Poor inpatient care for older people

Dear Sir,

We carefully read the very interesting editorial "Poor inpatient care for
older people", (1) which was published in the BMJ.
In spite of our condition of underdeveloped country, Cuba is facing a
quickly population aging process. The demographic transition, that
occurred in about one hundred years in developed countries, did so in
Cuba, in only several decades. In 2009, life expectancy at birth was 78
years, infant mortality 4.7 per 1 000 live births, natality was only 11.6
per 1 000 inhabitants, and the proportion of persons at 60 years and over
in the population was 17.4%. Furthermore, the group of 80 years and over
is the people segment that faster increases its proportion year after
year. (2) Health care for these "oldest old" persons is one of the main
task that our hospitals face nowadays.

Surgical interventions in very old patients, requires balancing pros
and cons, the costs and benefits of their convenience. Many factors
should be taken into consideration in the final decision to operate or
not, the same that are included in the comprehensive geriatric assessment,
the clinical method applied to geriatric patients. (3)
When the discussion is about elective procedures, the inclusion of a
geriatrician in the team is always desirable. However, the great majority
of surgical interventions practiced in the 80 years and over patients are
urgent ones, many of them during duty hours, and in those cases, surgeons,
anesthesiologists, patients and relatives have to assume, in short time,
not only the decision to operate or not to operate, but when and which
type of intervention. At those moments, if the doctors who are involved
are not trained in a geriatric approach, fatal consequences could happen after the operation. Maybe the surgical results are good from the
technical point of view, but the general result for the older patient
could not be so. As Parker and Conroy wrote, factors such as nutrition,
comorbidities, incapacities, and especially a previous diagnosis of
frailty, are determinants on the final result of major surgical procedures
in these cases. (1)

Also we agree with them that basic geriatrics is needed for all medical
professionals, and the pre and postgraduate education programs have to
include these contents. But not only knowledge, also training about these
topics. (3,4)

Fortunately, at least in Cuba, now it is a thinking of the past the idea
in the majority of medical doctors, that a patient at advanced age is
near to death, adducing that the elder has no options and his or her
admission to some services of the hospital -including intensive care and
operating theatre- is forbbiden. (4) This is another reason to impulse the
appropriate use of scarce financial resources in adequate perioperative
care of the oldest old, in times of economic crisis.

Prof. Alfredo Espinosa-Brito, MD, PhD;

Prof. Angel J. Romero-Cabrera, MD, PhD;

Prof. Alfredo Espinosa-Roca, MD, PhD;

Ass. Prof. Marta Casanova-Gonzalez, MD, M Sc;

Yenisei Quintero-Mendez, MD, M Sc

References

1. Parker SG, Conroy S. Poor inpatient care for older people. BMJ
2011; 2011; 342:d373

2. M?s P. Addressing Cuba's Aging Population: Why Epimapping Needs to Go
Local. MEDICC Review 2011;13(1):56.

3. Espinosa Brito AD, Romero Cabrera AJ. Evaluacion geriatrica: Metas,
metodo e implementacion. Rev Asoc Colom Gerontol Geriatr 2008;22(3):1184-
91.

4. Romero Cabrera AJ. Perspectivas actuales en la asistencia sanitaria al
adulto mayor. Rev Panam Salud Publica 2008;24(4):288-94.