I will start by mentioning that clinical experience and intuition came before evidence based medicine. This being said I would like to point out to the fact that more and more of our patients are ( and will be ) nonagenarians and they may represent an age group with distinct bio-psycho-social characteristics. Should we define them as a distinct group ? Could you , dear colleagues indicate publications devoted to this subject ?
Dear Dr. Leibovitz.
Perhaps these attached references may be helpful.
Sincerely.
Article Caring for Older Americans: The Future of Geriatric Medicine
Article Toward the realization of a better aged society: Messages fr...
Dr. Leibovitz,
Gerontologists have defined a segment of the population who are over 85 years of age as the 'oldest-old' and also consider biological and social age as more important than chronological age. As such, quality of life remains an issue for adults in their nineties due, primarily, to the pitfalls of the Western culture with respect to current healthcare and social prescriptions for elders. Below is a citation and an attached link to an article that addresses these issues. A new way of thinking is necessary to create proper legislation for adequate medical care and medical education of healthcare professionals and healthcare providers.
Bennett, J., Flaherty-Robb, M., (May 31, 2003). "Issues Affecting the Health of Older Citizens: Meeting the Challenge". Online Journal of Issues in Nursing. Vol. 8 No. 2, Manuscript 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No2May2003/OlderCitizensHealthIssues.aspx
- Joan A. Vaccaro, PhD
http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No2May2003/OlderCitizensHealthIssues.html
Dr. Leibovitz, as I understand it, the death rate increases after age 70 but for those surviving past age 85 or so, the death rate temporarily doesn't increase as fast. In other words, the oldest survivors are healthier and once they reach age 90, they have a better chance of reaching age 100 than do most people who are age 80! So yes I would say that the 'healthy' nonagenarians are somewhat of a special group, are healthier than many people in their 70s and 80s, and are more active socially and physically. It is difficult to say if it's possible to predict who they are before they reach their 90s.
Scientific American had an article on this a while back:
http://www.scientificamerican.com/article/the-oldest-old/
Dear colleagues - Thank you for the publications you indicated . These are very important with respect to the challenges of the health care system ( including health education and health literacy ) and society all over. The over 90 elderly present already now with clinical problems that should be guided by evidence based medicine ( EBV). There are very few EBV in clinical matters of the 90+. Research on this subject should be encouraged .
Dear Arthur,
I share with you the same interest and concern for the "evidence-lacking zone" affecting the very elderly population (>80 years old).
The most important evidence based publication for me in this cohort which is immediately actionable is the Third International Stroke Trial, led by Professor Peter Sandercock in Edinburgh, UK.
Their IST-3 trial was a prospective international multicentre randomised open-treatment design looking at the benefits and harm of thrombolysis in patients with ischaemic stroke.
They managed to enrol 3035 patients in 156 hospitals in 12 countries. Out of these 3025 patients more than 50% were 80 years of age or more, and equally distributed between the treatment group with rt-PA and control group with no rt-PA. Both groups otherwise received same level of care in an organised stroke unit.
The main findings were that despite an early hazard in the first 7 days, there was no difference in terms of mortality rates at 6 months between the 2 groups, with the treatment arm having better functional outcomes. The benefits remain true for patients > 80 years old.
The key point to make is that these patients were looked after in an organised stroke unit setting and had access to stroke rehabilitation for up to 6 months and beyond. Without the availability of both, the benefits may not be the same.
"The IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. The Lancet , Volume 379 , Issue 9834 , 2352 - 2363."
The full text of this paper is available under open-access at the Lancet.
I look forward to hearing more from your Clinical and epidemiological research on old old and beyond elderly project. We are also in the process of engaging our students at the National University of Singapore in terms of research and will hopefully be able to generate some interest in this very area.
Much obliged,
S.C
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60768-5/abstract
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