Elderly Patients: Understanding the Risks of Surgery

Surgery For the High Risk Older Patient

An Older Adult Recovering From Surgery
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The thought of having surgery can be rather intimidating, but for older adults who have been repeatedly told that they are “high risk” for surgery, the thought can be downright scary. While it is true that an elderly person has a higher risk of complications during and after surgery, that does not mean that a person should expect the worst during or soon after surgery just because they are no longer in their youth.

If you or someone you love is elderly and needs surgery, there is good news: Health care in general is doing a much better job of caring for the elderly, and that means better outcomes after surgery. That said, it is important to be aware of the potential issues facing elderly surgery patients as well as what can be done to help prevent complications in this age group.

Who Is Considered Elderly?

The strict definition of elderly is an individual who is 65 years of age or older. This definition is dated, and while it remains accurate, in this day and age there are many 65-year-olds who are running marathons, working full time, and enjoying life to the fullest. The same is true of individuals in their 70s and 80s, and more than ever before, people in their 90s are living independently and enjoying active lives. This trend is expected to continue as people continue to live longer.

Our perception of the term elderly has changed as the lifespan has increased and as people are more physically fit and active throughout their lives.

 For some, an elderly person is a frail older adult, others simply look for white hair, but when it comes to surgery there is some merit to the idea that you are only as old as you feel. 

Geriatrics: Every Surgeon’s Specialty?

Geriatrics is the specialty of caring for adults 65 and older. As the population is aging, the simple fact is that most surgeons who treat adults, regardless of specialty, are specializing in the care of the elderly.

 This isn’t because they are pursuing additional training in the field of geriatrics; they are becoming geriatric specialists by default as over half of all surgeries performed in the United States are performed on adults over 65.

Certainly some specialties perform more geriatric surgeries than others. For example, an orthopedic surgeon specializing in joint replacements would see far more older patients than a plastic surgeon specializing in breast augmentation, but overall, more surgery patients are elderly than not. 

It is this change in the surgery patient population that has allowed dramatic progress in the quality of care provided to the older adult. Quite simply, the more one does something, the better one gets at that something, and that includes hospitals providing care to the older surgery patient.

Chronological Age Versus Physiological Age

If you are technically elderly, not acting your age may be a great thing. When we talk about age, the mind and body are often not in synch. Surely you know that young person who “acts old” or that older person who seems to have more energy than people decades younger.

Chronological age is a simple fact. You are __ years old. Physiological age is how old your body is based on wear and tear, and this is far more difficult to calculate.

Cars are an excellent example of chronological age versus physiological age. Your car is 2 years old—that’s good right? But the “physiologic” age of your car? That depends on whether it has 10,000 miles on it or 200,000 miles, and how many accidents it has been in, and whether your car smells like your dog, whether or not you changed the oil according to the manufacturer’s recommendation, and how the tread on your tires looks.

As a person contemplating surgery, the younger the physiological and chronological age, the better. This is because, all things remaining equal, it is safer to have surgery when you are 50 than when you are 90.

A teenager is more likely to be healthy than someone middle aged.

To illustrate the difference between chronological age and physiological age, imagine identical twin sisters who are 85 years old:

  • One has never smoked, exercises for an hour a day, eats a low fat diet heavy on salads and fruit, and was diagnosed with high cholesterol and high blood pressure in her 50s but followed the doctor’s advice and changed her diet and never needed medication for either condition.
  • Her sister is the opposite: She smokes a pack of cigarettes per day, avoids exercising as much as possible, loves eating fast food, meat, cheese, and fried foods and rarely eats fruits and vegetables. She takes medication for high blood pressure, high cholesterol, has had a heart attack, and has been told that she may need to take medicine for diabetes in the near future.  

When it comes to chronological age these sisters are only minutes apart. Physiologically, sister #2 is much older, her body has sustained far more illness and disease and harm than the body of sister #1. If they both need a hip replacement, which one do you think would have the lower risk of problems during surgery and complications after the procedure?

Predicting the Risk of Surgery in the Elderly

In our example above, sister #2 has a much higher risk of complications during her recovery from surgery. We don’t need a medical degree to understand the significant differences between the two sisters and their lifestyles and health history. In recent years, surgeons decided they needed a better way to predict the risk that older patients face when having surgery, because simply looking at their age was not good enough. They needed a way to determine who, essentially, was sister #1 and who was sister #2, and created the Comprehensive Geriatric Assessment to be used prior to surgery.

They looked at a large group of elderly surgery patients and their outcomes after surgery and analyzed their personal characteristics to see if it was possible to predict who was going to do well and who would struggle during two time periods—the first month of recovery immediately following surgery and the 11 months that followed.

When they looked at surgery patients who were 65 and older, they were able to determine multiple factors that helped predict the risk of death during surgery.

Factors that doubled the risk of death in the month after surgery:

  • Age 75 or older
  • Female: this is particularly true of one specific surgery—open heart bypass
  • Severe angina (chest pain) before surgery

Factors that tripled or quadrupled the risk of death:

Factors that were more common among those who died:

  • Cancer
  • Low albumin levels: this is protein in the blood, low levels can be a sign of malnourishment
  • Dependence in activities of daily living: The patient who can take care of their own needs  before surgery has a greater ability to take care of their needs after surgery, and is generally invested in maintaining independence.
  • Dementia: Confusion decreases the patient’s ability to make excellent choices, to participate in rehabilitation and be their own best cheerleader during the recovery process.
  • Delirium: Even short episodes of confusion can hinder recovery
  • Short mid-arm circumference: This is a sign of frailty, and short arm circumference may be indicative of low muscle mass, small boned (typically in women) or malnutrition.
  • Malnutrition

Avoiding Surgery

It is easy to say that the elderly should avoid surgery, or take their time preparing for a procedure to decrease their risk factors, but most surgery is unplanned and necessary, and can’t be delayed indefinitely. Avoiding surgery when it is possible to have a less invasive treatment is good advice for the patient, regardless of age. That may mean trying medication, physical therapy, and less invasive procedures before choosing surgery.

