Dear Doctors: Our dad is 82 years old and may need to get a pacemaker. My brother and I recently read that surgery is hard on older people, both physically and mentally. Is getting a pacemaker going to be risky? He’s physically pretty weak, and we’re worried the surgery will be too much for him.

Dear Reader: A pacemaker is a small medical device that keeps the heart beating at a steady rhythm. It consists of sensors, which monitor the heart rate, and a battery-operated pulse generator, which sends corrective impulses to the heart. A pacemaker can adjust a heartbeat that is too slow, and it can correct potentially dangerous heart arrhythmias. A catheter is used to thread the sensors through a vein that leads to the heart. The pulse generator, which is about the size of a matchbox (or smaller), is implanted just beneath the skin of the chest. (A new, tiny pacemaker known as a Micra, which consists of a single piece, is placed directly into the heart.)

For a patient who is in good health, the procedure to implant the two parts of the pacemaker is considered a minor surgery and is sometimes done on an outpatient basis. However, recent studies have shown that when older patients are also frail, even minor surgical procedures can be risky. Frailty is a term used to describe certain effects of aging that, when taken together, carry an increased risk of poor health outcomes. These include physical weakness, diminished endurance, poor balance, loss of skeletal mass and loss of muscle mass. When a physical assessment finds three or more of these characteristics, the person is considered to be frail. Visual and cognitive impairment can also play a role in a determination of frailty.

A study published last year in the Journal of the American Medical Association found that, compared to other patients in good health, older adults who are also frail are more likely to die after minor surgical procedures. That study looked at post-surgical mortality rates in 433,000 older patients, mostly men, who underwent procedures at Veterans Administration hospitals between 2010 and 2014. The patients who met the criteria for frailty had an increased risk of death in the weeks and months following the surgeries. The mortality rate rose dramatically for patients who were considered to be very frail.

We think it would be wise for you to begin by meeting with your father and his cardiologist to learn what specific condition the pacemaker will address. Your father should also undergo a frailty assessment. If, as you suspect, he meets the criteria for frailty, the next question for your father’s physician is: Which carries the greater risk -- the condition that the pacemaker is expected to treat or the procedure to implant it? If it’s decided that the pacemaker is necessary, a prehabilitation program may be helpful. That’s when a surgical patient prepares with a program of nutrition, exercises to improve strength and endurance, and mental training to manage stress. Your father's medical team can create a specific program for your dad, and help him prepare for the surgery.

(Send your questions to askthedoctors@mednet.ucla.edu. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: Our mom is going through chemo and radiation, and she’s feeling bad about herself. Do you think the makeup and wig program at her hospital might help? We’ve suggested it, but she’s worried it’s frivolous to care about your looks when you’re fighting cancer.

Dear Reader: The moment that someone learns they need to undergo treatment for cancer, their life is radically altered. There’s the fear and uncertainty about the future, the challenges posed by the treatment itself, and the mental, emotional and spiritual toll that the entire process often takes. Learning that they’re seriously ill disrupts an individual’s sense of self.

This includes the physical changes that take place during the course of treatment, which often cause psychological distress. Hair loss, which includes eyelashes and eyebrows; weight loss; surgical alterations; surgical scars; skin pallor; loss of muscle mass and muscle tone; lymphedema, or swelling because of damage to the lymphatic system; prolonged exhaustion; and changes to sexual function all hit at the core of our identity. Anything that can help the person feel safer, stronger and more like their old self is a blessing. All of which is to say that, no, there’s nothing frivolous about wishing to look better, because it goes a long way toward helping you feel better during a difficult and isolating time.

Most hospitals and cancer-treatment centers now offer programs like the one you’ve discussed with your mother. Many are staffed by licensed beauty professionals, including hairstylists, makeup artists, aestheticians and nail technicians who volunteer their expertise. The focus is on helping patients to manage the appearance-related side effects that arise during and after cancer treatment. These programs help patients with skin-care routines, makeup techniques, manicures and pedicures, and wigs, turbans and other types of head coverings.

The physical changes from the rigors of breast cancer treatment can be unexpected and scary, and these programs help women cope. In addition to hair loss, some types of chemotherapy and radiation cause skin to become thin, dry and fragile. Sometimes women experience changes to pigment or find that their skin becomes itchy or burns quite easily when exposed to the sun. Chemotherapy can also affect the nails, which can become cracked and turn a darker color. The programs offer instruction in specific beauty techniques, as well as guidance on the skin-care and makeup brands and products that are kindest to skin and safest for cancer patients.

For women who have decided against breast reconstruction following mastectomy, these programs often include help with selecting and fitting prostheses and finding sources for the bras, swimsuits and other clothes that have been specially designed to accommodate them. Just as valuable are the human connections that are made. Staff members are often cancer survivors themselves, and, thus, understand exactly what each patient is going through. They also offer a view of post-treatment life. Fellow patients using the hair, skin and makeup services also become a valuable source of comfort and support. Families and friends can offer love and empathy, but only someone who has had cancer can truly understand the experience.

(Send your questions to askthedoctors@mednet.ucla.edu. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: My uncle tested positive for the coronavirus last winter and wound up in the hospital. He was lucky, and he recovered, but it is six months later and he still is not completely better. He says he’s what’s known as a “long-hauler.” Can you please explain what that is, and why it happens?

Dear Reader: From its earliest days, the coronavirus pandemic put science and medicine on the steepest of learning curves. The virus had never been seen before, and the disease that it causes, now known as COVID-19, was a complete unknown. As months passed and the data accrued, we continued to learn about the many ways that the novel coronavirus affects the human body. We’ve also become aware of the different trajectories that the illness it causes can take. Some people, as we now know, develop only mild symptoms. Others have no symptoms at all. Some struggle with serious or fatal cases of COVID-19, while others experience moderate disease with complete recoveries. But as the number of cases continues to grow, and doctors share and pool their data, a troubling trend has emerged.

Unlike the flu, the disease that in many respects it resembles, COVID-19 is not always a short-term illness. For many people, as with your uncle, recovery becomes a long and uncertain process. A survey conducted by the Centers for Disease Control and Prevention last spring found that up to 35% of COVID-19 patients continue to feel the effects of the disease long after tests show they were virus-free. This appears to be similar to what was seen with SARS (severe acute respiratory syndrome), the coronavirus-caused illness that first emerged in 2002. Some patients who had been hospitalized with SARS continued to experience impaired lung function two years after first becoming ill.

Patients who continue to experience lingering symptoms, now referred to as “post-COVID syndrome,” have come to be known as long-haulers. Unlike the steady recoveries we make from a cold or the flu, long-haulers experience repeated setbacks. A day or two of good health will be followed by a sudden recurrence of fever or lung inflammation. Fatigue, exhaustion, chills and headache come and go and then come again. Some patients find themselves back in the hospital for treatment of acute symptoms. For many long-haulers, the cognitive difficulties that can accompany a severe bout of COVID-19 never completely vanish. And as the disease drags on with no end in sight, a growing number of people with post-COVID syndrome report dealing with feelings of anxiety and depression that interfere with daily life.

As with so many questions related to the novel coronavirus and COVID-19, the causes of post-COVID syndrome are not yet known. One promising line of inquiry is looking at whether viral particles that remain within the body may be setting off powerful immune reactions. Meanwhile, many COVID-19 long-haulers say they are finding emotional safe harbor in online support groups made up of fellow survivors. They exchange information, share strategies and find comfort in knowing that, in this particular long journey, they are not alone.

(Send your questions to askthedoctors@mednet.ucla.edu. Owing to the volume of mail, personal replies cannot be provided.)