Nearly one in seven older adults will die within a year of major surgery, according to a major new study that sheds light on the risks older people face when undergoing invasive procedures.
Older patients with probable dementia (33% die within a year) and frailty (28%), as well as those undergoing emergency surgery (22%), are particularly vulnerable. Advanced age also amplifies the risk: patients aged 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, fills a notable research gap: Although patients 65 and older undergo nearly 40% of all surgeries in the United States, Detailed national data on the results of these procedures have largely disappeared.
“As a field, we’ve been really negligent in not understanding long-term surgical outcomes for the elderly,” said Dr. Zara Cooper, professor of surgery at Harvard Medical School and director of the Center for Geriatric Surgery at Brigham and Boston Women’s Hospital.
Information on the number of older people who die, develop disabilities, can no longer live independently or have a significantly impaired quality of life after major surgery is particularly important.
“What older patients want to know is, ‘What’s my life going to be 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 traditional health insurance claims data and survey data from the National Health and Aging Trends Study covering the period 2011 to 2017. (Data from private Medicare Advantage plans was not available at that time, but will be included in future studies.)
Invasive procedures that take place in operating rooms with patients under general anesthesia were counted as major surgeries. Examples include procedures to replace broken hips, improve blood flow in the heart, excise colon cancer, remove the gallbladder, repair leaky heart valves, and repair hernias, among many others.
Older adults tend to have 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 any cognitive issues, noted Gill, professor of medicine, epidemiology and investigative medicine at Yale.
Two years ago, Gill’s team conducted research that showed that one in three older adults had not returned to their baseline level of functioning six months after major surgery. Those most likely to recover were older people who had undergone elective surgeries for which they could prepare in advance.
In another study, published last year in the Annals of Surgery, his team found that around 1 million major surgeries occur each year in people aged 65 and over, with a significant number nearing the end of life. . Remarkably, data documenting the extent of surgery in the elderly population has been lacking until now.
“It opens up all sorts of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were decisions to perform surgery made after elucidating the patient’s priorities and determining whether surgery would achieve them? said Dr. Clifford Ko, professor of surgery at 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 type of decision-making, Ko described a patient who, at age 93, was told he had early-stage colon cancer in addition to pre-existing liver, heart, and and lungs. After careful discussion and after being informed that the risk of poor results was high, the patient decided not to undergo invasive treatment.
“He decided he’d rather take the risk of a slow-growing cancer than face major surgery and the risk of complications,” Ko said.
Still, most patients choose surgery. Dr. Marcia Russell, staff surgeon at Veterans Affairs Greater Los Angeles Healthcare System, described a 90-year-old patient who was recently diagnosed with colon cancer during an extended hospital stay for pneumonia. “We spoke with him about the surgery, and his goals are to live as long as possible,” Russell said. To help prepare the patient, now recovering at home, for future surgery, she recommended that he undertake physical therapy and eat more protein-rich foods, measures that should help him become stronger.
“He may need six to eight weeks to prepare for surgery, but he’s motivated to improve,” Russell said.
The choices older Americans make to undergo major surgery will have broad societal implications. As the population over 65 grows, “covering surgery is going to be a financial challenge for Medicare,” noted Dr. Robert Becher, assistant professor of surgery at Yale and research collaborator with Gill. Just over half of Medicare spending is on inpatient and outpatient surgical care, according to a 2020 analysis.
Additionally, “almost all surgical subspecialties will experience labor shortages in the coming years,” Becher said, noting that by 2033 there will be nearly 30,000 fewer surgeons than needed to meet expected demand.
These trends make efforts to improve surgical outcomes for older adults even more critical. Yet progress has been 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 acquire recognized expertise in geriatric surgery. So far, less than 100 of the thousands of eligible hospitals are participating.
One of the nation’s most advanced systems, the Center for Geriatric Surgery at Brigham and Women’s Hospital, exemplifies what is possible. There, elderly candidates for surgery are screened for frailty. Individuals deemed frail see a geriatrician, undergo a thorough geriatric assessment, and meet with a nurse who will help coordinate post-discharge care.
Prescriptions “adapted to geriatrics” are also launched for post-surgical hospital care. This includes evaluating elderly patients three times a day for delirium (an acute change in mental status that often afflicts elderly hospitalized patients), moving patients as soon as possible, and using non-narcotic painkillers. “The goal is to minimize the harms of hospitalization,” said Cooper, who is leading the effort.
She told me about a recent patient, whom she described as a “social woman in the early 80s who still wore skinny jeans and went to cocktail parties.” This woman presented to the emergency room with acute diverticulitis and delirium; a geriatrician was called before the 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 remained involved in her care, “she is doing great,” Cooper said. “That’s the kind of result we’re working very hard for.”