Back to the Future? Please, no more studies “in the elderly”!
Shane O’Hanlon is a geriatrician and digital media editor for the British Geriatrics Society. He tweets @drohanlon Zoe Wyrko is a geriatrician and workforce lead for the British Geriatrics Society. She tweets @geri_baby
Sometime back in the 80s, when we were both nippers, Marty McFly got the chance to travel 30 years into the future and see how the world would change. Around this time in the medical literature it became common to take an interesting concept and tag “in the elderly” onto the end of it. Back then, we had articles on burns, epilepsy, even blunt chest trauma “in the elderly”. It was generally accepted that once you hit 65, *everything* changed. Suddenly you would be most unlikely to have surgery, palliation became the default, and you were fairly much on your way out. Because, after all, while nobody would ever dream of grouping neonates up to 40 year olds (the age we have just reached) into one group, surely it is acceptable to assume everyone from 65-105 is identical?
If we had been geriatricians at the time (think Doogie Howser, but with a cardigan and MDT) we would have expected that the future would see the end of the idea of an “elderly patient”. We might have predicted that doctors everywhere would appreciate [the actual fact] that older people are a very diverse group. That age was just a number and – yes – although it’s associated with comorbidity, you will see some 100 year olds in excellent health and conversely some 50 year olds in very poor health. We would have expected that the concept of frailty would be well established. The simple idea that everyone has a different reserve and that this is worth measuring. That people would have an individual assessment. Rather than just treat everything differently once you reached 65.
Climbing out of the DeLorean, how we would have cried to see where we are today. Already this year we have seen articles on distal radial fractures “in the elderly” (No! Not the orthopods – they work with geriatricians every day!), gait disorders, fall injuries and hip fractures in the elderly (orthopods: we told you already!)… Last year gave us neurological emergencies, combined inguinal hernia, even perineal tap water burns in the elderly (what?)… We fail to see how age is still considered to be so important in the medical literature. Our message as geriatricians is that if you rely wholly on age you will miss some very fit people, and you will intervene on some very unfit people. What is worse, age is used as a widespread exclusion criterion in many clinical trials and very few consider frailty in their trial population. As liaison geriatricians we work with colleagues in orthopaedics, surgery, cardiology, oncology and other specialties to ensure they receive the necessary support to offer their patients CGA when necessary.
We take “An 85 year old nursing home resident” and turn them into “A fit, independently mobile cognitively intact lady who is suitable for consideration for surgical resection of her synchronous localised bowel and renal tumours”. So come on everyone! Stop doing trials and articles of stuff “in the elderly”. Understand frailty. If you don’t understand it, ask a friendly geriatrician.
For although we are mouthing off in this article (it gets more people to read it, you see) in reality we are very happy to explain this stuff. That frailty is measurable. That it is dynamic. That you can optimise people. That it is worth taking the fairly small amount of time to think about frailty with every patient you see. That people who believe frailty just means you are thin or cachectic need to be educated. That clinical trials need to include people of all ages and not have silly age cut offs or talk about “elderly patients” like they are a different species. When the inevitable reboot of Back to the Future is announced, we hope as they travel a further 30 years into the future that age is well down the list of patient factors, and that people get the individual assessment they deserve. As one enlightened neurosurgeon said back in 1987, “these benefits should not be denied to patients simply because they are old”.
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