Rise Seen in Medical Efforts to Treat the Very Old

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New York Times
Published: July 18, 2008
When Hazel Homer was 99, more than one doctor advised that there was little to be done about her failing heart except wait for it to fail a final time. But Mrs. Homer was not interested in waiting to die of what many would call old age.

Now, at 104, her heart is still ticking, thanks to a specialized pacemaker and defibrillator that synchronizes her heartbeat and can administer a slight shock to revive her if her heart falters.

Her operation, a month before her 100th birthday, reflects what some doctors are hailing as a new frontier in medicine: successful surgery for centenarians. But others say that such aggressive treatment for what are euphemistically known as the late elderly can be wasteful and barbaric, warning that the rush to test the limits of technology can give patients false hope and compound their health challenges with surgical complications.

“She’s just a peek into the future,” said Dr. Steven M. Greenberg, a Long Island cardiologist who performed Mrs. Homer’s surgery, for which the average Medicare reimbursement at the time was $35,000.

Data is hard to come by, since people over 75 are scarcely represented in clinical trials, but several geriatricians said that procedures that two decades ago were seldom considered for people in their 90s are now increasingly commonplace. They include hip and knee replacement, cataract surgery, heart valve replacement, bypass operations, pacemaker implantation and treatment for slow-growing cancers that afflict areas like the prostate.

According to the Census Bureau, there were 90,422 centenarians in America in June, up from 50,454 in 2000, and demographers project there could be 1.1 million by 2050. As for 104-year-olds, the Social Security Administration said that 2,114 of them currently receive benefits.

With such rapid growth of centenarians, debate has mounted over how far to go “” not to mention how much Medicare money to spend “” in providing major medical services to extend already very long lives.

Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, which has studied the last two years of life, said there is much research suggesting that most aggressive treatment of late-stage chronic diseases does not actually prolong life and can actually decrease its quality. Of Mrs. Homer, Dr. Goodman said, “the odds are that she’s really an amazing exception.”

“The question is not a relatively healthy, smart, sensible 99-year-old getting a life-prolonging procedure, one that prolongs the quality of life,” Dr. Goodman added. “The question becomes the 82-year-old with dementia who has cancer or congestive heart failure.”

Bruce Nudell, a senior health care analyst at UBS, said that the defibrillator would likely not have been approved in Europe, adding: “America always tends to overtreat the sickest people.”

But Dr. Tom Perls, founding director of the New England Centenarian Study at Boston University Medical Center, said that people who reach 100 “have demonstrated a survival prowess.”

“It’s much more the case of the older you get, the healthier you’ve been,” Dr. Perls said. “In my experience, when they’re completely cognitively intact, you cannot in any way or form predict their mortality.”

Dr. Greenberg, a cardiologist at St. Francis Hospital in Roslyn, N.Y., said that Mrs. Homer, who has a live-in aide at her tiny bungalow perched on a canal in East Rockaway, N.Y., is his oldest patient, and one of a handful of people her age who have received this type of heart device nationwide. But he said that he has implanted about two dozen devices like hers in patients 90 or older over the past five years.

He also counted among his patients a 93-year-old “with a full head of hair” who got a defibrillator in his 80s and was still practicing law, as well as a man in his early 90s who just had a bypass operation and was still working as an architect.

Dr. Robert E. Michler, chairman of cardiothoracic surgery at Montefiore Medical Center in the Bronx, said that several years ago, while at Ohio State University Medical Center, he performed what is known as “off-pump” heart surgery (performed without using a heart and lung bypass machine) on a 94-year-old woman who had been turned down for the operation at another hospital. Here in New York, Dr. Michler has replaced an aortic valve in a 97-year-old man (who three weeks before had married a 63-year-old woman with her heart valves intact).

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