From the Guidelines
The best management approach for this 91-year-old male with multiple serious conditions would be palliative care focused on symptom management and quality of life rather than aggressive treatment. Given his advanced age and complex comorbidities (untreated colon cancer, abdominal aortic aneurysm, pulmonary arterial hypertension, ascites, cardiomegaly, and severe coronary calcific arteriosclerosis), the risks of surgical intervention or aggressive cancer treatment likely outweigh potential benefits. The patient's abdominal aortic aneurysm, measuring 2.8 cm in diameter, is below the threshold for elective repair, which is typically considered for aneurysms ≥5.5 cm in diameter 1. Therefore, periodic surveillance with ultrasound every 5 years is appropriate for the aneurysm, as recommended for aneurysms 2.6 to 2.9 cm in diameter 1. A palliative care specialist should coordinate with cardiology, oncology, and geriatrics to manage symptoms. Pain control might include acetaminophen 500-1000mg every 6 hours as needed, with potential opioid management such as low-dose morphine 2.5-5mg every 4-6 hours for breakthrough pain. Diuretics like furosemide 20-40mg daily may help manage ascites and cardiac symptoms. Oxygen therapy should be provided as needed for dyspnea. Nutritional support and regular monitoring of fluid status are essential. This approach prioritizes comfort and dignity while acknowledging the patient's advanced age and multiple life-limiting conditions, where aggressive interventions would likely cause more suffering without meaningful extension of life. Goals of care discussions with the patient and family are crucial to establish preferences regarding hospitalization, resuscitation status, and end-of-life wishes. Key considerations in management include:
- Symptom control for pain, dyspnea, and ascites
- Regular monitoring of the abdominal aortic aneurysm
- Coordination of care among specialties to prioritize quality of life
- Open communication with the patient and family about goals of care and end-of-life preferences.
From the Research
Management Approach for a 91-year-old Male with Multiple Conditions
The patient's condition is complex, involving untreated colon cancer, abdominal aortic aneurysm, pulmonary arterial hypertension, ascites, cardiomegaly, and severe coronary calcific arteriosclerosis. Considering the patient's age and multiple comorbidities, management should focus on symptom relief and quality of life.
Pulmonary Arterial Hypertension (PAH) Management
- Treatment of PAH has shown significant progress, with three groups of drugs proven useful: endothelin receptor antagonists, phosphodiesterase inhibitors, and prostacyclin and its analogues 2.
- Endothelin receptor antagonists have been shown to improve exercise capacity, Borg dyspnoea score, and cardiopulmonary hemodynamics in patients with PAH 3.
- Combination therapy of endothelin receptor antagonists and phosphodiesterase-5 inhibitors may be beneficial in treating PAH, as demonstrated by the combination of ambrisentan and tadalafil (AMBITION trial) 4.
Abdominal Aortic Aneurysm (AAA) Management
- There is no medical treatment proven to limit AAA progression, but metformin use has been associated with lower AAA growth and AAA-related events in some studies 5.
- However, more randomized controlled trials are needed to verify the effectiveness of metformin in AAA management.
Overall Management
- Given the patient's age and multiple comorbidities, a comprehensive management plan should prioritize symptom relief, quality of life, and close monitoring of the patient's condition.
- The patient's untreated colon cancer, abdominal aortic aneurysm, and severe coronary calcific arteriosclerosis should be carefully considered in the management plan.
- Regular follow-up and monitoring of the patient's condition, including the abdominal aortic aneurysm, are crucial to prevent complications and ensure timely interventions if necessary.