Rise Seen in Medical Efforts to Treat the Very Old

By ANEMONA HARTOCOLLIS
18 july 2008--When Hazel Homer was 99, more than one doctor advised that there was little to be done about her failing heart except wait for it to fail a final time. But Mrs. Homer was not interested in waiting to die of what many would call old age.
Now, at 104, her heart is still ticking, thanks to a specialized pacemaker and defibrillator that synchronizes her heartbeat and can administer a slight shock to revive her if her heart falters.
Her operation, a month before her 100th birthday, reflects what some doctors are hailing as a new frontier in medicine: successful surgery for centenarians. But others say that such aggressive treatment for what are euphemistically known as the late elderly can be wasteful and barbaric, warning that the rush to test the limits of technology can give patients false hope and compound their health challenges with surgical complications.
“She’s just a peek into the future,” said Dr. Steven M. Greenberg, a Long Island cardiologist who performed Mrs. Homer’s surgery, for which the average Medicare reimbursement at the time was $35,000.
Data is hard to come by, since people over 75 are scarcely represented in clinical trials, but several geriatricians said that procedures that two decades ago were seldom considered for people in their 90s are now increasingly commonplace. They include hip and knee replacement, cataract surgery, heart valve replacement, bypass operations, pacemaker implantation and treatment for slow-growing cancers that afflict areas like the prostate.
According to the Census Bureau, there were 90,422 centenarians in America in June, up from 50,454 in 2000, and demographers project there could be 1.1 million by 2050. As for 104-year-olds, the Social Security Administration said that 2,114 of them currently receive benefits.
With such rapid growth of centenarians, debate has mounted over how far to go — not to mention how much Medicare money to spend — in providing major medical services to extend already very long lives.
Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, which has studied the last two years of life, said there is much research suggesting that most aggressive treatment of late-stage chronic diseases does not actually prolong life and can actually decrease its quality. Of Mrs. Homer, Dr. Goodman said, “the odds are that she’s really an amazing exception.”
“The question is not a relatively healthy, smart, sensible 99-year-old getting a life-prolonging procedure, one that prolongs the quality of life,” Dr. Goodman added. “The question becomes the 82-year-old with dementia who has cancer or congestive heart failure.”
Bruce Nudell, a senior health care analyst at UBS, said that the defibrillator would likely not have been approved in Europe, adding: “America always tends to overtreat the sickest people.”
But Dr. Tom Perls, founding director of the New England Centenarian Study at Boston University Medical Center, said that people who reach 100 “have demonstrated a survival prowess.”
“It’s much more the case of the older you get, the healthier you’ve been,” Dr. Perls said. “In my experience, when they’re completely cognitively intact, you cannot in any way or form predict their mortality.”
Dr. Greenberg, a cardiologist at St. Francis Hospital in Roslyn, N.Y., said that Mrs. Homer, who has a live-in aide at her tiny bungalow perched on a canal in East Rockaway, N.Y., is his oldest patient, and one of a handful of people her age who have received this type of heart device nationwide. But he said that he has implanted about two dozen devices like hers in patients 90 or older over the past five years.
He also counted among his patients a 93-year-old “with a full head of hair” who got a defibrillator in his 80s and was still practicing law, as well as a man in his early 90s who just had a bypass operation and was still working as an architect.
Dr. Robert E. Michler, chairman of cardiothoracic surgery at Montefiore Medical Center in the Bronx, said that several years ago, while at Ohio State University Medical Center, he performed what is known as “off-pump” heart surgery (performed without using a heart and lung bypass machine) on a 94-year-old woman who had been turned down for the operation at another hospital. Here in New York, Dr. Michler has replaced an aortic valve in a 97-year-old man (who three weeks before had married a 63-year-old woman with her heart valves intact).
And then there is Dr. Michael E. DeBakey, the pioneering heart surgeon who died Friday at age 99. Two years ago, Dr. DeBakey underwent an aortic-dissection repair procedure that he himself had long before devised — but only after doctors in Houston convened an ethics committee to decide whether it was appropriate.
