As an oncologist, Dr. Gwen Nichols is well versed in the life and death considerations of cancer patients of all ages. Below, she shares some of the special issues that elderly patients face as participants in the healthcare system.
What are the special risks of starting elderly people on new medications?
Side effects vary by the patient's age, and the severity of side effects also varies by age. Also, elderly patients are often on more than one medication, and interactions with other medications is a very important consideration in making treatment decisions. Problems with sleep, eating, and depression may be more relevant in older patients as well.
Elderly people often have more than one health condition requiring multiple medications. Do some drugs do more harm than good?
One of the most important issues for elderly patients is the high likelihood of developing heart disease. If a patient's new drug therapy has additional side effects-fluid overload, difficulties with heart function, abnormal heart rhythms, anemia-this can be devastating for someone who has a prior heart condition. Now that we have more successful therapies for a variety of medical problems and patients are living longer, it is common to see people who have more than one cancer or more than one medical condition at the same time in their seventies and eighties, so watching out for these problems is important.
It is often harder for elderly patients to get around. What problems does this pose?
Many of my older patients are living alone, and even getting your prescriptions can be much more complex for someone who isn't driving regularly or getting about easily. It's also often necessary for the patient to come back and forth for frequent testing, in order to make judgments about proper dosages of medicine. Often that's much tougher for elderly people, and these difficulties should be considered when making decisions about which therapy is best for an individual patient.
How does life expectancy affect treatment decisions?
Life expectancy means one thing at age twenty or thirty, and something very different at age seventy or eighty. Not that elderly people shouldn't expect a long and healthy life, but if they can be promised good, quality life and ten more years with a less drastic therapy, this is worth considering.
Elderly patients are sometimes too frail to undergo certain therapies. What is the psychological impact on an elderly patient who learns that he or she may never be eligible for the actual cure of a diagnosed disease?
Often the goals for an elderly patient are not necessarily to cure a disease. I think that quality and quantity of life issues, rather than the ultimate goal of cure, may be very much more relevant for an elderly patient. Most of my older patients want to be well enough to do the things that they've been waiting for retirement to do, and so the choices of therapy are based on these goals. Living a few years longer but feeling very sick during a good portion of that time often isn't the choice that older patients want to make. That's not to say that they shouldn't be offered all types of therapy; we shouldn't discriminate based on a chronological age, but all the factors that make up a treatment decision are based on what their goals are for their life.
I like to encourage patients who are not eligible for curative treatment to think about their disease in a different way. We have many good treatments for many conditions that we cannot cure. Like hypertension or diabetes or other potentially fatal diseases that have good treatments, patients with cancer may need treatment for the rest of their lives. But you can live a full life, even if you always have your disease. And there are many people who are living with all kinds of diseases that live very, very well.
Do you think that a person's loved ones influence decisions about therapy?
There's no question that many people are pushed to more aggressive therapies because their families want them to try to live longer out of their affection. But it's very important to make that decision without succumbing just to pressure from family members, because in the end, the decision will affect the patient more than anyone, and ultimately it is their decision.
What biases might doctors or other health professionals have against elderly patients?
Many physicians may feel that using a new medication in an older patient is just more difficult, because there are more potential side effects and it may be more difficult to do the testing you need to do to monitor whether the treatment is working. Often older patients don't have the same resources to be able to go back and forth and get the testing done. And yes, even reimbursement issues are different for the physicians, for the amount of time that they have to spend with an older patient versus a younger patient. So these are very real issues that may affect an older patient, and they're ones that most physicians don't like to talk about, but they clearly exist in the physician medical marketplace.
And sometimes physicians just assume that older patients don't want to be experimental research subjects. That they may want a simpler solution rather than a more complicated solution. But it's very important to learn about your patient's desires, and find out whether they fall into what we think is typical for an older patient.
We forget that there are lots of people who are in their seventies and eighties who are very healthy. Not every 75-year-old is the same, and it's very important not to just look at the chronological age, but the physiologic age when you're talking to a patient about their options for therapy.
