Complex Surgeries Often Have Poor Outcomes for Older Patients

People are having more surgeries at older ages both in the hospital and in other settings. While this may be good news, it may not actually be what many older people would choose if they knew all the facts – but this is another subject. The point here is that surgeries are conducted too often on older people who are too frail to fully recover.

Overall surgeries have become more successful. In many cases they are also more complicated. With advanced techniques risky surgeries are possible for very old patients. Patients and families may be given surgery treatment options even though the odds are stacked against a good outcome There are many risk factors to consider.

For example, imagine a situation where an 85 year old man under treatment for congestive heart failure needs a knee replacement. Figuring out how to manage the heart treatment is just as important as taking care of the new knee. And if the man lives alone and depends on his daughter who comes by his house three or four times a week to do some cooking and take care of his needs, then post surgery care will be a challenge. If the man also happens to have some cognitive loss such as memory problems and occasional confusion, imagine how much more improbable a successful surgery is likely to be.

Fortunately there is something new happening in medicine today that relates to this problem. Physician groups, and in particular the professional society for surgeons, are studying this age-related issue concerning surgery. They are studying what happens when older patients have surgery to find conditions that could identify the older patients who have higher risks for poor outcomes after surgery. These are all things that can be identified before a surgery. They have also found that the more risk factors an individual has, the higher the risk of a poor post surgery result. A poor surgical result ranges from complications requiring additional treatments, to never returning to the previous level of independent living, to death in the worst cases.

As a family caregiver you can become familiar with the risk factors. Then when surgery is proposed for your parent or other loved one you will be prepared to ask the right questions. You will be able to gather the information you need to make a truly informed decision about the proposed surgery. If your family member has more than one of the risks it is even more important to ask about alternatives to surgery. There always are alternatives, even if it involves doing nothing.

Here are seven conditions that medical researchers have found lead to higher risk for poor outcomes after surgery:

  1. Advanced age. If a person is over 85 years of age the risk increases, however age alone isn’t sufficient for high risk. But advanced age generally means the individual is more likely to be frail and more vulnerable.
  2. Impaired cognition. This means that the individual experiences some form of dementia or cognitive problem. By age 80 nearly one in four older adults has some loss in cognitive abilities. This includes problems with memory or difficulty understanding and following instructions. When a person with cognitive loss has surgery he or she is more likely to experience delirium after surgery.
  3. Delirium risk. As many as half of all older patients experience delirium after surgery. This could show up as confusion, anxiety, disorientation and difficulty having a conversation. Sometimes this clears up quickly, but delirium becomes a problem when it lasts for weeks or longer. When delirium occurs, recovery is delayed. This can mean more post surgical complications and can require the need for institutional care after surgery. In severe cases this risk factor increases the chance of death.
  4. Impaired functional status. Functional status refers to the person’s ability to care for him-or- herself independently. This includes moving around, dressing, personal care, eating and other activities of daily living. It also includes more complex tasks like using a telephone, shopping, preparing meals, and taking responsibility for medications. Almost all surgery results in a period of time spent in bed and with less ability to move around. Loss of functional ability is common. If a person starts with functional loss it is more likely that additional decline will occur after surgery.
  5. Impaired mobility. The ability to move around on one’s own goes along with functional status. And the confinement that is associated with post surgery care will make it more difficult to moving around. Prolonged bed rest leads to increased weakness and can impact balance and ability to walk. Loss of mobility increases the risk for several post operative complications such as infection, pneumonia, and blood clots. So if mobility is impaired before surgery the post surgery confinement will make things worse.
  6. Malnutrition. Malnutrition in older adults is more common than most people think. People living in their own homes may have difficulty obtaining and preparing adequate meals. For a variety of reasons some people who live in supportive environments like assisted living and nursing homes also have high rates of malnutrition. Once a person is in a hospital the opportunities to eat – and someone to encourage them to do so – might not be the highest priority for nursing staff. These factors increase the likelihood of malnutrition. Obviously a person getting inadequate food and liquids is more likely to suffer from post surgical complications. This applies especially to infections.
  7. Difficulty swallowing. Another closely related risk factor is difficulty swallowing. This results from several reasons and is associated with malnutrition. The risk of contracting pneumonia also rises for those who have difficulty swallowing.

Patients’ and families’ hopes are raised by the possibility of success of a proposed surgery. This can make it difficult to think and ask about other potential consequences. Surgeons, whose focus is to solve problems, don’t always consider the unintended consequences of a particular surgery or procedure.

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Most people over 85 will have some of the risk factors listed. In fact reviewing this list might scare you if you see several risk factors that apply to your parent. Perhaps this is a good thing. Many older adults go through surgery because it seems to be the best solution for some specific medical problem. But, when decisions are made without considering the factors above the consequences might be quite different than what was expected.

Surgeons have a principle of “doing what’s right for the patient.” As advances in medicine have allowed surgery to be performed on more and more frail and fragile older adults many doctors are realizing this isn’t always the best treatment plan. More and more doctors realize that doing the right thing might not involve surgery because sometimes the solution to one problem might make another problem worse.

As these physician groups continue their work we can expect to see more practice standards to support surgeons and hospitals in following their principle of doing what is right. In the meantime you can be prepared to ask questions and consider alternatives to surgical procedures.

See Tips for a Hospital Stay if you decide to proceed with surgery.

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