Mrs. Homer did not receive a regular pacemaker, which is fairly common, but a biventricular defibrillator, which synchronizes her heartbeat and can automatically shock her to save her from a fatal arrhythmia. (So far, her doctor said, the shock has never been delivered.) In 2007, about 55,000 people received such combination devices according to Dr. Greenberg, a consultant to the three main manufacturers of the device, who estimated that people 90 or older accounted for fewer than 100 of the devices.
Dr. Karen P. Alexander, an associate professor of cardiology at Duke University, said the defibrillator might go too far. “Many people say that would be a nice way to go when you’re 100: to be sleeping and have your heart stop,” she said. “The defibrillator component would very possibly prevent that.”
Mrs. Homer’s cardiologist, Dr. Gary R. Friedman, said that without the operation, he did not expect her to live past 100. She turned 104 on April 27.
Before a heart attack at 95, her only previous hospitalization had been during the birth of her daughter, Jane Sturm, now a robust 81.
But over each of the next four years, Mrs. Homer, who has three granddaughters and a great-grandson, was hospitalized nearly every other month, for heart failure and fluid in her lungs. Mrs. Sturm said her mother would emerge each time weaker than when she was admitted.
But even at 99, Mrs. Homer loved life and did not think of herself as sick. After one cardiologist’s office turned her down for surgery because of her age, Mrs. Sturm, a retired school guidance counselor, retorted, “That’s too bad, because her main concern coming over here was, was her skirt flared out enough.”
Dr. Greenberg was reluctant to perform the operation at first.
“You get a lot of criticism for doing this sort of thing,” he said. “People say it’s not cost-effective, she’s going to die anyway. That’s a fact you deal with in every patient, but particularly in the elderly.”
Dr. Greenberg admits he “wouldn’t have wanted to advertise” the operation on Mrs. Homer immediately afterward, when it was unclear how long she would survive. Now he argues that the operation, which was covered by Medicare, cost less than repeated hospitalizations for heart failure. “People pay more for their BMW, which will not save their life,” Dr. Greenberg said.
Dr. Friedman said Mrs. Homer’s heart is much stronger since the operation, and that her health is generally good — akin to that of, perhaps, a 94-year-old. Her only hospitalization since the procedure has been a brief stay for pneumonia, he said.
“She might have passed away in 2004, so theoretically Medicare wouldn’t have been putting a lot of money out,” he noted. “But our goal, as a society, hopefully, is quality of life with some kind of cost we can afford.”
Until four years ago, Mrs. Homer lived alone in the East Rockaway bungalow, with its plant-filled sunroom overlooking a grassy backyard and a canal filled with small boats. She and her daughter had moved there, joining Mrs. Homer’s parents, during the Depression, after she and her husband, a traveling salesman, split up.
A framed 100th birthday card from the White House sits in a place of honor on an antique side table (watching “Antiques Roadshow” on PBS is one of Mrs. Homer’s pleasures).
She told how her father had sent her to secretarial school, and how she paid rent to her parents by working as a stenographer. (She retired in 1961.)
She showed off the pink polish on her fingers and toes, marveling that her aide, Roz Simpson, cared enough to give her a manicure and pedicure. She admitted that she had a passion for ice cream in the afternoons. And she complained that her family had switched her old bed for a hospital bed.
Mrs. Homer kept up a tart banter, chiding Mrs. Sturm for not visiting enough. “Lord knows when I’ll ever see her again,” she said, slyly.
She said she never greeted guests in a bathrobe, and always matched her earrings to her outfit. “I’m always dressed,” she said. “I don’t dress quite as fancy, but I have a skirt and blouse on every day.”
She did not seem to mind her wheelchair or her faulty vision and hearing, but her missing teeth are a bother because, she said, “I can’t talk right.”
Mrs. Homer was more circumspect about her age, first saying it was 94, then joking that she was 110, and ultimately saying, “Your age, that’s nobody’s business.”
Asked what she liked most about her life, Mrs. Homer said simply: “That I’m alive, I guess. That’s the big thing. That I’m alive.”