Each case is unique: Just because avoiding surgery is a good idea doesn’t mean it is always possible, or that it is the wisest choice. A frank discussion with the surgeon recommending the procedure may help clarify if surgery is absolutely necessary or if other treatments are available.

Treating the Elderly Fairly

The older patient deserves the same quality of care and the same access to information needed to make healthcare decisions as younger patients. That means, first and foremost, not making surgery decisions based solely on one factor: chronological age.

John, 85, has appendicitis. Appendicitis is rare in the elderly, but it happens. He fails treatment with IV antibiotics, which is the first course of treatment instead of surgery in some hospitals. His appendicitis gets worse, he’s in more pain, but the surgeon says he shouldn’t have surgery because he is high risk for fatal complications. This scenario is ridiculous, but is an excellent example of the ageism that the elderly may face in in the healthcare system.

John needs surgery, regardless of his age, and the surgery is a life-saving procedure. John’s age is irrelevant at this point, because his life depends on the procedure. John’s life will be extended by having the procedure, and shortened dramatically without it. The same need for surgery is often present for those who need heart surgeries, orthopedic surgeries that will enable to patient to continue to walk, and other serious and necessary procedures.

Chronological age is one piece of the puzzle, as is the patient’s individual level of risk of serious complication or death after surgery, the benefits of having the procedure, and the patient’s ability to recover fully after the procedure.

Preparing for Surgery When Possible

The older adult, more than any other age group, benefits greatly from taking the time to “fine tune” their health prior to surgery. This means improving the patient’s health in small and large ways prior to surgery.

How the patient's health is fine-tuned varies between individuals. It may mean improving blood glucose levels in the diabetic patient, smoking cessation for the pipe smoker, and improving iron levels in the anemic patient. This effort to improve the health, even in small ways, pays off big in the elderly because they tolerate complications after surgery poorly. Preventing problems means less physical stress on the body during and after surgery.

Preparing for Recovery After Surgery

Older patients are much more likely to require rehabilitation including physical therapy, or even a stay in a rehabilitation facility, than the average surgery patient. They are at higher risk of sleep disturbance due to medications, pain and a change in environment, which in turn can contribute to delirium, a type of confusion after surgery.

In general, the older patient will have a longer recovery time than a younger patient, and is expected to have more complications. In short, the elderly surgery patient will require more support than a younger one, from both professional healthcare providers and other individuals in their family and social circles.  Enlisting the help of friends and family prior to surgery will help make sure that the patient’s needs are met after the procedure.

When preparing for surgery, the older patient may also want to consider the arrangements that will be necessary after surgery. For example, if the surgeon indicates a stay at a rehabilitation facility will be necessary, the patient can choose the facility they prefer prior to surgery, and even visit if they choose.

Experts Agree to Avoid This Geriatric Surgery

Multiple medical boards, which are groups of physicians practicing the same specialty and working toward the best possible quality in those specialties, advise against performing surgery on the elderly patient with advanced Alzheimer’s disease or severe dementia. Most groups take a quality of life over quantity of life approach, and oppose invasive and often painful procedures for individuals who are no longer aware of themselves. This typically includes life-saving and life-extending procedures, but varies from group to group.

One topic they agree on is the recommendation against procedures that are artificially life-sustaining for patients who are no longer alert or oriented due to dementia. These groups state that interventions such as a feeding tube are not appropriate in this case of severe cognitive decline. Research shows that feeding tubes do not extend the average patient’s life span, but do dramatically increase their risk of forming decubitus ulcers (bedsores).

The Alzheimer’s Association concurs, stating that it is “ethically permissible to withhold nutrition and hydration artificially administered by vein or gastric tube when the person with Alzheimer’s disease or dementia is in the end states of the disease and no longer able to receive food or water by mouth.”

Many patients who feel strongly about not being placed on a ventilator or having a feeding tube complete an advanced healthcare directive, a legal document that clearly states the patient's wishes, prior to surgery.

A Few Words from Verywell

It is true that the elderly often have more health problems than younger patients, and they may have a greater need for surgery, but they also face age related bias when being evaluated for their medical and surgical needs.  Age is only one aspect of evaluating a patient's risk for a procedure, and should not be the only factor that determines whether surgery is performed or not.  Yes, age is important, but overall health, level of function, the severity of disease that is present and many other factors must be considered as well. 

Sources:

Assisted oral feeding and tube feedling. Alzheimer's Association. http://www.alz.org/documents_custom/statements/assisted_oral_tube_feeding.pdf.

Naughton C, Feneck RO, Roxburgh J, Early and late predictors of mortality following on-pump coronary artery bypass graft surgery in the elderly as compared to a younger population. http://ejcts.oxfordjournals.org/content/36/4/621.long. 2009.

Filardo, G, et al, Excess short-term mortality in women after isolated coronary artery bypass graft surgery. Open Hearthttps://www.ncbi.nlm.nih.gov/pubmed/27042323. March 2016

Kim, SW, Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surgery. 2014.

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