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A colleague calls me about an octogenarian patient scheduled for cancer surgery.
That patient has been “cleared” by anaesthetics and the medical team promises “support” but, despite the reassurances, I can see why the surgeon has her doubts. The patient has several health problems that, taken together, amount to significant impairment. For such patients, even small complications can spell big trouble.
There is an old joke in medicine: “When in doubt, cut it out.” But emerging evidence tells us to proceed slowly, especially when it comes to the elderly. For such patients, more is not always better – and can often be worse.
I am part of a geriatric oncology service which combines the expertise of an oncologist, geriatrician and allied health professionals to tailor cancer treatment. Our youngest patients are often in their 70s, the oldest (who said he only came to humour us) is 100.
To assess people’s fitness for cancer treatments including surgery, radiation and chemotherapy, we use geriatric assessment tools to interrogate domains not routinely assessed – cognition, mobility, nutrition, emotional health, community support and aged-care services, to name a few. It’s easy to see why this kind of deliberate information gathering is helpful not just for cancer patients but all elderly patients to plan their healthcare.
But what is interesting is how often people are surprised by the findings once they are laid bare. Suddenly, the person who “might be a bit slow” is found to be falling, every fall increasing mortality. Someone who “didn’t look all that bad” has impaired judgment and can’t make decisions. Caregivers are found to be emotionally spent – and keeping mum about it.
I have found myself reflecting on this phenomenon in the context of former US president Joe Biden’s vulnerabilities. Over time, his speech became halting, and he was mixing up names. His gait was slow and, when he fell, he had difficulty getting up. His mood was variable and he seemed to need more rest between tasks. He appeared physically frail.
Amid widespread concerns about Biden’s stamina, it is said that the people closest to him, including his wife, protected him. Reasons include their devotion to him, his determination to appear vital, and the pursuit of the White House seen as “the family’s project”.
An article in the New York Times explained the thinking among insiders: “The consensus was that Mr Biden might look old, but he was not too old for the presidency.”
In the medical world, the analogous idea is “the patient might look old but should be just fine for major intervention”.
The problem is that most elderly patients don’t just look old – they are old and suffer from the cumulative impact of multiple comorbidities. Their “regular” aches now inhibit function; their need for daytime rest is not indulgent but necessary; their emerging forgetfulness deserves sympathetic oversight, not turning a blind eye.
In an age alert to even implied discrimination, there is a temptation to declare that elderly people shouldn’t be treated differently.
Obviously, not all elderly people are the same. My mother’s gym instructor is approaching 95 and is the fittest person in the room. My friend’s octogenarian dad plays an impressive schedule of cricket. But for every vigorous elderly person, there are many others who experience the indignities of ageing that could be addressed with a pragmatic approach.
In my clinic, I meet once-professionals who now struggle to speak cogently and past runners who need help getting out of a chair. For them, the real disservice is when those around them see these warning signs and then unsee them. Relatives may do so out of loyalty or because it’s easy to miss subtle decline. Doctors, for their part, often fail to consider things they are not trained to fix. A surgeon doesn’t treat dementia. An anaesthetist doesn’t manage rehabilitation. An oncologist doesn’t perform the cancer operation.
Increasing sub-specialisation means patients see more doctors for less cohesive care. The older you get, the more scrutiny your health deserves, with formal tools rather than casual chatter.
In the case of my older patients, we often discuss the alternatives to an all-or-none approach. It may be prudent to avoid aggressive surgery but consider treatments not strictly curative but distinctly better for quality of life. Or to proceed to aggressive treatments accepting a high risk of needing residential care. We incorporate the expertise of occupational therapists, physiotherapists, dietitians, palliative care workers and others to keep people healthier for longer. Last week, I met a daughter who exulted that the best thing about her mother’s geriatric assessment was the home rehab referral that restored her confidence to walk. The mother was obviously relieved that she was cured, but seemed even more grateful to be on her feet.
I wonder if, surrounded by doctors of the highest calibre, Biden was advised of a comprehensive geriatric assessment to formally assess his physical and cognitive function. This information could have been the basis for informed discussions rather than a guessing game about how fit is fit.
Not a lot about the health of privileged world leaders is relevant to my patients. But when it comes to appreciating the vulnerabilities of the elderly and helping them make decisions in their best interest, Biden’s story has been an object lesson from the world stage.
The surgeon who approached me had the right instincts. Her patient was even frailer in person than on paper, and we made a joint decision for a non-surgical approach.
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Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
