YOU ARE NEVER TOO OLD TO HAVE SURGERY
Those in their 80s, and beyond, are by far the major beneficiaries of modern surgery, as it is increasingly recognised that there is no longer an age limit on surgical intervention.
The origins of this shift in perspective can be traced to the publication in 1993 of an article in the New England Journal of Medicine under the heading: “Too Old for What?”
This “exercise in clinical problem solving” concerned an “independent and active” 87-year-old woman who consulted her doctor with increasing breathlessness. This, it transpired, was due to a combination of having a tight aortic valve (aortic stenosis), together with marked narrowing of her coronary arteries. It was, in short, astonishing she was still alive.
There was no alternative, if something was to be done, other than open heart surgery. This would involve splitting her sternum, opening up her heart and replacing the aortic valve, while also bypassing the narrowing of the coronary arteries with vein grafts taken from her leg.
This was duly carried out, following which, she developed kidney failure, wildly fluctuating blood pressure, severe abnormalities of heart rhythm and other complications requiring three months in intensive care. But she survived and once back home “resumed her active social schedule” with the prospect of a further life expectancy of at least five years.
The die was cast. In the aftermath of “Too Old for What?”, the issue, when confronted by the dilemma of whether to perform heroic heart surgery on an “independent and active” 87-year-old, was no longer “Should we?” but rather “Why shouldn’t we?”
Thirty years on her options are vastly better still. Rather than gruelling and traumatic open heart surgery, she would have a valve implant (or TAVI), where a thin catheter inserted into an artery in the wrist is manoeuvred upwards to the heart, through which the replacement valve is inserted.
Those narrowed coronary arteries are more of a challenge and would, until recently, have required bypass grafts. But it is now reported that a sophisticated form of angioplasty – to dilate the coronary arteries from within – together with a stent to restore blood flow to the heart muscle, can be performed at the same time as the valve implant. If all goes well she could return home the same day.
There is a welcome new alternative to the usual sleeping pills
Further to doctors’ reluctance to prescribe sleeping pills (such as zopiclone) long-term to those afflicted with chronic insomnia, due to dependency, Professor Guy Leschziner, consultant neurologist who specialises in sleep disorders, draws attention to the merits of a novel form of drug treatment that avoids this hazard.
The intriguing back story starts with a discovery by researchers investigating the phenomenon of excessive daytime sleepiness (EDS) in Doberman Pinschers (to which they are particularly prone). This is due to a deficiency in the neurotransmitter orexin, whose primary function is to maintain wakefulness.
This might seem of little practical utility to humans until, in a masterful exercise in lateral thinking, it was suggested that designing a chemical to block the orexin transmitter might, by countering wakefulness, induce sleep in those with chronic insomnia.
And so it has turned out. At a seminar on Recent Advances in Medicine, Prof Leschziner reviewed the evidence that Daroxident (as orexin is known) markedly improves both the quality and duration of sleep by, on average, an extra hour.
There is no impairment of daytime functioning – a feature of drugs such as zopiclone – nor does dependence seem to be an issue, as its discontinuation is not followed by rebound insomnia.
Side effects – headaches, dizziness and low mood are reported to be “minimal”. Approved by the health watchdog NICE, it is now available on prescription.
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