As people age, surgery and anesthesia can take a greater toll on their bodies and minds. Recovery may take longer. In many cases, however, patients in their late 60s, 70s and beyond can do just as well postoperatively as much younger patients. To determine surgical risk, it’s important to look at the whole person beyond his or her birthdate.
Special considerations for older adults include possible frailty, chronic conditions, current medications and mental health status. Where people live, how they function and their individual health goals all matter. For some older patients, watchful waiting may be preferable to invasive surgery. If you or a loved one is contemplating or preparing for surgery, here’s what clinicians should look for.
[See: 10 Ways to Prepare for Surgery.]
Old age alone is not to blame for increased surgical complications. That was a major finding from a large review of 44 studies comprising more than 12,000 patients 80 and older who underwent elective surgery. However, frailty, smoking, mental impairment and depression increased the risk for experiencing complications in this age group, according to the study released January in the journal BMC Medicine.
Frailty or Strength
A simple hand-squeeze test at the doctor’s office is one way to tell whether a patient might be too frail for surgery. Using a device called a hand-grip dynamometer — typically used to test hand and forearm strength in athletes — in conjunction with a patient’s body mass index, clinicians can quickly and precisely measure frailty, according to a study in the May 2018 issue of the Journal of Vascular Surgery.
It’s known that frail patients are at increased risk for complications, readmission to the hospital after being discharged and what’s called “non-home discharge” — having to go to a nursing home or rehabilitation facility — after surgery, says study author Dr. Matthew Corriere, a vascular surgeon and an associate professor of surgery at the University of Michigan.
“We’re trying to look at someone’s reserve for recovering from stress,” Corriere says. “Surgery can be a stress for a patient.” If someone is already finding it challenging to live independently, he says, it’s important to gauge frailty when considering an elective surgical procedure. Putting off surgery while watching symptoms may be wiser, he says, especially if an intended procedure is not life-prolonging.
For example, Corriere says, patients with a type of peripheral artery disease called claudication get cramping leg pains when they walk. “They’re not necessarily at risk for amputations and it’s not something that’s going to kill them,” he says. “So we’re trying to decide: Should we do an intervention that might make their symptoms better? There’s an option in that situation to decide: I’d just rather have a little cramping leg pain from time to time than to have a procedure.”
Whether patients are in their 70s, 80s or 90s, surgical risk should be considered on an individual basis, Corriere emphasizes. “We see some 90-year-olds who are clearly frail when we watch them get out of their chair, and they need a few people to help them up on the exam table,” he says. “That’s one end of the spectrum. The other end is the 90-year-old patient who’s walking 18 holes of golf, working in their yard and stuff like that.”
[See: 11 Things Seniors Should Look for in a Health Provider.]
Patients’ chronic medical conditions, even if seemingly unrelated to a surgical procedure, can affect their outcomes afterward. An older patient with diabetes and heart disease, for example, faces higher risk than a same-aged peer in better health.
Although orthopedic surgery is generally safe for patients ages 80 and older, those with no or few accompanying health conditions are less likely to have surgical complications from spinal fusion surgery, hip replacements or knee replacements than other octogenarians, according to a large study published in July 2014 in the Journal of Bone and Joint Surgery.
Older adults often take multiple medications to treat a variety of conditions. It’s essential to go through drug regimens with each patient, including any over-the-counter medications and nutritional supplements they take.
Mental Status
Delirium — sudden confusion, hallucinations and other mental disturbances like hallucinations — is a distressing surgical side effect. Older patients are more likely to experience postoperative delirium. Those with mild cognitive impairment or dementia are particularly vulnerable.
Cognitive assessments can be helpful in predicting patients who are at high risk for delirium, says Dr. Julia Berian, a general surgery resident at the University of Chicago Medical Center. Delirium can affect patients’ recovery, length of hospitalization and their ability to be discharged back home rather than to a facility, she says.
Ideally, mental status assessment is part of a comprehensive evaluation performed by a geriatrician or nurse practitioner who specializes in the care of older patients. However, other health professionals can assess cognition fairly quickly using standardized tools whenever surgery might be needed.
“An acute illness that requires a conversation about whether or not to have an operation can be a marker at which point people have to reassess,” Berian says. For older patients who have never had a cognitive assessment, she says, a preoperative workup can be the ideal opportunity.
[See: 7 Reasons to Call Off a Surgery.]
Not Age Alone
Surgery can boost quality of life for older patients on many levels. With severe hearing loss, for example, surgery to restore hearing often improves speech and speech perception, self-esteem and even mental status, according to a March 2016 study on cochlear implant surgery in the Journal of Otology.
Patients ages 70 and older tolerated the procedure well, with complication rates similar to those of younger patients, according to the review of evidence. Patients’ overall medical well-being and physical status had more impact than their age on their risk from general anesthesia.
Following the inner-ear surgery, more than 80 percent of elderly patients had better cognitive scores. Depression was significantly reduced. “It is clear that age alone should not be considered a barrier to implantation,” the study authors concluded.
What Patients Want
A movement is underway to improve and establish standards for preoperative assessments of older patients. The Coalition for Quality in Geriatric Surgery Project, spearheaded by the American College of Surgeons, offers best practice guidelines for health care providers on evaluating older surgical patients throughout the operative process.
Detailed recommendations for clinicians include how to assess decision-making capacity; heart, lung and functional status; frailty and nutritional status, as well as advice on medication management and preoperative counseling.
Berian contributed to the ongoing quality project in her previous role as a research scholar with the American College of Surgeons. First and foremost, she says, clinicians need to understand each patient’s personal values and health goals.
For some patients, Berian says, “that might mean: ‘I don’t care if I have to live in a nursing home — I actually enjoy the company. What really makes me happy in life is being able to be around my grandchildren.'”
However, goals differ from patient to patient. “You might have another older adult who really values their functional independence and says, ‘I want to live alone,'” Berian adds. “‘I want to be able to do my gardening. I don’t want to be in a home. I don’t want to be functionally impaired. And that’s my priority.'”
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Is Surgery Right for Your Older Loved One? originally appeared on usnews.com
