Evaluating surgical risks for older adults
For older adults, surgery presents a different set of challenges and risks compared to younger patients. Age-related physiological changes reduce the body’s reserve, increasing susceptibility to complications. A thorough preoperative evaluation is crucial and extends beyond standard medical history to include geriatric-specific factors. This holistic assessment helps determine the patient's capacity to tolerate and recover from a procedure.
Key factors beyond age
While chronological age is a consideration, it's not the primary determinant of surgical fitness. A multi-faceted approach is necessary to determine the best path forward for an 85-year-old patient. The key areas of evaluation include:
- Frailty: Frailty syndrome, characterized by decreased strength, endurance, and physiological function, is a significant predictor of surgical outcomes. Assessments measuring grip strength, walking speed, and weight loss can help identify frail patients who may benefit from prehabilitation to improve their surgical tolerance.
- Functional Status: This refers to the patient's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). A patient's baseline mobility, ability to dress themselves, and manage their finances can indicate their potential for recovery and post-surgical independence. Frailty and poor functional status are major risk factors for poor outcomes.
- Cognitive and Mental Health: Cognitive impairment, such as dementia, and mental health conditions like depression and anxiety, can increase the risk of postoperative complications. A history of cognitive issues or depression is a risk factor for developing postoperative delirium (a temporary state of confusion) or postoperative cognitive dysfunction (long-term memory or thinking problems).
- Comorbidities: The presence of multiple chronic conditions, such as heart disease, lung disease, or kidney problems, increases surgical risk. Managing these conditions effectively before surgery can help mitigate complications.
- Type and Urgency of Surgery: The risks vary significantly between a planned, elective procedure (like a joint replacement) and an emergency surgery (like for a hip fracture). Elective surgeries allow time for pre-operative optimization, while emergencies present higher risks.
The process of shared decision-making
For an octogenarian, the decision to undergo surgery should be a collaborative process involving the patient, their family, and the medical team. This approach, known as shared decision-making, ensures the patient's personal goals and values are at the forefront.
- Goal Talk: The conversation begins by discussing the patient's priorities. What matters most to them? Is it prolonging life at any cost, preserving independence, or maintaining a specific quality of life? For some, the prospect of a lengthy recovery in a skilled nursing facility might be less desirable than living with their current condition, depending on the severity.
- Option Talk: The healthcare team explains all available options, including surgery, less-invasive alternatives (e.g., medication, physical therapy), and conservative management (no intervention). The potential benefits, risks, and expected outcomes for each option must be clearly communicated, taking into account the patient's specific health profile.
- Decision Talk: This step involves the patient, with input from their family and clinicians, weighing the options against their personal goals. A decision aid tool can be used to help visualize the benefits and harms of each choice. For instance, a patient might prioritize improving mobility to remain independent, which could outweigh the surgical risks for a successful hip replacement.
Mitigating risks and planning for recovery
If the decision is made to proceed with surgery, robust pre- and post-operative planning is essential to maximize the chances of a positive outcome. This involves a coordinated approach from a multidisciplinary team, potentially including geriatricians, anesthesiologists, surgeons, and physical therapists.
- Prehabilitation: In the weeks leading up to an elective surgery, a patient can engage in a 'prehab' program to improve strength, mobility, and nutritional status. Walking, balance exercises, and light resistance training can significantly improve recovery.
- Medication Review: A full review of all medications, including supplements, is crucial to prevent interactions with anesthesia and minimize postoperative complications like cognitive issues or bleeding.
- Anesthesia Planning: An anesthesiologist experienced in geriatric care can tailor the anesthetic approach. Using shorter-acting drugs and considering regional anesthesia over general anesthesia, where appropriate, can reduce the risk of delirium.
- Postoperative Care: The recovery plan should address potential challenges common in older adults, such as delirium, falls, and pain management. Early mobilization, ensuring proper hydration and nutrition, and involving family to help with reorientation are all critical for a smooth recovery.
Comparing treatment approaches
| Feature | Surgery | Non-Surgical Treatment |
|---|---|---|
| Risks | Higher for older adults; risk of anesthesia complications, delirium, infection. | Lower procedural risk; potential for disease progression or inadequate symptom control. |
| Recovery | Often involves longer hospital stays and a more intensive rehabilitation period. | Recovery is generally shorter and less intense, with fewer risks of major complications. |
| Effectiveness | Can offer a definitive fix for the underlying problem, potentially with a better long-term outcome. | Symptom management may be less complete; chronic conditions may continue to affect quality of life. |
| Quality of Life | Potential for significant improvement if successful, but carries a risk of functional decline. | Focuses on managing symptoms to maintain or improve current quality of life, avoiding major risks. |
Conclusion: Age is just a number in a larger equation
The question of whether an 85 year old should have surgery has no single answer. The decision is highly personal and should be based on a thorough, holistic assessment that considers the patient's overall health, functional capacity, cognitive status, and personal goals for quality of life. While surgery carries increased risks for older adults, advancements in perioperative care and a multidisciplinary approach have made it a viable and successful option for many. Open and honest communication between the patient, family, and healthcare providers is the most important step in charting the right course of action.
For more in-depth information on preparing older adults for surgery, the American College of Surgeons offers valuable resources and best practice guidelines: https://www.facs.org/.
