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When I was a surgical intern rotating through the cardiac service in 1980, it was very rare that the cardiologists would perform a cardiac catheterization on anyone older than 70. “What for? We are not going to send them to surgery at that age…” By the time I left the clinical practice of cardiac surgery two decades later, nearly one quarter of my patients were eighty years or older. Similarly, if you go to the National Medical Library and put the word “octogenarian” in the search column, you receive a listing of some 527,450 articles on the topic. However, what is really interesting is that until around 1985, there were only approximately two dozen articles per year. Since that time there has been a steady acceleration in scientific publications on the topic, culminating last year in some 39,623. Why the tremendous increase in interest in the elderly?Octogenarians represent the fastest growing segment of our population. Maturing of the “baby boomers” combined with improved care of the elderly has resulted in a major demographic shift. In the past fifty years, when the population of the United States has slightly more than doubled, the population 75-84 years of age has more than quadrupled, while that for those over 85 has grown more than sevenfold. During this same period, the death rate for those 75-84 has decreased by over 60%, while that for those over 85 has decreased by nearly half. Life expectancy for an 80 year old is currently 8.2 years for a man and 9.7 years for a woman. Despite these remarkable advances, over 40% of the very elderly manifest cardiovascular disease and nearly one third will die from it. Similar population trends have been noted elsewhere in Western world.
The medical community has certainly responded to these trends. For example, in 1977, Andreas Gruentzig introduced a procedure to remove the atherosclerotic blockage in coronary arteries by percutaneously introducing a catheter into the arterial system with an inflatable balloon that could crush the diseased tissue and restore normal blood flow. No surgery. No general anesthesia. Now cardiologists perform diagnostic catheterizations on elderly patients with the possibility of finding a lesion or two suitable for “angioplasty.” Frequently what was found was severe and extensive coronary artery disease beyond the therapeutic bounds of angioplasty, and surgeons were called. Initially, results for cardiac surgery in octogenarians recorded mortalities in the 20% range. However, over the ensuing two decades, mortality for coronary artery bypass surgery in octogenarians dropped to the 2% range, rivaling that for younger patients. Advances in surgical technique, intensive care, medical therapy, patient selection all played a role.
In recent years another transforming technology has been introduced—percutaneous aortic valve replacement. Aortic stenosis is primarily a disease of the elderly—one which is ultimately lethal and one which has no medical therapy because it results from a mechanical problem (progressive narrowing of the valvular orifice separating the main pumping chamber of the heart, the left ventricle, from the major arterial conduit of blood to the body, the aorta). Because these patients are frequently elderly and many have multiple associated morbidities, not to mention the problems that may have developed in the heart itself in its attempt to compensate for this obstruction to outflow, somewhere in the range of one third of these patients are never referred for surgical intervention. Although the technology is far from perfected, there is already clear evidence that this transcutaneous aortic valve replacement (TAVR) can be life-saving for elderly high risk patients with aortic stenosis.
All of this progress is evolving in an environment that is increasingly concerned with the costs of care. One TAVR valve, without the associated procedural, hospital and physician expenses, costs $30,000. As we struggle to deal with increasingly scarce resources, how do we determine the most appropriate application of these potentially life-saving therapies in an elderly population? How do we integrate the increasing medical awareness of “frailty” as a risk factor for interventional therapy in the elderly population? What is the wisest application of scarce resources when such a large percentage of total expenditure appears to be in the final months of life? The optimist will point out that it is the remarkable nature of the medical advances that we have made that presents us with such challenging decisions as a society. The doctors can and should continue their quest for new and improved therapeutic approaches, but we as an aging society need to decide how we choose to apply them. As I slowly but inexorably reach that age group myself, I recall the pop prophet of a previous generation, “…I was so much older then, I’m younger than that now.”
