Cardiovascular Disease in the Octogenarian and BeyondBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7189.1015 (Published 10 April 1999) Cite this as: BMJ 1999;318:1015
Nanette K Wenger
Martin Dunitz, £75, pp 456
ISBN 1 85317 581 1
Old age could be defined as that time when you may be deprived of beneficial services simply because of your years. Old age is also the time when your treating cardiologist ought to be considering many factors in addition to simply your cardiac function. An octogenarian qualifies as old on both counts. Defining old as 80 years and over is a bold move, given that many authors writing on system diseases in elderly people extrapolate evidence from those aged 50 and over, a tendency that is particularly alarming to pentagenarian geriatricians.
There is good reason to know something about heart disease in this population. Disability in an 80 year old person is as likely to arise from cardiovascular diseases as any other cause, and the expected further 8-9 years of life are as likely to be terminated by cardiovascular disease as any other cause. A book on the subject, though, has got to answer some fundamental questions. Is there any evidence about heart disease in those aged 80 and over, and is there any evidence of benefit from treatment? Does the elderly person actually want the treatment, and, if so, is society willing to pay for it?
The evidence of benefit from active treatment exists and is excellently set out in this comprehensive text. The older the population studied, the more events prevented per number of people treated. This applies to interventions as different as treating systolic hypertension and using tissue plasminogen activator rather than streptokinase after myocardial infarction. The greater benefit is a consequence of the greater number of events occurring. But even in cardiac rehabilitation and exercise programmes, older people show the most dramatic improvement in exercise capacity.
The evidence of benefit is encouraging; the evidence that elderly people are failing to receive the treatment is not. Older people are less likely than younger people to receive beneficial treatment and are less likely to receive thrombolytic treatment or β blockers after myocardial infarction. Some of the decreased use may be explained by delayed or atypical presentation or by comorbid conditions providing contraindications or an increased risk of adverse effect. The lower use of aspirin or cardiac rehabilitation in older people, though, is a little more difficult to explain away.
Perhaps older people do not want the intervention. After all, isn't it quality of life rather than quantity that is important for this age group? A study published in 1998 suggests that very elderly (80-98 years old) hospitalised patients would prefer increased quantity of life in their present state of health to a shorter time in excellent health. It is always impressive when a text cites a paper from its year of publication, especially when the paper shakes some commonly held, comfortable assumptions.
There is a fine balance between therapeutic nihilism and therapeutic futility when treating elderly people. Clear, thorough, and comprehensive texts such as this help to get the balance right.