and answering every question that they have,” he said. “If it requires a second visit with a significant other or other family member, so be it.”