Nearly one in seven older adults die within a year of major surgery, according to a major new study that sheds light on the risks seniors face when undergoing invasive procedures.
Particularly vulnerable were elderly patients who were at risk of dementia (33% died within a year) and frailty (28%), and patients undergoing emergency surgery (22%). Advanced age also increases the risk: patients aged 90 or over were six times more likely to die than those aged 65 to 69.
The study, published in JAMA Surgery by researchers at Yale School of Medicine, addresses a significant gap in research: Although patients 65 and older receive nearly 40 percent of all surgeries in the U.S., detailed national data on the outcomes of those procedures The data is mostly missing
“As a field, we’ve been really remiss in not understanding long-term surgical outcomes in older adults,” 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, become disabled, can no longer live independently, or experience a significant deterioration in quality of life after major surgery.
“What older patients want to know is, ‘What will my life be like?'” Cooper said. “But we haven’t been able to answer that with data of this quality before.”
In the new study, Dr. Thomas Gill and colleagues at Yale University examined traditional Medicare claims data from 2011 to 2017 and survey data from the National Trends Study on Health and Aging. (Data for private health insurance advantage plans were not available at the time, but will be included in future studies.)
Invasive procedures performed in the operating room under general anesthesia are considered major surgery. Examples include procedures such as replacing a broken hip, improving blood flow to the heart, removing colon cancer, removing the gallbladder, repairing a leaky heart valve, and repairing a hernia.
Older adults tend to have more problems after surgery if they have a chronic medical condition such as heart or kidney disease; if they are already frail or have limited mobility; if their ability to care for themselves is impaired; Yale Medicine, Epidemiology Gill, a professor of science and research medicine, pointed out that if they have cognitive problems.
Two years ago, Gill’s team conducted a study showing that one-third of older adults had not returned to their baseline level of function six months after major surgery. Those most likely to recover are older adults who can prepare ahead of time for elective surgery.
In another study, published last year in the Annals of Surgery, his team found that about 1 million major surgeries occur each year in people 65 and older, including a large number near the end of life. Notably, data documenting the extent of surgery in older adults has been lacking to date.
“This raises all kinds of questions: Are there good reasons for these surgeries? How is appropriate surgery defined? Is the decision to perform surgery made after eliciting the patient’s priorities and determining whether the procedure is achievable?” said Dr. Clifford Ko, professor of surgery at UCLA School of Medicine and director of research and optimal patient care at the American College of Surgeons.
As an example of such a decision, Ko describes a 93-year-old patient who learned he had early-stage colon cancer in addition to preexisting liver, heart and lung disease. After an in-depth discussion and informed of the high risk of poor outcome, the patient decided not to proceed with the invasive treatment.
“He decided he would rather risk the slow progression of the cancer than major surgery and complications,” Ke said.
Despite this, most patients opt for surgery. Dr. Marcia Russell, a surgeon at the Veterans Affairs Healthcare System in the greater Los Angeles area, described a 90-year-old patient who recently learned he had colon cancer during a lengthy hospital stay for pneumonia. “We talked to him about surgery, and his goal is to live as long as possible,” Russell said. To help the patient, who is now recovering at home, prepare for future surgery, she recommends that he undergo physical therapy and eat more high-protein foods, steps that should help him grow stronger.
“He might need six to eight weeks to be ready for surgery, but he’s motivated to improve,” Russell said.
The choice older Americans make to undergo major surgery will have wide-ranging societal ramifications. With an increase in the population over 65, “it will be financially challenging for Medicare to cover surgery,” noted Dr. Robert Becher is an assistant professor of surgery at Yale and a collaborator on Jill’s study. According to a 2020 analysis, more than half of Medicare spending is for inpatient and outpatient surgical treatments.
What’s more, “nearly every surgical specialty will face a workforce shortage in the coming years,” Becher said, noting that by 2033, the number of surgeons needed to meet projected demand will drop by nearly 30,000.
These trends make efforts to improve surgical outcomes in older adults all the more important. Yet progress has been slow. The American College of Surgeons launched a major quality improvement initiative in July 2019, eight months before the onset of the covid-19 pandemic. It requires hospitals to meet 30 criteria to gain recognized expertise in geriatric surgery. So far, fewer than 100 of the thousands of eligible hospitals have participated.
One of the most advanced systems in the country, the Geriatric Surgery Center at Brigham and Women’s Hospital, illustrates that anything is possible. There, frailty screening is performed for older adults who are suitable for surgery. Those judged to be frail consult with a geriatrician, undergo a full geriatric assessment and meet with a nurse who will help coordinate care after discharge.
An order for “geriatric-friendly” post-surgery hospital care has also been initiated. This includes assessing elderly patients three times a day for delirium (an acute change in mental status that often afflicts elderly hospitalized patients), mobilizing patients as soon as possible, and administering non-narcotic pain medications. “The goal is to minimize the harm of hospitalization,” said Cooper, who led the work.
She told me about a recent patient who she described as “a social woman in her 80s who still wears skinny jeans to cocktail parties.” The woman presented to the emergency department with acute diverticulitis and delirium; a geriatrician was called in prior to surgery to help manage her medications and sleep-wake cycle and recommend nonpharmacological interventions.
With the help of family members who visited the patient at the hospital and continued to be involved in her care, “she is doing well,” Cooper said. “That’s the kind of outcome we’re trying to achieve.”