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Monday May 25, 2020
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June 2006 - Volume 2 - Issue 12

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The Care of the Elderly: The Challenge Before Us

At the recent international meeting of the American Association of Thoracic Surgery I was struck by the findings of a study suggesting the possible mechanisms for the failure of VEGF therapy in the elderly. VEGF, or vascular endothelial growth factor, is a naturally occurring hormone which was touted as a possible cure for nonreconstructable vascular disease (i.e. disease so extensive that vascular bypass surgery or percutaneous stenting would not be possible). Despite very encouraging laboratory advances, clinical results to date have been disappointing. What was particularly striking about the presentation was that the mean age in the "elderly group" was 75, while the mean age of the "control" group was 65—an age which, until recently, was considered by the medical community to itself be elderly. Even more impressive was the fact that even though only 10 years separated the groups, the results were demonstrably different.

These findings highlight several points:

  • The aging process is not necessarily linear—the rate of physiologic change may actually accelerate over time (accounting for why the above-mentioned results were different in groups only a decade apart, which would not likely have been the case comparing, for example 65 year-olds with 55 year-olds)
  • Care of the elderly cannot be simply viewed as merely care of younger patients with more comorbidities—i.e. hypertension, lung or kidney or heart disease, etc. Certainly older patients are more likely to have multiple comorbidities, but the aging process itself has clinical impact independent and additive to those associated conditions.
  • Research in the laboratory may yield promising results which are not readily translated into the clinical scenario for many reasons, one of which is most certainly advanced age.

    Life expectancy has improved dramatically in this country over the past several decades. In fact, the portion of the population older than 75 is the fastest growing, and is expected to quadruple over the next 50 years. Those who reach age 80 have a life expectancy of 6-8 years (shorter for men, longer for women). These developments have resulted in an increasing portion of healthcare being devoted to care of the elderly.

    These changes have evolved with a limited medical understanding of how aging itself impacts basic cellular mechanisms such as apoptosis (programmed cell death), vascular responsiveness, inflammatory response, DNA repair, etc. It should be noted however that there is a certain biological "selection" process operative here in that those individuals who have survived into their eighties and nineties represent a relatively "healthier" segment of the population to begin with.

    So how does/should all of these factors inform our care of the elderly? Here at the Florida Heart Research Institute we undertook a study several years ago of over 1000 consecutive patients age 80 and older who underwent isolated coronary bypass surgery. The goals were to assess perioperative survival and complications, as well as long term survival and quality of life as assessed by the patients themselves. We discovered the following:

    1. Perioperative mortality, although low, was higher than for younger patients, but declined steadily throughout the course of the study period, as surgical technique and expertise in the care of the elderly improved
    2. Perioperative complication rate stayed relatively unchanged, despite the above-mentioned advances
    3. Long-term survival was comparable to the general population of elderly without coronary artery disease
    4. Long-term patient perception of quality of life amongst the survivors was comparable to or better than the general population of elderly people.

    This study demonstrates several extremely important points which can help us in the care of the elderly:

    1. We should be extremely reluctant to deny advanced medical therapeutics to the elderly on the basis of age alone. Decisions must be made on an individualized basis.
    2. Having established point #1, it must be understood that the physiology of the elderly is more complex and fragile, and, despite our best efforts, it is likely to be more vulnerable to both the disease and to curative therapeutics.
    3. Despite the difficulties inherent in the treatment of the elderly, attention to detail and rational individualized treatment, even aggressive treatment, can yield long-term satisfying and beneficial results.
    4. More research is needed to better define how to best treat an increasingly elderly population in the most appropriate manner.

    The challenge before us demands knowledge, care and compassion—and our senior citizens deserve nothing less.

  • Dr. Paul Kurlansky, board certified cardiothoracic surgeon, Director of Research at the Florida Heart Research Institute, can be reached at (305) 674-3154 or DoctorWu18@aol.com.
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