As We Age, How Safe Is Surgery?
Experts say age alone is not a risk factor in having a procedure
(Editor’s note: This story is part of a series for The John A. Hartford Foundation.)
As you age, your body’s heart, kidney, lungs and other organ functions deteriorate. Under normal conditions, this is nothing to worry about. But when faced with intense stress, like a surgical procedure, the body can’t always bounce back.
“Replacing someone’s hip when they’re eighty-five is harder than when they’re fifty. That becomes a more difficult task. Your body takes longer to recover,” says Dr. Clifford Ko, a colorectal surgeon at the University of California and director of research and optimal patient care at the American College of Surgeons.
Adults age 65 and older account for more than 40% of all inpatient surgical operations and 33% of outpatient procedures each year. But, unsurprisingly, this population faces higher rates of post-procedure mortality and complication rates.
Rather than writing a patient off surgery because of their age, decisions should be based on their functional age.
Now, a new effort hopes to improve the health outcomes of older patients undergoing surgery.
The Risks of Surgery
“In modern surgery, it’s a rare event to die from surgery,” says Dr. Emily Finlayson, director of the University of California San Francisco’s Center for Surgery in Older Adults. “The risk comes from being able to recover.”
But death from surgery can still happen. In a 2017 study of patients ages 68 to 95 who had emergency abdominal surgery, for example, 20% died.
And older adults are at risk for almost every potential complication, including infection and heart, lung or kidney problems, says Dr. Mark Katlic, Sinai Hospital of Baltimore’s chief of surgery and director of Sinai Center for Geriatric Surgery.
Among older patients, those over 80 are particularly vulnerable.
In a 2006 study looking at more than 7,000 surgical procedures in adults over 65, morbidity and mortality rates were 28% and 2.3% respectively, but in patients older than 80, those rates climbed to 51% and 7%.
Other studies have concluded similar findings, particularly for patients 80 and up undergoing major surgery related to lung, esophageal and pancreatic cancer; they’re also more likely end up in nursing homes after surgery.
However, experts say that age itself is not a risk factor in surgery. It’s just that people tend to have more chronic health issues as they get older, so they are also more likely to have surgical complications.
In a study published last year in the journal BMC Medicine, researchers reviewed scientific literature to find that factors other than age, like frailty, smoking, mental impairment and depression, increased the risk for complications after surgery.
Until now, there had not been uniform standards set for evaluation and care of older patients undergoing surgery.
One method for predicting health outcomes of older patients is the Comprehensive Geriatric Assessment (CGA). Under the CGA, doctors look at patients’ medical illness and physical decline as well as social factors to determine health outcomes. But in a 2018 review study, researchers found that the assessment may not be as beneficial for surgery. While they found evidence that CGA can improve outcomes in people with hip fractures, there was not enough evidence to suggest the assessment is effective in other surgeries.
Now experts say they’ve come up with first-of-its-kind standards for older patients undergoing surgery. The American College of Surgeons (ACS) launched a new program this summer — the Geriatric Surgery Verification (GSV) Program — designed to help hospitals improve outcomes for patients 65 and older. (The program is supported by The John A. Hartford Foundation, a Next Avenue funder.)
For more than three years, a coalition of doctors and health care professionals worked to study and evaluate why older patients had poor outcomes after surgery and what measures could improve those outcomes.
“One of the hallmarks of giving good care is standardization,” said Ko, who led the work on the GSV program. “There were a number of things we as a health care system could do better. The best way we could implement it in an impactful way is to develop a program that includes standards and protocols.”
This program presents 30 new surgical best practices and will be taking applications from hospitals that want to implement the standards and receive support from the ACS.
One of the most important standards of the program is screening for geriatric vulnerabilities. Rather than declining a patient for surgery because of age, decisions should be based on the person's functional age.
“Can you dress yourself, bathe yourself, shop for yourself? If you answer no to any of those, that puts you at higher risk for complications,” Katlic says.
Both Finlayson and Katlic participated in the team to determine best practices for the GVS program.
Fragility, cognition, mobility, depression, how much support how someone has at home — those are all also factors to be considered. These are mostly non-traditional factors, and in particular, “fragility is an emerging concept that goes beyond chronological age. You can be eighty and really fit, or you can be fifty-five and have a lot of physical function issues and maybe cognitive issues,” Finlayson says. Fragility is more about resilience in mind and body, she adds.
These factors in combination can be much more significant than having heart disease or kidney problems.
Another standard is improving communication to understand what patients want to get out of a surgical procedure and what’s most important to them in the aftermath.
Katlic says doctors need to ask older patients what’s a larger priority: length of life or quality of life?
“Someone with a cancer might want to live long enough to get married, so length of life is important to them. Even if it would mean that they have to live with help,” Katlic says. “Someone else might say the length of my life is not as important as remaining independent.”
That has not always been a discussion because doctors have assumed most people would want to live longer, Katlic says.
Doctors should also understand patient wishes, like end-of-life plans and advance directives, Ko says.
As our population ages, more people over 65 will face the risks of surgery complications, and Ko says that implementing these types of standards can go a long way to providing the best care for older patients and preventing poor results after surgery.
Hospitals will be applying for the program in October 2019, and ACS will begin site visits of hospitals in early 2020.