Disclaimer: The following article is for general information purposes only and not intended as medical advice. Always discuss your individual circumstances with your trusted physicians and other caregivers.
A study published in JAMA Surgery (a publication of the Journal of the American Medical Association) by researchers at the Yale School of Medicine in 2022 found that nearly 1 in 7 older adults die within a year of undergoing major surgery. An additional troubling conclusion in the study is that while patients 65 and older account for almost 40% of all surgeries in the U.S., there are significant gaps in detailed data about the outcomes of these procedures.
But as reported by Kaiser Health News, which produces in-depth journalism about health issues, the study did shine light on the risks seniors face when having invasive surgery. Among the findings are that patients suffering from dementia are especially vulnerable when it comes to surgery, with fully one-third of such patients dying within a year. Older patients described as “frail” have a 28% mortality in a year, and those having what is defined as “emergency surgery” suffer a 22% mortality rate.
Kaiser quoted Dr. Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston, as saying: “We’ve been really remiss in not understanding long-term surgical outcomes for older adults.” In addition to the mortality rates, the study also exposed how many older patients develop disabilities and can no longer live independently after major surgery. Dr. Cooper went on: “What older patients want to know is ‘What’s my life going to look like [with surgery]?’ But we haven’t been able to answer with data of this quality before,” Dr. Cooper said, referring to the study findings.
“This opens up all kinds of questions”
The physicians in the Yale study looked at several years and various sources of data, including claims under traditional Medicare. Invasive procedures that take place in operating rooms under general anesthesia were considered major surgeries (e.g., hip replacements, cardiac surgeries, cancer operations, hernia repairs, etc.) They noted that patients experience more problems after surgery if they have chronic conditions such as heart or kidney disease, if they already have mobility issues, or if they have cognitive problems. A preceding study also found that 1 in 3 older adults had not returned to their baseline level of functioning six months following major surgery, and that a “significant number” of the one million surgeries performed annually on individuals 65 and older were done near the end of their lives.
“This opens up all kinds of questions,” one researcher said, according to the Kaiser report. “Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?”
Slow uptake on quality improvement effort
While some patients might consider the risk of declining treatment in certain scenarios to be less than the risk of an invasive surgery, more patients statistically choose surgery. Experts note this has societal and fiscal implications. A research collaborator on the Yale study noted that as the 65-plus population keeps expanding, covering surgeries for seniors will be “challenging” for Medicare. What’s more, he added, “nearly every surgical subspecialty is going to experience workforce shortages.”
Kaiser noted that the American College of Surgeons launched a quality improvement program in 2019 that requires hospitals to meet 30 standards to achieve expertise in geriatric surgery. “So far,” stated Kaiser, “fewer than 100 of the thousands of hospitals eligible are participating.” One of the more advanced systems cited by Kaiser is the Center for Geriatric Surgery at Brigham and Women’s Hospital. There, older candidates for surgery are screened for frailty and may undergo a thorough geriatric assessment prior to surgery. They may also receive “geriatric-friendly” orders for post-surgery care. This might include regular assessments for delirium, getting patients moving as soon as possible, and using non-narcotic pain relievers.
Age perceptions and quality of elderly care are evolving
Verywell Health (VH), an online source of health and wellness information curated by health professionals, has also looked at the subject of surgery risks for the elderly. (VH launched in 2016 and states that its content is created by more than 100 health experts and reviewed by board-certified physicians.) VH posted their findings and perspectives in an article written by Jennifer Whitlock, RN, MSN, FN, whose expertise is in critical care and surgery. The article was reviewed by Jennifer Schwartz, MD, an assistant professor of surgery in the Yale School of Medicine.
The author-reviewer team concluded that 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.” This is because health care in general keeps doing a better job of caring for the elderly and achieving better surgery outcomes. They also point out that the very perception of who is “elderly” is evolving as lifespans increase and people stay physically fit and active longer into their lives.
