Should the elderly risk major surgery? New research offers guidance

Nearly 1 in 7 older adults die within a year of undergoing major surgery, according to a major new study that sheds much-needed light on the risks older people face when they have invasive procedures.

Older patients with probable dementia (33% die within a year) and frailty (28%) and those having emergency operations (22%) are particularly vulnerable. Advanced age also increased the risk: patients 90 or older were six times more likely to die than those aged 65 to 69.

The study in JAMA Surgery, published by researchers at the Yale School of Medicine, addresses a notable research gap: Although patients 65 and older undergo nearly 40 percent of all surgeries in the U.S., detailed national data on the outcomes of these procedures are up to largely absent.

“As a field, we’ve been really remiss in not understanding long-term surgical outcomes in older people,” said Dr. Zara Cooper, professor of surgery at Harvard Medical School and director of the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston. .

Of particular importance is information on how many older people die, develop disabilities, can no longer live independently or have a significantly reduced quality of life after major surgery.

“What older patients want to know is, ‘What is my life going to look like?'” Cooper said. “But we haven’t been able to respond with data of this quality before.”

In the new study, Dr. Thomas Gill and colleagues at Yale examined claims data from traditional Medicare and data from the National Survey of Trends in Health and Aging, covering the period 2011-2017. (Data from private Medicare Advantage plans were not available at this time, but will be included in future studies.)

Invasive procedures that are performed in operating rooms with patients under general anesthesia are considered major surgeries. Examples include procedures to replace broken hips, improve blood flow to the heart, remove colon cancer, remove gall bladders, repair ruptured heart valves, and repair hernias, among many others.

Older people tend to experience more problems after surgery if they have chronic conditions such as heart or kidney disease; if they are already weak or have difficulty moving; if their ability to care for themselves is compromised; and if they have cognitive problems, noted Gill, a professor of medicine, epidemiology and research medicine at Yale.

Two years ago, Gill’s team conducted research that showed that 1 in 3 older adults had not returned to their baseline level of functioning six months after major surgery. Elderly people who have had elective surgeries for which they were able to prepare in advance are most likely to recover.

In another study published last year in the Annals of Surgery, his team found that about 1 million major surgeries are performed on people 65 and older each year, including a significant number at the end of life. Notably, data documenting the extent of surgery in the older population is thus far lacking.

“It raises all kinds of questions: Are these operations done for a good reason? How is the appropriate operation determined? Were the decisions to perform surgery made after clarifying the patient’s priorities and determining whether the surgery would achieve them?” said Dr. Clifford Koh, professor of surgery at the UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

As an example of this kind of decision-making, Ko describes a patient who, at age 93, learned that he had early-stage colon cancer in addition to existing liver, heart, and lung disease. After extensive discussion and after being told that the risk of poor outcomes was high, the patient decided to forgo invasive treatment.

“He decided he’d rather take the risk of a slow-growing cancer than deal with major surgery and the risk of complications,” Ko said.

However, most patients choose surgery. Dr. Marcia Russell, a staff surgeon at the Los Angeles Veterans Affairs Health System, described a 90-year-old patient who recently learned he had colon cancer during an extended hospital stay for pneumonia. “We talked to him about the surgery and his goals are to live as long as possible,” Russell said. To prepare the patient, now recovering at home, for future surgery, she recommended he undergo physical therapy and eat more high-protein foods, measures that should help him get stronger.

“He might need six to eight weeks to prepare for surgery, but he’s motivated to get better,” Russell said.

The choice that older Americans make to undergo major surgery will have broad societal consequences. As the over-65 population increases, “covering surgery will be a fiscal challenge for Medicare,” noted Dr. Robert Becher, an assistant professor of surgery at Yale and a Gill research associate. Just over half of Medicare spending is devoted to inpatient and outpatient surgical care, according to a 2020 analysis.

What’s more, “almost every surgical specialty will experience labor shortages in the coming years,” Becher said, noting that in 2033 there will be nearly 30,000 fewer surgeons than needed to meet projected demand .

These trends make efforts to improve surgical outcomes in older adults even more critical. Yet progress is slow. The American College of Surgeons launched a major quality improvement program in July 2019, eight months before the covid-19 pandemic hit. It requires hospitals to meet 30 standards to achieve recognized expertise in geriatric surgery. So far, fewer than 100 of the thousands of eligible hospitals participate.

One of the most advanced systems in the country, the Center for Geriatric Surgery at Brigham and Women’s Hospital, illustrates what is possible. There, elderly people who are candidates for surgery are screened for frailty. Those judged to be frail see a geriatrician, undergo a thorough geriatric evaluation, and meet with a nurse to help coordinate care after discharge.

“Geriatric” orders for post-operative hospital care have also been initiated. This includes assessing older patients three times a day for delirium (an acute change in mental status that often affects older hospital patients), moving patients as quickly as possible and using non-narcotic pain relievers. “The goal is to minimize harm from hospitalization,” said Cooper, who is leading the effort.

She told me about a recent patient whom she described as “a socialite in her early 80s who still wore skinny jeans and went to cocktail parties.” This woman came to the emergency department with acute diverticulitis and delirium; a geriatrician was called before surgery to help manage her medications and sleep-wake cycle and to recommend non-pharmaceutical interventions.

With the help of family members who visited this patient in the hospital and continued to care for her, “she’s doing great,” Cooper said. “This is the kind of result we are working very hard to achieve.”

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