Like most podiatrists, a large portion of my practice revolves around care for older patients. In fact, I’ve fallen somewhat into the niche of diabetic limb preservation which, in many cases, deals with older patients. I hesitate to use the word “elderly” here because the definition of that word is entirely too subjective. Besides, I can only imagine the hate email I’d receive from certain members of our community on the cusp of receiving a certain government health insurance plan that shall remain nameless. In fact, that is just the problem I’d like to discuss with today’s Practice Perfect: the subjectivity of treating the “advanced aged.” What age is too old to do surgery? Is there an age cutoff after which only nonsurgical care is appropriate? Is it ageist to determine care based strictly on chronological age?

I can recall two specific patients of advanced age from my practice which elucidate this situation. On the one hand I performed a second toe amputation on a 93 year-old female with worsening cellulitis and osteomyelitis. On the other, I performed a first MTP joint fusion on an 82 year-old female. Now, in both cases I was supremely cautious and considered my choice of procedures and perioperative planning very carefully (more so in the second patient – the first had few choices).

As in all surgery it’s the details that matter. My 93 year-old patient was physiologically her chronological age but with a worsening infection that without surgery would have potentially lead to her death. It was beyond a quality of life issue. On the opposite side of the health spectrum, my 82 year-old patient physiologically appeared to be in her late 60’s. She had a painful end stage hallux valgus that had previous unsuccessful surgery with significant residual pain that affected her quality of life. Incidentally, I chose a fusion because of her large intermetatarsal angle, end-stage disease, and active lifestyle. I used an interfragmentary screw and plate to allow early weightbearing with a walker assist.

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Here’s my simple conclusion about age: it doesn’t matter. Our job as physicians is not to pass judgment on patients based on their age (just as it’s not appropriate to judge based on sex, race, creed, or color). Our job is to present our patients with all of the reasonable treatment options and assist them with our knowledge and experience to make their own decisions to improve their quality of life. If that means scheduling surgery at 80 or 90 years-old then so be it.

I do think, though, the surgeon has considerable influence over his or her patients and needs to consider this responsibility and some important factors when determining a treatment plan.

1. Understand the differences in this age group from the average patient.  Remember the phrase “children are not small adults?”  The same is true for the advanced aged. An 80 year-old has a different physiology than a 45 year-old with different medical considerations. 
2. Realize it is not always about optimal function but often quality of life.  The textbook approach often fails when it hits these patients in the real world.
3. There’s no crystal ball.  No doctor can determine the life expectancy of his patient.  You just can’t tell a patient a surgical procedure is not possible simply on the basis of their age.  That patient may have one year or ten years, and your surgery may improve the quality of that one or ten years, and who are you to say that is not significant and worthwhile for that patient?
4. Know your patient.  Each patient must be evaluated fully, considering all potential perioperative and postoperative issues.  That 82 year-old may be healthier than the 55 year-old you’ve already scheduled for surgery.  Know them well and anticipate the complications.

As in all things in life balance is the key.  As medical science progresses, our patients will live even longer lives and experience pedal issues much later into life.  We’re also likely to see worse deformities with the potential for more complex reconstruction that will push our creativity.  Either way, sticking to the principles of quality patient care will lead to improved quality of life for all of our advanced-age patients. 

What do you think?

GET IN ON THE DISCUSSION There are several eTalks topics taking place right now on PRESENT Podiatry. Get in on the discussion, or start one of your own.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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