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How Old Is “Old”?

Date: April 5, 2024

I don’t know if this is factually true, but a long time ago I read a story about Eskimo culture several generations ago. Old women who were no longer of any use to the tribe were put on ice floes and allowed to drift away. I assume old men did not have to go through this ritual, since most of them probably got killed one way of the other before they got to be old men. For some reason, this image of an old woman on an ice floe got stuck in my mind.

I guess one of the ways we can define civilized society is by looking at the ways we take care of our weakest members. Babies are easy to love, they are such a wonderful bundle of hope and renewal. But I often wonder whether “old” people are short changed, even in advanced and affluent societies like ours. CLL is a disease that strikes more often in older people and often the burden of the disease and taking care of the victim falls upon children and sometimes grand-children. When is it appropriate to “advise” grandma to accept purely palliative treatment, instead of opting for therapy that may have more of an impact on the CLL and perhaps prolong her life several more years? When is it the right time to opt for hospice care and not put the old lady through more aggressive therapy? This is not a trivial question. Information is at the center of making good therapy choices and many of our older patients do not have quite the same access to on-line information. If the individual cannot make informed choices because of lack of access to the same resources you and I have, it becomes even more important that we act as honest brokers on their behalf, be their eyes and ears to the best of our ability.

The Medscape article below is troubling, because it suggests our cultural assumptions of what constitutes an old person drives medical decisions too many times. Americans tend to be an impatient lot and CLL is a frustrating disease to some of us because it is an indolent cancer. It is the constant drip-drip-drip of Chinese water torture, if you know what I mean. It neither kills right away nor can we cure it once and for all. Be sure that when you make therapy decisions, either for yourself or for a CLL patient you love, the decisions are not based on momentary impatience and frustration.

Be well,

Chaya
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Abstract

Medscape Article (You may have to register for Medscape before you can read the full article. Registration is free of charge and is definitely a useful thing to have.)

Aging, Frailty, and Chemotherapy

Posted 03/28/2007

Lodovico Balducci, MD

Background: In many cases, elderly individuals have not been offered life-saving interventions due to the assumption that these treatments would be too toxic to tolerate.

Methods: This article offers an overview of the biology of aging, reviews the assessment of an individual's physiologic age, and explores the medical definition of frailty and its implications in cancer treatment.

Introduction: The public perception of advanced aging involves the inability to survive alone due to chronic diseases and the combined loss of mobility, sensory functions, and cognition. This image of the older-aged individual, which has been cultivated in literature and figurative arts, has been called frailty, implying that the older person has limited tolerance of even minimal stress. From a medical standpoint, the classification of aging as frailty has been unfortunate. It has prevented life-saving interventions, including antineoplastic treatment, in older individuals on the assumption that these treatments would be too toxic to tolerate. Contrary to this prediction, the majority of older individuals appear to benefit from cancer treatment to an extent comparable to that of younger individuals,[1] and only a minority of these patients should be excluded from treatment due to reduced tolerance. Cancer is mostly a disease of the older-aged individual, and it is expected to become even more common with the aging of the population.[2] To ensure optimal treatment of the older cancer patient, it is important not only to dispel the impression that frailty is unavoidable but also to recognize that the older population is highly diverse, which requires individualized assessment and treatment plans. The management of cancer in the older-aged patient should be guided by individual estimates of life expectancy and functional reserve (ie,each patient's ability to benefit from and tolerate treatment) rather than by chronologic age.

Results: The definition of frailty is controversial. Rather than chronologic age, a more accurate assessment relies on individual estimates of life expectancy and functional reserve, including serum levels of interleukin 6 and D-dimer, the levels of a number of inflammatory cytokines, and the circulating level of C-reacting protein. Decision making for optimal cancer treatment in the older-aged patient benefits from a comprehensive geriatric assessment, a functional test, and a laboratory evaluation to determine a patient's life expectancy and functional reserve.

Conclusions: Most older patients appear to benefit from cancer treatment to an extent comparable to that of younger individuals, and only a minority of these patients should be excluded from treatment due to reduced tolerance.

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