Considering a Very Elderly Patient for Hip Replacement
Advanced age, when considered as an isolated patient characteristic, is actually a desirable characteristic in a patient being considered for hip replacement, due to the reduced requirement for implant longevity. However, it is often said that a patient is too old to have a hip replacement. These types of comments are really expressing a concern for the comorbidities and associated processes that occur at a higher rate in the very elderly. Most surgeons who specialize in hip and knee replacement do not have an age limit for patient selection, but specifically evaluate the risks and benefits for each patient.
Hip Replacement is for the Patient Not for Their Carers
The very elderly are in a unique socioeconomical position, in that their medical care is often managed by a family member or carer. Whereas most patients interested in hip replacement surgery identify their own symptoms and seek medical attention themselves, the very elderly are often brought into the office by an individual who is concerned about their symptoms or functional decline. It is extremely important for the physician to ascertain the patient's point of view regarding their disease process. In order to substantiate a need for hip replacement, the patient should clearly indicate that their hip disease is causing a significant decline in their quality of life. Attaining this communication from the very elderly patient is sometimes difficult due to interruption or leading by family or carers. It is not uncommon to observe a family member pushing an elderly patient toward surgery, when the patient may feel that their quality of life and symptoms are tolerable.
After establishing the fact that the patient perceives a need for intervention, it is equally important to establish hip arthritis as the true etiology of their symptoms and disabilities. The very elderly frequently have confounding diseases such as heart failure, anemia, depression, malnourishment, spinal stenosis, radiculopathy and claudication, which all lead to declining functional ability. This group of patients must be carefully questioned and examined in order to ensure a successful result after hip replacement. In many specific situations, one of the confounding diseases is more functionally limiting than the hip, making it unlikely that the hip replacement will significantly improve function. For these patients, it is important to emphasize that the only reason for hip replacement is pain relief, as their expectation may be that the surgery will dramatically improve their function. Clarifying this issue often decreases the patient's interest in surgery, as the impetus for their interest was functional improvement and not necessarily pain relief. A clear understanding of the patient's specific complaints, disability and desire for surgery is critical to properly evaluate the potential benefit of hip replacement.
Declining Quality of Life
The most important consideration in selecting a very elderly patient for THA is the patient's perceived decline in quality of life.[2–4] Regardless of radiological findings, objective examinations, family input or medical history, the patient must reveal a deep sense that their quality of life has declined to an unacceptable level. Without this acknowledgement, there is no clear motivation to move ahead with surgical intervention. As a contrast to the previous example of a very elderly patient whose carers appear to be inappropriately promoting surgery, there are also circumstances where carers minimize or deny a significant functional deficit. However, even in this setting, some patients reveal that their quality of life has declined so significantly, usually due to pain, that they would rather pass away than continue living in the present state. For this group of patients who perceive a dramatic decline in quality of life due to hip pain, the potential benefit of hip replacement is considerable. Even in the face of significant risk, surgeons may be willing to perform a hip replacement if the very elderly patient has expressed a clear and substantial decline in quality of life.
Aging Health. 2011;7(6):803-811. © 2011 Future Medicine Ltd.