When it Comes to Surgery, Age is Just Part of Equation
By Marge Dwyer
Beth Israel Deaconess Medical Center correspondent
Who's in better shape for surgery: a fit 75-year-old who swims laps every day and takes two medications, or a 52-year-old couch potato who has high blood pressure, heart disease and diabetes and is on five prescriptions?
Chronologic age is only half the story, says Dr. Julie A. Moran, a geriatrician in the Senior Health program at Beth Israel Deaconess Medical Center in Boston.
Yet you can't ignore the fact that the heart, lungs and other organs of the 75-year-old are two decades older than those of the 52-year-old.
"Age is just part of the equation when deciding whether an older person is fit for surgery," says Dr. Moran.
As a doctor who specializes in providing comprehensive care for patients 65 and older, Dr. Moran often advises older patients and their families — as well as their surgeons — on how to optimize the care of patients who are planning to undergo an operation.
"We look at the patient's overall physical condition and whether they have chronic illnesses that could complicate surgery," she says. "We examine their social, functional, and emotional needs and help them plan for their recovery after the surgery."
Deciding when surgery is appropriate for people age 65 and over is an increasing issue. Older people are the fastest growing part of the population. People age 65 and older will make up 20 percent of the U.S. population by 2030. The longer people live, the more likely they will face surgery. It is estimated that 30 to 40 percent of all surgeries in the nation each year are performed on those 65 and older.
Thankfully, advancements over the past few decades in preoperative screening, anesthesia, perioperative (care during the operation) and postoperative care, in addition to newer surgical techniques, make surgeries like hip replacements or heart surgeries possible for seniors. However, surgeries in the elderly — particularly those in their 80s and 90s — are not without risk.
One large study published in 2005 showed that advanced age alone poses a higher risk of mortality after surgery when compared to patients in their 60s and 70s. One in five patients over the age of 80 studied sustained one or more complications following surgery. However, age wasn't the strongest risk factor for poor outcomes. Among all patients studied, the presence of chronic illness and low physical functional abilities placed patients at higher risk, regardless of their age. Therefore, it is important to take all of these factors into consideration when discussing surgical plans.
"As patients age and become surgical candidates later in life, it is vitally important to have a comprehensive assessment of all elements of risk before proceeding with surgery," says Dr. Moran, who also directs BIDMC's Geriatric Consultation Service. "Clearly, as we get to be in our 80s and 90s, we have older organ systems and facing surgery has special concerns."
While careful evaluation by doctors and planning by the elderly patient and his or her family can improve the outcome of many surgeries, sometimes patients requiring life-saving surgery following an accident, the removal of a cancerous tumor or other medically necessary surgery don't have the luxury of time to plan for the procedure.
"With emergency surgery, the stakes are higher," says Dr. Moran. "Often, decisions must be made within a much smaller window of time when things happen unexpectedly."
On the other hand, surgical advancements enable many procedures today to be performed as outpatient procedures. Less-invasive surgeries with smaller incisions and lighter anesthesia have opened the door to surgeries for older people that may not have been possible in the past.
Weighing the Risks
If you are age 65 or older and considering major surgery, make an appointment to have a pre-operative discussion with your geriatrician or primary care doctor to thoroughly discuss the risks and benefits of the surgery. Bring a family member or friend with you to listen, take notes and ask questions.
Among the questions Dr. Moran recommends discussing with your doctor:
- What are your goals for the surgery? This is an important time to set goals and make realistic expectations. For example, do you want to have your hip replaced so that you can take walks with your grandchild or play golf? Are you hoping to cure or eliminate an illness or condition? Would this even be possible?
- What are the risks and benefits? How will your life be impacted? For instance, are you willing to undertake six weeks of rehabilitation or endure physical discomfort to improve your quality of life or live longer? What do you hope to gain by going through with surgery? Perhaps you might wonder what the consequences may be if you forgo surgery altogether?
- What medications do you take? A thorough review of your medications is essential to optimizing your preoperative care. Patients need guidance about how to manage their medications in the weeks leading up to surgery, and it is critically important to communicate medication concerns or recommendations to the surgical team.
- How long will the recovery likely be? Older patients often have a longer recovery time and are more at risk for a loss of function, such as the ability to care for themselves independently. They are at higher risk of losing strength after surgery and may require placement in a rehabilitation facility for nursing care and physical therapy before they can go home.
- Are you strong or frail? Dr. Moran evaluates the overall functional status of the patient, including how well they perform daily activities, walk, climb stairs and get up out of a chair. Are you a patient who plays tennis three days a week and does all of your own housework, or do you have difficulty walking one city block? "The more physically robust you are, the better 'physical reserve' you have to withstand a few days in bed following a hospitalization," she says. "Patients who are physically frail can rapidly lose strength when immobilized after surgery."
- Are your heart and lungs in good condition? A key concern is the impact of anesthesia and stress of the procedure on aging cardiac and respiratory systems. A thorough, individualized assessment is essential prior to surgery.
- How much social support do you have? "The 85-year-old with supportive family members and friends available to visit them in the hospital and help when they return home is likely to recover more quickly than the patient who has no social support," Dr. Moran says.
- Can you return home after hospitalization? If you are in good condition for a knee replacement, but live in a third-floor walk-up apartment, your plans to return home would not be physically possible with your knee immobilized.
- What are your wishes if the surgery doesn't go well? How would your goals of care change if the outcome of surgery was not as you had hoped? Dr. Moran advises the patient to name a health care proxy and have an advance medical directive in place before surgery: "It is important to open up this issue for discussion to encourage patients to think about their preferences, to clarify any unclear terms, and to urge them to continue this discussion at home with their loved ones."
Memory and Moods
It's important for doctors to screen for memory or mood difficulties prior to surgery. When not appropriately identified, these conditions can worsen outcomes. Depressed patients are less able to cooperate with postoperative care and are at higher risk of losing weight and physical strength after surgery.
Older patients, particularly those with memory loss and dementia, are at greater risk of delirium, an acute state of confusion. In the postoperative period, there is higher risk for developing delirium as the patient has been through anesthesia, may be on pain medication, and is now in an unfamiliar environment where they may have IV lines, drains, urinary catheters, and frequent interruptions for nursing care and vital signs.
But there are measures that can be taken to help prevent confusion in older patients. These include:
- Getting patients up and moving as soon as possible after the procedure.
- Minimizing overnight interruptions and making efforts to preserve the patient's sleep/wake cycle.
- Keeping patients oriented to time and day by having clocks and calendars available.
- Minimizing invasive IV lines, catheters and tubes when possible.
- Making sure patients have eyeglasses, hearing aids and dentures, if needed.
- Encouraging visits by family and friends.
- Making sure the pain is not over or under treated.
- Avoiding medications that are not well tolerated in elderly patients, which could worsen confusion.
If there is a possibility that you may need to go to a rehabilitation facility after surgery, Dr. Moran advises being proactive by identifying facilities that have good reputations, provide good nursing care, and are convenient to your home, family, and friends. Coming to the hospital with a small list of your preferred rehab facilities will help you avoid making a rush decision in the hospital prior to discharge.
Her other advice? "Stay as active and as strong as possible — that is the key."
Also, prior to surgery, reduce drinking of alcohol, optimize your nutrition, and ask your doctor about whether you need to stop your medications — especially aspirin, other blood thinners and herbal supplements — before surgery.
"This is not the time to be passive," Dr. Moran says. "When heading into surgery, the patient should be an active participant with the healthcare team as they work to achieve the best possible outcome possible."
Above content provided by Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.
Posted March 2013