Should mother-in-law with dementia have TAVR (heart valve replacement) surgery?


My 89-year-old French mother-in-law moved in with us about three years ago. Because she has aortic stenosis/ congestive heart failure, the cardiologist is recommending that she have transcatheter aortic valve replacement surgery (TAVR). He mentioned that they would have to use general anesthesia. She is legally blind and very hard of hearing; besides heart issues she doesn't have major health problems such as diabetes or kidney. She is a smoker though. My big concern is that MIL has moderate dementia and I fear that the procedure could make things worse on this front. As I mentioned in previous posts, she does not qualify for Medicare/Medicaid and we would have to pay for skilled nursing care if she needs it. It's not open heart, but it's still a delicate surgery with associated risks such as stroke and requiring a pacemaker. Do any of you have thoughts or experiences with surgery on elderly folks with dementia?

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She's 89 years old and has dementia? Ain't no way I'd go along with surgery for her. Ask the doctor what alternatives there are to relieve symptoms.

Does she have a different specialist who manages her dementia? A neurologist or geriatric psychiatrist? If so, I'd discuss this with them.

Cardiologists focus on fixing hearts. That is their life mission. I don't blame this doctor for recommending this "solution." But I think you need to take a broader view with a goal of maintaining quality of life and dignity for MIL. Many doctors, especially geriatricians, do have this broad view. It doesn't seem to me that this cardiologist does.

I highly recommend the book "Being Mortal" for a very insightful look at what matters most at the end of life.
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Reply to jeannegibbs

I agree with jeannegibbs completely. My mom is almost 80 with dementia, and there's no way I'd let her go under general anesthesia now. My dad had general anesthesia at 71, to put a shunt in to drain water off his brain. He "disappeared" on us almost overnight.  He had general anesthesia again at 74 for a hip replacement, and that's when he died, while still recovering from surgery in the hospital. 

Plus I also agree that cardiologists, and any kind of specialists, are frequently focused exclusively on their specialty. They do not always see or process the "whole picture." I've actually found that many specialists in general are very uninformed about dementia. If your MIL has a GP, I'd definitely recommend talking with him or her, and if you haven't already, get MIL a referral to geriatric psych before you make any decisions about general anesthesia.
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Reply to Dorianne

There is a small percentage that the procedure can go wrong and it ends up being open heart surgery. Ask the surgeon about those risks. Even if there is a 3 day hospital stay, there is follow up rehab. Her dementia can lead to hallucinations where all strength building ends with no progress. Be prepared for 10s of thousands of out of pocket expenses.  How much more longevity do you expect? The congestive heart failure will not be cured
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Reply to MACinCT

My mother had TAVR over three years ago, at age 88. It was remarkable; she recovered very quickly. She didn't have dementia, though. 3.5 years later, she is quite a bit frailer, and her balance is horrible. But I can't blame the TAVR for that.

Just WHO would be paying for this surgery, if your MIL doesn't have Medicare/Medicaid????
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Reply to CTTN55

Have you considered consulting a palliative care provider? It might be a good idea to have one involved with health care decisions going forward. I agree surgeons are going to recommend surgery. It's what they do. A palliative care group should concentrate on quality of life.
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Reply to Marcia7321

Just no.

Not that it matters, but how would this surgery and hospitalization be paid for?  It would likely include at least an overnight in the CCU.
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Reply to BarbBrooklyn

Depends what sort of dementia. If it's vascular dementia, improving her blood circulation may help her.

But is anyone apart from the cardiologist recommending this? I'd talk it through with her PCP/GP at the very least.
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Reply to Countrymouse

Wow this is a tough decision. I would weigh the pro’s & con’s carefully. I am assuming she is symptomatic is that she gets SOB easily, has swelling of her extremities and is generally fatigued. I also assume her docs have had her on a diuretic and blood pressure meds to assist her heart in pumping.
There is not much else you can do without invasive aortic valve repair. The blood in her heart now is mixed - oxygenated & unoxygenated due to the faulty valve thus her body is not getting the oxygen it needs to continue to perfuse her organs - brain included.  
The risks are enormous. If you feel the surgery will improve her quality of life after surgery then go for it.
If not, your choices are slim. You say she has dementia now - most likely this will get worse after general anesthesia. Could be much worse.
I don’t know if I would put my mother through the surgery, to be honest not because it may not be successful as it probably will be to fix the immediate problem; it’s the after effects I fear. So my opinion would be a “no”. Unless you and your family accept that she may very well not make it & it may hasten her death.
I wish you peace with your decision.
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Reply to Shane1124

My MIL had this surgery. It deepened her dementia, she refused to go to rehab and starved herself to death. To be honest, I don't remember if she had TAVR or open heart, I suspect the latter.

Does your MIL have an advanced directive? What does it say?

My mom's said "no extraordinary measures" which is terribly vague. When mom developed heart block, we talked to the cardiologist, who told us that a pacemaker was not an extraordinary measure by anyone's standard.

Something to consider when talking to all of the docs. Have you read Atul Gawande's "Being Mortal"? Great book for making you think about how to approach these problems.

I mentioned CCU before: my husband had open heart surgery to replace his aorta and aortic valve when he was in his 50s. As he came out of anesthesia, he attempted to pull the ventilator tube out; the two nurses in the room prevented that, I would not have been able to. He was also quite wired up all over his chest for telemetry for several days after the surgery; will MIL do well with that?
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Reply to BarbBrooklyn

For what it's worth ...

Last year my FIL (now 90) had an emergency TAVR. He appears to have mild-to-moderate dementia (undiagnosed, because both MIL and FIL resist diagnosis, and yes, the "children" have tried, and are still trying, to persuade them to get a full evaluation for him).

He did ... great! He's now stronger physically. As for cognition, well, there was some *slight* improvement, and he holds steady to this day ... although he definitely still has deficits, and the current steadiness will not hold forever (or even for long).

It's such a carpshoot. TAVR is incredible. Right now, it's considered experimental, but from what I can see, TAVR *should* most likely be the go-to procedure, with open-heart being a Last Resort to be used only under specific circumstances.

BUT ... BUT ... this is a tough decision. For my FIL, TAVR was the right way to go -- this time. But then, he has few other debilitating conditions, is still capable of most ADLs, and, since birth, he's always been One Stubborn Dude (insert cheers and sighs here).

So MUCH depends on the patient's whole picture: physical, emotional and cognitive. Our generation has been plopped into uncharted territory. We can only do our best, with our loved one's reality firmly kept in mind.
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Reply to Confounded

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