How to best care for super seniors: A portrait of a favourite patient group

I have a delightful 96-year-old patient who tells me jokes. “Doc, if I’d have known I would live this long I would have taken better care of myself!” Or, “When I wake up, if I am not in the obits I know it is going to be a good day.” The secret to caring for the very old is to do as little as possible. Remember, all the protocols and guidelines we follow were invented for the mythical 40-year-old 70 kg man. So, if you try to lower blood pressure to target, you might make your very old patient fall and break a hip. If you aim for an HbA1C of 6.0, they might go too low and slip into a coma. Low can kill you in seconds, high in decades. Super-seniors in my practice I’ve been a family doctor for 30 years, and before that an emergency doctor for 20. My practice of 1,400 is 60% seniors and I look after two nursing homes. My mom and mother-in-law died at age 98. I’ve looked after hundreds of 90-year-olds and about 10 centenarians (auto correct says centurions but they are not that old). My oldest was a woman of 108, who had a picture of herself on the wall driving a motorcycle at age 93. One 95-year-old still roars around in a little red sports car that I covet—and passes her driver’s tests with ease. Read: We need to teach freshly minted physicians how to pace themselves Most over-90s are women because more men smoked back then. My dad told me that the tobacco companies sent free cigarettes to Canadian soldiers who were serving overseas during the Second World War. How patriotic. Also, most patients didn’t get their cholesterol, blood pressure or blood sugar checked in the old days. Doctors were too busy treating sick and injured patients to do much prevention. Medications had severe side-effects too, so blood pressure pills made you feel bad even though they were treating an asymptomatic disease. U.S. President Franklin Delano Roosevelt died of a cerebral hemorrhage at age 63, a few weeks before the Second World War ended. His blood pressure was sky high. He was often seen with his jaunty cigarette in a holder. The Americans thought he died due to three, four-year terms as president. They felt his death was due to stress, so they limited future presidential terms to two. People in their 90s also tend to have good arteries. The ones with bad ones have died. I always tease them and say, “Why did all the men die early; did they have a harder life than you?” They stare at me over their glasses and say, “You young whippersnapper (I love this), we are tough because we worked harder than you.” Read: How to avoid college complaints Very old patients are often tiny women on few meds. They are at high risk for malnutrition (tea and toast diets) and osteoporosis. They are usually widows who eat alone. Eating is a social activity, and they tend to not do as much and become frail. I try to get them set up with friendly visitor programs and meals on wheels. I ask them what their goals are and then sit back and shut up. Most tell you they want to die in their house and avoid a nursing home. I tell them how to do this by suggesting they get a home care assessment, which is free—they have paid for it with their 70 years of taxes. Don’t just do something, stand there The biggest piece of advice I can give you is to try to not do anything. Just keep your very old patients healthy and happy and socially connected. Loneliness is their biggest risk factor. Avoid meds, and if you have to use them, adjust for kidney and liver problems, and your patient’s probable tiny size and lack of muscle mass. Avoid benzodiazepines that can make elderly patients fall. They usually have insomnia due to daytime napping and osteoarthritic pain, so a Tylenol at bedtime can help. What are your tips for treating these wonderful people? Comment below or email me at drjohncrosby@rogers.com P.S.: If you are thinking of taking on super-seniors as patients, I highly recommend it. They don’t Google, they respect doctors, they are not trying to bag work and they are living history, unfiltered by writers, historians or politicians. They don’t talk on their dumb phones while you are seeing them, either. Read: There is no doctor shortage

How to best care for super seniors: A portrait of a favourite patient group

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JohnWyatt Crosby

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