Surgery Holds Danger for Seniors. Who's Most at Risk?
Surgery can be a daunting prospect at any age. Now, researchers say they've spotted two key factors upping the odds of a poor surgical outcome in seniors.
Older adults who are either frail or suffering from dementia have high rates of death in the year following a major procedure, a new U.S. study finds.
Researchers found that among Americans aged 65 and older who underwent major surgery between 2011 and 2017, 13% died in the following year. And some seniors were at particular risk: One-year death rates were 28% among older adults who were frail, and nearly 33% among those with probable dementia.
The extent to which the surgery, itself, precipitated those deaths is unclear.
"Over a year, it's harder to make a direct linkage to the surgery," said lead researcher Dr. Thomas Gill, a professor of geriatric medicine at Yale School of Medicine.
But, he added, it is likely the procedures often played an important role in those older adults' deteriorating health.
Gill said the overall death rate in the study group, at 13% over one year, is substantially higher than would be expected for Americans that age.
Does that mean many older people were having operations that should not have been done?
That might be true in some cases, said Gill. But he thinks the bigger issue is that the most vulnerable seniors need better care both before and after surgery.
To start, Gill said, geriatric patients should be assessed for frailty or early dementia (which is often undiagnosed, he noted) ahead of an elective surgery.
Those with signs of frailty -- such as low weight, slow movement or fatigue -- might benefit from therapy to improve their fitness, for example. And anesthesiologists, Gill said, might make different decisions on the type of anesthesia used during the procedure, based on information from those pre-surgery assessments. (Click here for more on geriatric anesthesia).
For patients with probable dementia, he said, it's particularly important to prevent and treat delirium. That's a common post-surgery complication for older adults, but it can be especially serious and long-lasting in those with dementia.
Those pre-surgery assessments are critical, agreed Dr. Daniel Anaya, chief of gastrointestinal surgery at Moffitt Cancer Center in Tampa, Fla. All patients need to be evaluated ahead of surgery, he noted, but geriatric patients have unique concerns.
"This study brings to light how important that process is," said Anaya, who wrote an editorial published with the findings Oct. 19 in JAMA Surgery.
But besides assessing patients' health, Anaya said it's also important to discuss their expectations and goals, and figure out how to best support their quality of life.
The findings are based on a nationally representative sample of 992 older Americans, 65 and up. All underwent at least one major surgery between 2011 and 2017 -- "major" being defined as any invasive procedure done in an operating room under general anesthesia. (It did not include minimally invasive procedures done via thin scopes.)
Not surprisingly, one-year death rates after emergency surgery were much higher than after elective procedures: about 22% versus 7%. Similarly, age made a big difference: People in their 80s and 90s were anywhere from 2.5 to six times more likely to die than people in their 60s.
But age was not the whole story. Frailty was a major factor, the study found: Of older people who were not frail, only 6% died in the year following surgery -- versus 28% of those who were frail.
Meanwhile, the death rate among people with no signs of dementia was just under 12%, compared with nearly 33% among those with probable dementia.
None of that means that elderly adults with those conditions should not have surgery.
But Gill said that when surgery is recommended, patients and families should make sure there is a "clear indication" for it, and discuss the potential benefits, risks and alternatives. If they do decide on surgery, he said, they should ask whether there are any ways to optimize their health ahead of the operation.
As for post-surgery care, Gill suggested asking whether a geriatrician -- a specialist in elder care -- can be part of the team.
Older adults and their families not only care about how many years they have, but the quality of that time, Gill pointed out. He said his team plans to study other post-surgery outcomes for elderly patients, including their daily functioning and time spent at home rather than a health-care facility.
The American Geriatrics Society has help for finding age-friendly health care.
SOURCES: Thomas M. Gill, MD, Humana Foundation professor, geriatric medicine, Yale School of Medicine, New Haven, Conn.; Daniel A. Anaya, MD, chief, gastrointestinal surgery, Moffitt Cancer Center, Tampa, Fla.; JAMA Surgery, Oct. 19, 2022, online