JRSM >
Volume 94, Number 7 >
Pp. 370-371
Medicine for the Elderly, Forester Hill Health Centre, Aberdeen AB25 2AY, Scotland, UK
The paper by Miss Farquharson and colleagues caused me considerable concern. In terms of study design, my fundamental objection is that, although the authors claim that their new ‘star rating’ scale can be equated with biological age, they present no evidence to this effect. They acknowledge that biological age is a multidimensional concept, but they then go on to propose a unidimensional scale containing five categories. The reference they quote in support of their five-point scale having anything to do with biological age is an abstract which simply reproduces the contents of Box 1 in the present paper. It would appear to me that all references to biological age should be struck from the paper, and that we should simply regard the publication as a proposal that a new five-point ‘starring’ system should be used when referring older people for surgery.
Even if the paper is rewritten in these restricted terms, however, a number of disquieting features remain. The star rating proposed in Box 1 is heavily value laden, and the values that are implied (none are actually made explicit) will trouble many old people, their relatives and their doctors. From Box 1, it would appear that cognitive impairment in a patient features very large in the surgical decision-making process of Farquharson et al., as even a mild degree of mental deterioration is enough to lose a patient one or more star grades. Because Table 1 indicates that a loss of even a single grade is likely to be translated into denial of surgical intervention for large numbers of older people, this point cannot go unchallenged, especially as the authors offer no evidence to support their proposal. The second main factor that appears to feature in Box 1 is loss of independent living. It would seem that the requirement to have another person to help you with the activities of daily life is enough to demote you from four-star to three-star status, and entry to a residential home puts you down a further grade, with the associated surgical intervention rate falling from 42% to 26%. A third factor that appears influential in Box 1 is related to the authors' personal views on what is a ‘reasonable’ set of interests and activities for an individual human being to undertake. It would seem that a restriction of interests to ‘family and television’ leads to a loss of star status even though these are major pastimes for the majority of young and old people in the UK (including many doctors after a hard day at work).
Box 2 gives more detailed insights into the authors' attitudes when faced with individual older patients, but raises even more concerns. What is the relevance of whether a person is deaf (with or without a working hearing-aid) when a decision is being made about the risks and benefits of potentially life-saving surgery? What aspects of ‘biological age’ are the authors trying to illustrate through their discussion of wheelchair use in their three-star patient? This patient is about to be ‘marked down’ a star rating because he created a poor initial impression by arriving in a wheelchair, but then it turns out that he has just borrowed it for the day, so his star status is preserved. Many people with a disability, who may or may not use a wheelchair, would resent the implication that wheelchair ownership is a natural factor to be incorporated into a surgical risk assessment system. Farquharson et al. might claim that they are simply trying to assess the functional status of the patient by asking about wheelchair use, but there are many existing validated scales that could do this for them and one of the fundamental duties of anyone who proposes a new assessment scale is to check out scales already in existence.
The authors' preoccupation with minor cognitive dysfunction is again evident in Box 2. As a doctor who works daily with older people, I frequently encounter patients with cognitive dysfunction who are otherwise very fit and are more contented with life than many younger people. If such patients have a treatable surgical condition that is threatening their very existence or their quality of life, why should they be denied surgical treatment provided that the relatively small probability of significant post-operative cognitive decline is taken into account? Even in the case of the one-star patient in Box 2, in whom an examination ‘appears to cause distress’, perhaps the quickest way to relieve the distress in some situations would be to treat the underlying surgical problem.
I am sure that Farquharson et al. would agree with me that any patient of any age with a potentially treatable surgical problem deserves an individual assessment to try to establish the potential risks and benefits of an operation. Such an individualized assessment might well take into account multiple factors such as functional status, comorbidity, cognitive function, and leisure activities, and at the end of this assessment process the patient and surgeon might decide surgery is not desirable. However, because of the limitations referred to above, I feel that the five-star grading system proposed in the paper would actually be detrimental to an individual assessment. If the authors feel otherwise, they will need to embark on the protracted and arduous process required when any new scale is being developed for clinical use2.
REFERENCES
Colorectal Research Unit, North Hampshire Hospital, Basingstoke RG24 9NA, UK
We are delighted at the interest shown in our paper by Dr Jolobe and Professor Seymour and agree with both correspondents that all patients, whatever their age or physical or mental handicap, deserve individual assessment of the potential risks and benefits of any surgical or medical intervention.
We were, however, saddened by Professor Seymour's criticism of our attitude to older patients, and in particular his implication that we are somehow denying elderly patients appropriate surgical treatment on the basis of a hearing-aid or the use of a wheelchair. The hearing-aid and the wheelchair were only part of the description of the circumstances of the hypothetical patients described in Box 2, and used to test a hypothesis that surgeons consider physical, mental and social factors in addition to chronological age and medical co-morbidity when striving to make the best decision for an elderly patient.
As general surgeons we too work daily with older people, and many of those on whom we operate are in their 80s and 90s. We are aware that some patients are in advanced old age in their 70s and others not until nearly 100. It was this anomaly that we were trying to address when using the phrase ‘biological age’ and must apologize if our understanding of its definition was inaccurate. The star rating scale is simply a measure of the physical, mental and social limitations advancing age has placed on an individual. We are not preoccupied with cognitive dysfunction. It is merely taken into consideration, alongside physical independence and social functioning, to which Professor Seymour also objects.
We no more ‘demote’ patients by describing them as ‘old for their age’ than by describing a mature child as a ‘post-pubertal eleven-year-old’. We do not make value judgments in our paper. The paper only addresses whether the physical, mental and social limitations associated with advancing age, as distinct from chronological age itself, are influential factors for a surgeon trying to make the right decision for a patient.
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