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.
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October 2011“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.
If patients don’t have a list and don’t know their medicines, “I actually use that as a bit of a warning sign that they aren’t on top of their health and we really need to think, can they do all of the follow-up?” he said. In fact, difficulty taking medication can be one of the first signs of cognitive impairment.
At the University of Kentucky in Lexington, a preoperative anesthesia clinic allows anesthesiologists to consult with patients, especially the large numbers who are taking anticoagulants for cardiac conditions. Sanford M. Archer, MD, professor of otolaryngology-head and neck surgery at the university, said uncontrolled bleeding is clearly a concern during surgery, particularly for endoscopic techniques that don’t permit surgeons to cauterize or tie off blood vessels. In many cases, though, cardiac patients on anticoagulants can be switched to temporary medications to get them through surgery and then given another alternative like Lovenox until after they’ve recovered from the operation.
Surgeons also should pay special heed to a patient’s “functional reserve” or ability to bounce back from a surgery. One relatively straightforward way to do so is to assess a patient’s independent daily living activities. “Can they pay their bills? Can they get around their house? Can they make it to the store to buy groceries?” Dr. Dale said. “Those things are actually very tightly tied to life expectancy.” Additionally, the answers may help a surgeon evaluate whether patients sent home after big surgeries can take care of themselves.
Non-physician staff can administer a more formal test, a 13-point scale called the Vulnerable Elders Survey (VES-13), which highlights patients at risk for deteriorating health and functional ability. If necessary, geriatricians may conduct a longer evaluation known as a comprehensive geriatric assessment.
The mental competency of an older patient also demands a proper assessment. Dementia not only limits overall life expectancy, Dr. Dale said, but can also pose a significant risk immediately after a surgery. Given the added stress of surgery and anesthesia, patients who are cognitively impaired are at a much higher risk of becoming delirious, which can be a life-threatening condition on its own. In addition, patients who are not cognitively intact are less likely to follow up with the necessary postoperative care, thereby reducing their chances of recovery.
Overt dementia can usually be identified without screening tools, while offices can use rapid and straightforward methods like the Mini Mental State Exam to help sort out those patients who might require a more thorough examination. A newer test called the Montreal Cognitive Assessment (MoCA) helps identify milder forms of cognitive impairment.
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.”
Postoperative recovery also requires some forethought. Because the majority of otolaryngology-associated elective surgeries are deemed outpatient procedures, insurance companies normally won’t pay for an overnight stay unless a patient meets the DRG criteria. After receiving general anesthesia, however, patients are often disoriented. “If it’s an elderly patient who lives by himself, he absolutely needs to have someone staying with him postoperatively, even for a simple operation,” Dr. Archer said.
Fortunately, doctors have the postoperative discretion to admit older patients if necessary. Making that call, however, requires attention to details like oxygen levels and a patient’s frame of mind. Dr. Archer also recommends pondering where to schedule an operation for a patient whose surgery or recovery may carry higher risks. Again, an anesthesiologist can often help determine whether a patient is a better candidate for an ambulatory surgery center or for a hospital, where every surgeon has privileges.
Then there’s the question of when. Dr. Archer has delayed surgery for a year or more on patients who receive a cardiac stent, a procedure that requires a follow-up, yearlong course of anticoagulants. “You’ve got to wait until the time is right,” he said. “In some cases, it may never be right, and then you have to say, ‘You’re at horrible risk for this operation, I don’t think it’s worth it.’”
Telling patients that they aren’t good candidates for surgery requires sensitivity and diplomacy, however. “We have to have ways to talk with them that don’t make them feel so bad and allow you to get the message across,” Dr. Dale said. For a patient who may have multiple co-morbidities, he may say something like this: “I’m really more worried about your heart disease. You’ve had a heart attack and a stroke and now we’re considering a really pretty stressful surgery. I’m not sure that the surgery is the highest priority right now, and I think it would be best for us to concentrate on these other problems.”
Non-Elective Surgeries
Surgeons may not have the luxury of time when assessing patients for non-elective surgery, but Dr. Kost said the initial questions are still the same: “How is this going to help the patient, and is there a real benefit at the end of the day to having this procedure?”
Patients must be made aware of the benefits and risks, and involved in the decision-making process. And surgeons need to keep life expectancy in mind. “In some cases, the patient’s comfort is really much more important than trying to add an extra month of living,” Dr. Kost said. “You really want to be careful to not add to their suffering.”
The University of Pittsburgh’s Dr. Eibling, who specializes in head and neck surgery, said that what patients really want is to be able to go home again. “On an almost daily basis, we ask ourselves not, ‘Is this patient too old for surgery?’ but, ‘Will this patient be able to be rehabilitated after surgery?’”
When dealing with cancers of the head and neck, there’s another wrinkle: Although some cancers can be treated through non-surgical means, such as radiation or chemotherapy, some older patients may not be good candidates for these alternatives. “If an elderly patient has significant kidney or renal disease, they’re actually not a candidate for chemotherapy, because the chemotherapy would shut down their kidneys,” said Marilene B. Wang, MD, professor of head and neck surgery at the UCLA David Geffen School of Medicine in Los Angeles. “Surgery may be a better option then. So we do need to look at the complete picture.”
In some cases, Dr. Wang and her colleagues have even had patients undergo a coronary bypass or angioplasty to optimize a heart condition before proceeding with a cancer surgery. A multidisciplinary tumor board can be a particularly helpful guide for otolaryngologists. At these meetings, surgeons, radiation oncologists, psychologists, social workers, and other providers can offer their own perspectives about the benefits and risks of different interventions for specific patients. Collectively, Dr. Wang said, these specialists can decide upon the best course of treatment.
Resources
Choosing the best path forward requires clear guidance. Fortunately, otolaryngologists can call upon an expanding range of tools to help them decide on the best course of action for older patients. Multiple otolaryngologists, for example, have contributed to a free e-book, Geriatric Care Otolaryngology (entnet.org). The eight-chapter document, made available through the American Academy of Otolaryngology-Head and Neck Surgery, covers everything from age-related hearing loss to facial plastic surgery.
Meanwhile, the American Geriatric Society (AGS) has devoted a portion of its website and a section of its annual meeting to specialists like head and neck surgeons. The society has also helped to fund a free and largely Internet-based geriatric otolaryngology curriculum established by Emory University (http://otolaryngology.emory.edu).
Finally, the AGS is developing a set of geriatric competencies for surgeons, through a consortium of American Board of Medical Specialties surgical boards. Dr. Johns said the guidelines will help drive residency education, board certification, continuing medical education and maintenance of certification.
Assessing older patients may require additional effort, but experts said the overall goal should be the same regardless of age. “I think older people want the treatment that they rightly deserve,” Dr. Kost said. “They want to stay well, they want to be kept well and they want the same opportunities for treatment as you would offer to somebody who’s younger.” ENT Today
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