With seniors, special focus can be beneficial — in tough surgeries and more

surgery-300x120Recognizing that seniors face different health challenges than younger folks could help doctors and hospitals better safeguard older patients who undergo complex and demanding surgery.

Paying heightened attention to age’s changes also can be beneficial to older adults in protecting themselves from damaging falls and getting retirees to keep moving to stay fitter — without getting hung up on a mistaken exercise measure.

A specialty group within the American College of Surgeons may be on a beneficial course in recommending new geriatric guidelines for older patients, a rising number of whom undergo extensive procedures that once were considered risky for those of an advanced age, the New York Times reported. This is a significant issue in surgical practice, the newspaper reported:

People over 65 represent roughly 16 percent of the American population, but account for 40 percent of patients undergoing surgery in hospitals — and probably more than half of all surgical procedures. Those proportions are likely to increase as the population ages and more seniors consider surgery, including procedures once deemed too dangerous for them.

The surgical academy’s Coalition for Quality in Geriatric Surgery wants practitioners to look harder at the outcomes of procedures they are undertaking with patients, because, as the New York Times noted:

As older people undergo more operations, the coalition has focused on the results. Perhaps unsurprisingly, older surgical patients often fare worse than younger ones. One study reviewing major, non-emergency surgery in 165,600 adults over 65 found that mortality and complications increased with age; hospital stays often lengthened. Patients in their 80s undergoing major surgery for lung, esophageal and pancreatic cancer have substantially higher mortality rates than those aged 65 to 69, another study found; they’re also more likely to go to nursing homes afterward. Why? Older patients often have chronic health problems, aside from whatever the surgery is supposed to fix, and take long lists of drugs. The hospital itself, where they risk acquiring infections or losing mobility after days in bed, can endanger them.

The geriatric surgical specialists want their colleagues to communicate much better with patients, so they understand the risks, benefits, and realities of any procedures they undergo. Surgeons need to better understand the full picture of prospective surgical candidates’ lives, assessing if they have existing issues with cognition, advanced age, frailty, mobility, and nutrition. Can problems in these areas be addressed to strengthen patients before they get operated on? And when they under treatment, are there specially trained caregivers to help them in their recovery, including by ensuring they get age-friendly rooms and their need for opioid painkillers gets rigorously addressed?

This intensive review and support for patients comes at a cost, described by the surgeons’ specialty group as running “in the five figures,” the newspaper reported. But more robust care and communication with older patients may spare them and the health care system from invasive, painful, costly, and ultimately, unhelpful procedures. Paula Span, the “Old Age” columnist for the New York Times, rolls out in her article some sad and, frankly, grisly stories of patients who don’t get the medical counsel that might most benefit them.

These include the story of a wheelchair-bound 77-year-old woman with emphysema and on oxygen, suffering from weak kidneys, heart failure, and arthritis. She dreaded the idea of being a burden to her loved ones by ending up on life support systems. But this information wasn’t shared with her surgeons. They thought they talked to her, so she understood that she might not survive a major repair of a bleeding aneurysm with which she long struggled. They thought they explained that if the surgery went well, she might need kidney dialysis and a ventilator for however long she lived — and that she likely would spend whatever time she had in nursing home care.

The woman, confused or failing to understand, still told surgeons to go ahead. She ended up having multiple surgeries (one lasting for eight hours, the other for six hours), suffering cardiac arrest and resuscitation, and was in intensive care, sedated, bloated, and breathing only with mechanical assistance before her family told doctors they needed to stop.

In my practice, I see the harms that patients suffer while seeking medical services, and their nightmares in trying to deal with the skyrocketing cost, complexity, and uncertainty of therapies and prescription medications, too many of which inflict damages on them and their loved ones because they turn out to be dangerous drugs.

Putting patients’ rights and wishes at the fore

A fundamental right for patients is informed consent, which must be provided to them by all their medical caregivers. This means they are told clearly and fully all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom. But informed consent — already difficult to ensure with sick and injured patients — becomes a big issue when a candidate for extensive surgery is elderly and struggling. Patients while healthy, or relatively so, may consider working with their loved ones, doctors, lawyers, and financial advisers to ensure their wishes about their lives, especially near and at the end, get fully considered with the power of the advanced directive and other legal and medical planning tools.

The advance directive is a form that you can get from groups like the AARP (the documents vary, state by state). Be sure that everyone who might need to see the directive in stressful, potentially emergency situations know where it’s at, including, possibly as an attachment to your electronic health records.

By the way, patients and families also need to think carefully about resuscitation orders and the optimism that may underlie them. For the elderly, and especially for those who already are sick and frail, the most common procedure of CPR (cardiopulmonary resuscitation) can have poor outcomes. If patients are revived and sustain for some time, they often may experience pain: CPR may not seem invasive, but it often breaks ribs and can leave bruised patients in discomfort (rib injuries are among the most challenging, because they can affect all manner of everyday activities, including breathing, coughing, laughing, and eating). If elderly patients respond to CPR, they often then may need intubation and the statistics on that procedure aren’t rosy.

Protecting yourself in advancing age

We all, of course, may wish to take every measure we can to stay healthy, well, and out of the clutches of the health care system. We can do this by not smoking, eating in healthful fashion, not drinking excessive amounts of alcohol, and by exercising or at least getting up and moving around as much as possible. In our gadget-obsessed age, many of us rely on electronic fitness gear to nudge us along. But, no, the popular notion that 10,000 steps a day is optimal for our health turns out to have been an invention by clever marketers for a Japanese pedometer. New research suggests that for seniors, women in particular, walking achieves its best for exercisers in the 4,000 -7,000 steps a day. If you and your doctor agree that you can handle a more vigorous workout, go for it, of course.

Do take care to avoid what always has been and increasingly is a big problem for older adults: injurious falls. As the New York Times reported:

As the population ages, the number of older Americans who die following a fall is rising. A study published … in the medical journal JAMA found that for people over 75, the rate of mortality from falls more than doubled from 2000 to 2016 … ‘The most likely reason is that people are living longer with conditions that in the past they might have died from,’ [ said Elizabeth Burns, a health scientist at the Centers for Disease Control and Prevention, who was an author of the study]. In addition, she continued, older adults are on medications that increase their risk of falling. Women are slightly more likely to fall than men, but men are slightly more likely to die as a result of a fall.

The news article describes ways to protect yourself, and the preventive measures involve a little caution and a lot of common sense.

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