Offering surgical care for elderly patients can be challenging in that it’s a very heterogeneous group. You have everyone from those who are living independently, looking much younger than their stated age, to those who look much older than their stated age and are beginning to have some impairment, which they may be hiding from themselves or hiding from their family members, to more severely impaired people who are completely dependent on members of their family or friends in order to do daily care. It’s not unusual that a spot is found on the lung, a cancer is found in the colon, a breast lump is identified and so they are facing choices with surgical care.
We know that there are certain things that equate to risk of having complications afterwards, mostly related to how far you can walk, how independent you are, what your current strength is. So it’s trying to match up what those risk factors are with having an honest discussion about what can be changed, what can be not changed. For instance, you can’t change your age, your sex, your medical history; you can change your diet, you can change whether or not you’re consuming tobacco and alcohol, you can change what type of exercise that you’re doing. You can have a dramatic reduction in your risk if you engage in a programme for two or three weeks. So that’s what we’re advocating for the patients is to judge where they are. At the current time that the diagnosis is being made what is their current level of strength and if there is an occult frailty try to put them in a programme that will improve their strength prior to surgery.
As a patient what’s the best way to know what’s right for the individual?
The very best way is to go to a clinic that offers you access to multiple specialities seeing the same patients. So clinics that have expertise in surgical care and geriatrics and pulmonary medicine and cardiology and radiation oncology that you can meet multiple doctors in the same centre and talk about what are the treatment goals, what are the treatment choices. We find that the evaluation with a geriatrician in their own clinic is invaluable. They are able to offer us an understanding of how drugs are interacting with each other, what drugs can be stopped for two weeks before surgery to decrease the rate of complications. They help us with nutritional aspects of the patient; they help us with strength and conditioning that improves the entire programme.
There are surely still benefits to these programmes even when not being treated?
That’s absolutely right. So even if you engage in a strength and conditioning programme and you choose ultimately not to have surgery, it improves your chance of tolerating whatever the treatment is. Even if your choice is no treatment at this time but watchful waiting, as we call it, when you decide that you’re not going to make a decision now, you’re going to make a decision three months from now, just being in a strength and conditioning programme does improve your quality of life and it can affect mood, it can affect social relationships. You may be in a much better position in three months to consider therapy than you are right now.
What’s the take away message for a physician watching this?
The take away is that we have gotten to the point where if you look at surgical risks and how we measure surgical risk we used to always measure death. Operative death has gone way down with modern techniques; surgical morbidity remains an issue. But it’s time to consider other issues, like what’s the risk that the patient is going to end up in a nursing home? What’s the risk that the patient is going to have pneumonia or other complications? What can we do in a more patient and careful patient-oriented approach that we could improve over a 2-3 week time period to make the operation safer? That’s so intuitively obvious that people embrace it as soon as they hear it. It’s not an emergency to intervene right away, even though we all work within medical communities that want to portray that on to us, that you have to make a decision now as to how you’re going to treat that patient. Let it be patient-centred care, talk honestly, these are the things that we can do, these are the things that can change, these are the things that we can do to make you stronger and in a better position to undergo surgery or chemo or radiation. It’s true no matter what type of treatment that you choose.
