. -     .

If you are past 70, think twice before
submitting to optional surgery. At that age
there's a kind of double jeopardy.
First, do no
By Philip E. Ross
ancient medical motto needs
repeating in an age where the
urge to do something, any-
thing, often overpowers pru-
de.nee. Sometimes doing
nothing is the best a doctor
can do.
True, medicine increasingly,
offers studies that weigh thl°
benefits of drugs and surgery
against hidden risks. Sm:g_eo.ns
read us our chances of survival
from statistical tables, such. <\S
the one on this page. What
they often omit to say, howev-
er, is that surgery can derange
the mind. Life should be mea-
sured by more than duration.
A 73-year-old Toronto
woman recently broke her hip
and, rather than resort to a
cane, consented to the
implantation of an artificial
Surgical risk
Coronary bypass 40*
Coronary angioplasty 23
Hernia repair 17
Spinal fusion 14
Hip replacement 13
Prostate removal 9
Hysterectomy 7
Disc removal 5
Knee replacement 4
*Deaths within 30 days per 1,000 operations
for Medicare beneficiaries over 65.
Source: Medicare.
hip. The operation was a sue- Do you really need a new knee?
cess, she healed well and then -
she suddenly stopped speak-
ing or showing any interest in her
surrow1dings. Weeks later she recov-
ered her mental equilibrium, but it
wasn't quite the equilibrium she'd
had before.
A Boston man, 79 old, whose
family had noticed only the begin-
nings of senility, underwent a total
hip replacement. He descended. into
full-blown dementia afterward.
Months later he was better-living at
home-but still not well enough to
live on his own. He may spend his
last days in a nursing home.
Howard Spiro, a gastroenterologist
who heads the progr3:_111 for humani- ,
ties in medicine at Yale Medical
School, has witnessed tlus phenome-
non firsthand, although he concedes
that it is hard to quantify or even to
prove. "I'm 72, and I see that some
of my friends who've had surgery
aren't what they used to be," he says.
"The [surgeons] will say, 'The patient
looks good to me,' but then they
don't see what goes on in the home."
What's the matter? Some doctors
put much of the blame on anesthesia
and postsurgical painkillers. Another
theory holds that clots, which are
released into the bloodstream during
surgery and the convalescence that
follows, block blood vessels in the
brain, causing tiny strokes. Old
people are particularly vulnerable
because their arteries are often partly
blocked and they may already have
had a number of ministrokes.
Some surgeons, such as Andrew
Warshaw, chief of general surgery at
Massachusetts General Hospital,
argue that some candidates for
surgery are very sick and that sickness
predisposes them to mental prob-
lems. "I'll expose my bias," he says.
"Telling a candidate for prostate
surgery, 'would you rather get up
three times at night or risk losing
your brainpower'-man, that's really
loading the argument. Until we have
more reliable data, I would be very
wary of frightening people."
But most geriatricians agree
with Spiro in putting the
blame on the surgery and
anesthesia. "There are patients
with absolutely no [mental]
impairment, and after their
bypass they have it," sa s
Robert Butler, director ofth:
International Longevity Cen-
ter at New York's Mount Sinai
Medical School.
"I would not recommend
casually to patients over 70
that they go for surgery,"
Butler says. "There might be
occasions when the discom-
fort from a hip problem might
be only minimal, and you
don't need a replacement.
That's also true oflower-back
pain. It's horrible the way
some orthopedists rush in to
treat with surgery."
Why don't more doctors
warn their older patients of
the risk? In good part because
they simply aren't aware of the
extent of the problem. In an article in
Science & Medicine, Yale's Spiro
wrote: "Ifwe think about such mat-
ters, we may be reassured by studies
showing impairment to be only tem-
porary, as judged by psychological
tests . [However,] no one studies
amusement, empathy, association,
recall of minor events, poetic ability
or the quirks and delights that
account for personality."
Spiro continues: "Questionnaires
and answers from the patients them-
selves will cast little light, for how do
you know when part of yourself is no
longer with you?"
His advice: If in doubt about elec-
tive surgery, don't get it. •
Forbes • October 21, 1996

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