Are New Parameters Needed in Treating the “Old-Old”?

For the year 2010, the percentage distribution of the population in the United States over 85 years is projected to be 1.85% and for the year 2025 it is 2.03%.¹ A small percentage, but not insignificant numbers. Hence, geriatricians and primary care providers may need to recalibrate normals in managing the old-old (over age 85 yr).

To start, before writing a prescription, physicians must consider multiple factors, particularly in treating patients in this age group. A good general rule is start with a much lower dosage than usual.² Perhaps the best maxim to consider is to think of what Vince Lombardi, the legendary coach of the Green Bay Packers (a strong proponent of the run), said: “When you throw the football, three things could happen, and two are bad.” Not a bad concept when writing a prescription.

Should the goals in treating hypertension in this group be raised from the traditional 140/90 mm Hg? A recent study reported that a lower systolic blood pressure was associated with a higher mortality in this age group.³ Another recent study indicated that high systolic blood pressure was associated with a greater risk of dementia in the young elderly (< 75 yr) but not in older subjects.⁴ Adequate control of hypertension in early old age may reduce the risk of dementia.⁴ The HYpertension in the Very Elderly Trial (HYVET)⁵ provides unique evidence that hypertension treatment based on indapamide (sustained release) with or without perindopril, in the very elderly, aimed to achieve a target blood pressure of 150/80 mm Hg is beneficial and is associated with reduced risks of death from stroke, death from any cause, and heart failure. However, a Letter to the Editor from the Journal of the American Geriatrics Society⁶ and a series of Letters to the Editor published in The New England Journal of Medicine⁷ raised some questions about this study, such as patient selection and side effects. The letters were from Greece and Australia, and one was from Franz H. Messerli, a distinguished investigator in this field.⁷ Additional publications also have questioned this benchmark for the over-85 age group.^8,9 In a personal communication, a colleague at another institution informed me that especially problematic are those patients over 85 with orthostasis and hypertension and she has seen patients on both antihypertensives and fludrocortisones (to elevate blood pressure to prevent falls due to drop in blood pressure).

Depressive symptoms reduced active life expectancy by 3.2 years for old-old men and 2.2 years for old-old women. Timely diagnosis and treatment of depression in this group may delay the onset of disability and improve the quality of life, even at this advanced age.¹⁰

With advancing age, an increasing number of healthy individuals have laboratory signs of heightened coagulation enzyme activity.¹¹ This report indicated that the oldest-old do not escape the state of hypercoagulability associated with aging, but that this phenomenon is compatible with health and longevity. Hence, high plasma levels of coagulation activation markers in older populations do not necessarily mirror a high risk of arterial or venous thrombosis.

A study from Sweden documents the substantial and ongoing impact of periodontal disease in a sample of generally healthy community-dwelling older adults, and underscores the importance of continued periodontal disease prevention and treatment of the old-old.¹²

In not-quite old-old octogenarians, there is evidence of excellent results after coronary artery bypass graft surgery, with minimal increase in postoperative mortality and acceptable morbidity.¹³ The old-old are a special group to be considered in the clinical practice of geriatrics and gerontology. I just purchased the sixth edition of Hazzard’s Geriatric Medicine and Gerontology¹⁴—an outstanding standard textbook; however, in the index I found no listing under “old-old.”

The author reports no relevant financial relationships.

Dr. Finestone is Director, Institute on Aging, Associate Dean CME, Emeritus, Adjunct Professor of Medicine, Temple University School of Medicine, Philadelphia, PA, and Consortium Project Director, Geriatric Education Center of Pennsylvania Partially HRSA Funded (Consortium of University of Pittsburgh, Penn State University, and Temple University).