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.
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 and 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, IHPI member, and 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."
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.
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.