Observations: The Same Old Game?

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July 1, 2013 Volume 77, Number 7
Observations: The Same Old Game? N. Martin Giesecke, M.D. Editor, ASA NEWSLETTER

If we live long enough, most of us become accustomed to the sight of seeing one’s parents age. And then we become familiar with the view in the mirror, assuming we don’t develop macular degeneration or some other form of senile blindness, as we ourselves grow older. Even though most of us expect to age, it is still difficult to watch oneself, one’s friends, parents and spouses reach that age where the invisible line between health and infirmity is crossed.

As mentioned by Dr. Azocar on page 12 of this NEWSLETTER, the number of elderly in our population is growing at an alarming rate.1 There are at least two reasons for this. Probably the biggest factor is that the first group of baby boomers, born in 1946, has already reached the age that many of us once thought signified retirement – 65 years old. A second reason for the rapid growth in the geriatric population is the fact that people are living longer. And as pointed out by Dr. Azocar, just because we are living longer does not mean we are living healthier, as the age group including those 65 and older has seen a significant increase in the number of hospital days used compared to four decades ago.1

Unless we are pediatric anesthesi-ologists, we are seeing more elderly patients in our practices. Pediatric anesthesiologists cringe, and rightly so, when they hear someone remark that giving an anesthetic to a child is just like giving one to a small adult. And though most of us realize that analogy is misguided, so too is the analogy that caring for a geriatric patient is the same as caring for a 50-year-old. There are well-known physiologic derangements that occur with age, from pulmonary to musculoskeletal, from central nervous system to cardiovascular to digestive. But caring for these patients is not the same old game. For instance, since I graduated from medical school we have enriched our knowledge and understanding of cardiac dysfunction in the elderly. Diastolic dysfunction is now a well-respected condition; when I entered residency, it was likely only considered when deep-thinking cardiac physiologists gathered to discuss their work.

And with the growth in this segment of the population, will we be able to meet the challenges that inevitably arise as hospitals become full of patients of advanced age? Will there be enough geriatricians? Or will geriatricians even come to the hospital? Will there be enough hospitalists who understand what it is to care for this patient population? Certainly, our Society is engaged in this elemental change to medicine. But even as we become perioperative, geriatric specialists with-in the Surgical Home, will there be enough anesthesiologists out there to fill the need?

I have to admit that my own personal experience, at least as I watched the hospital care received by close family members, is that medicine is not ready for the onslaught of elderly patients. As planned, when a male relative recognized that his death was imminent, he told the doctors caring for him that he was ready for hospice care. But none of the doctors who cared for him in the hospital had known him long-term, so they were unsure of his commitment to hospice care. Thus, in my estimation, they were treating him as a 50-year-old who had much life still to experience. They certainly were not treating him like a near-octogenarian who had come to accept his looming death as a welcome part of the journey on this earth. And it took me persuading his internist, who had known this relative of mine for many years, to visit with the team at the hospital to get them on board. Then there is the care given a female relative, who had severe dementia. Sometimes she was so heavily sedated while in the hospital to repair a hip fracture that it seemed as if this course of therapy was chosen solely as a means to keep her quiet and still, so the hospital staff could focus their efforts on other (more?) meaningful tasks.

Maybe, though, my experience was just based upon the jaundiced view of a hospital-based physician (me). Perhaps none of my other family members saw things the same way. Maybe they saw this matriarch of the family resting peacefully. All I’m trying to say is that we still have a long way to go in learning how to care for this geriatric group of patients who will be spending more time in our hospitals. We need to keep that in mind as we evaluate how best to arrange the available resources for the future health care of our nation. Do we continue, as a public, to push end-of life-care to its financial limits, or do we sit back and realize that the matriarch has had a great life? She doesn’t need a percutaneous feeding tube to prolong her time on this earth after a stroke, or escalation of her dementia, took away her ability to swallow. And we, as a public, don’t necessarily need to pay for that percutaneous feeding tube.

One thing is certain: medicine is changing. And it certainly won’t be the same old game.

1. Azocar RJ. What is new with the old? ASA Newsl. 2013;77(6):12.