But they add: “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.” They note that as the overall population ages, “the simple fact is that most surgeons who treat adults, regardless of specialty, are specializing in the care of the elderly.” Such specialization is traditionally referred to as geriatrics, but it doesn’t mean these surgeons have pursued additional formal training in the field of geriatrics. Rather, “they are becoming geriatric specialists by default.”
Chronological vs. physiological age
The VH article points out that about 35% of all inpatient procedures and 32% of all outpatient procedures in the U.S. 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.” But the article observes that since the more one does something, the better one gets at it, the shifting of the surgery patient population has facilitated progress in the quality of care provided to the older adult.
VH also makes note of the distinction that often exists between chronological age and physiological age. Young people can act and feel old; older people can act and feel young. Chronological age is what it is—you are a certain age and can’t change that—but lifestyle habits can dramatically affect physiological age and, consequently, the degree of risk you run with regard to surgery.
“As a person contemplating surgery, the younger the physiological and chronological age, the better,” says VH. “This is because, all things remaining equal, it is safer to have surgery when you are 50 than when you are 90.” But physiological age is still pivotal. A healthy and active 80-year-old is virtually guaranteed to have a better surgery outcome than an inactive 80-year-old with chronic disease, poor diet, smoking history, high blood pressure, etc. The bottom line is that simply looking at a patient’s age is not good enough to predict their surgery risk.
Preparation can make a difference
Careful preparation for surgery and for post-surgery recovery can also make a huge difference. VH says an older adult benefits greatly from taking the time to “fine-tune” their health prior to surgery. This involves improving the patient’s health in small and large ways prior to surgery, as circumstances allow, which can vary from one patient to another. It may mean improving blood glucose levels in a diabetic, smoking cessation, improving iron levels in an anemic patient, or other health enhancements. Such measures can mean less physical stress on the body during and after surgery.
Following surgery, older patients are statistically more likely to require rehabilitation, perhaps including physical therapy or even a stay in a rehabilitation facility. This puts them at higher risk for sleep disturbance due to medications, pain, and a change in environment, which in turn can contribute to delirium, a type of confusion after surgery. Careful pre-planning to avoid these risks can make a difference in overall outcome. This planning can include making a judicious choice for a best rehab facility and designing a support network for the recovering patient.
“It is easy to say that the elderly should avoid surgery, or take their time preparing for a procedure to decrease their risk factors,” VH notes. “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, according to VH. That may mean trying medication, physical therapy, and less invasive procedures before choosing surgery. But “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.”
Equitable treatment for older patients
Last but definitely not least, there is the issue of treating older patients equitably and fairly. VH insists, “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 not making surgery decisions based solely on a patient’s age. For example, just because a surgery poses a high risk of potentially fatal complications due to a person’s age is not an ethically acceptable reason to refuse to do such surgery, especially if a patient’s life depends on it.
As VH puts it, “Chronological age is one piece of the puzzle, but so 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.”
This comprehensive context leads to some counter-balancing perspectives as well. VH gives the example of multiple medical boards that advise against performing surgery on the elderly patient with advanced Alzheimer’s disease or severe dementia—advice that considers both age and severely compromised health status. VH notes these boards are “made up of physicians practicing the same specialty and working toward the best possible quality in those specialties.”
VH points out that “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.” In this perspective, interventions such as a feeding tube (such as might be needed post-surgery) are not considered appropriate in a patient with severe cognitive decline, partly because research shows that feeding tubes do not extend the average patient’s lifespan, but do dramatically increase risk of adverse side-effects such as forming bedsores.
This gives all the more reason for older patients and/or their families to thoroughly discuss details of any contemplated surgery, including the potential positive and negative outcomes. VH notes that many patients who feel strongly about not being placed on a ventilator or having a feeding tube choose to complete an advanced health care directive that legally documents their preferences. Such directives typically address other quality-of-life health conditions as well. These documented preferences need to be followed as part of ensuring fair patient treatment.