Surgery is scary for everyone. What if something goes wrong? Is it possible you won’t wake up? What if it doesn’t help or makes your condition worse? These questions go through the minds of most people before they agree to a surgical procedure. But, for older patients, there is a higher risk of complications and harm, even for procedures that most consider routine. So, if you are over 65, or you have a loved one who is a senior, you should consider the ramifications of surgery before you agree to a procedure. Below you’ll find questions seniors should ask before surgery. These questions, plus the information in this post, can help you make the important decision regarding how to proceed for yourself or a loved one.
Note that the minimum age of a “senior” is often considered 65, many of the issues raised in this post are more of a concern for patients in their 80s and 90s.
The number of seniors having surgery is increasing.
In 2019, 10,000 people in the US turn 65 every day. And those over 65 are having a lot of surgical procedures. In fact, right now in the US, adults 65+ account for over 40% of all inpatient operations and 33% of outpatient procedures every year. Moreover, 25% of Medicare patients have surgery in their last three months of their life.
And, as one could easily guess, the number of seniors having surgery will increase as the population ages and the need for surgeries increases.
The goals of senior patients.
The goals for senior patients can be very different from those of younger patients. For instance, older patients may prioritize remaining independent with a reasonable quality of life and staying in their current home, instead of living longer at any cost. Also, a senior patient may prioritize the ability to spend his/her remaining time with family and friends over hospitalization and drastic measures. Thinking about your goals will help you make treatment decisions.
The vulnerability of older surgical patients.
There is no doubt about it, older patients are more vulnerable during and after surgery, as compared to younger patients. Unfortunately, common health problems related to aging, such as high blood pressure, clogged arteries, as well as heart and lung disease, increase the risk of side effects or complications during or after surgery. Furthermore, research shows that increasing age itself can increase the risk of complications and deaths following surgery.
Many senior patients never fully recover.
Unfortunately, according to a NY Times article, “a substantial proportion of older people who enter hospitals will never fully regain their physical or mental capabilities, even when the illness that brought them there is successfully treated.” Furthermore, research shows that surgery on “frail elderly patients generally has a limited ability to prolong survival or return patients to the quality of life they had before surgery.”
Risk is highest for nursing home residents.
It turns out that residents of nursing homes have substantially higher rates of death and of invasive interventions (such as mechanical ventilators and feeding tubes) after major surgery, as compared to other Medicare beneficiaries. Although you might think this is because nursing home residents tend to be older and sicker, there was a substantial increase in risk even when “compared with adults of similar age who had the same number of chronic illnesses“. So, if you or your loved one resides in a nursing home, talk to the doctor specifically about this issue and carefully consider risks before deciding on surgery.
The risks of anesthesia in older patients.
Unfortunately, the aging brain is more vulnerable to anesthesia. Two common anesthesia-related surgery risks are:
- Postoperative delirium is a temporary condition that causes confusion and disorientation, as well as a general unawareness of surroundings. Additionally, it can cause problems with memory and paying attention. These problems may not start until a few days after surgery, may come and go, but they usually disappear after a week.
- Postoperative cognitive dysfunction (POCD) is a more serious condition that can cause long-term memory loss. Additionally, POCD can make it hard to think, concentrate and learn. Unfortunately, certain conditions, including heart or lung disease, Alzheimer’s disease, Parkinson’s disease and a history of stroke, increase the risk for POCD. But, the only way to determine if a patient actually has POCD would involve conducting cognitive tests before surgery.
Invasive interventions bring risk.
Invasive interventions after surgery, such as ventilators, central lines and feeding tubes, make it even harder for seniors to recover. Why? These interventions increase the risk of infection and often keep patients in bed – both of which can lead to deteriorating health.
What are surgeons doing to address the needs of seniors having surgery?
In an ideal world, surgeons would take time to listen to their patients’ difficulties and desires. And they’d fully involve patients in the decision-making process. But, that is not always the case. In one study involving 60+ year-old patients, orthopedic surgeons only discussed the patient’s role in decision-making 15% of the time, and only evaluated how well the patient understood what surgery would involve 12% of the time.
However, it looks like things are going to improve for older surgical patients.
In July 2019, the American College of Surgeons (ACS) introduced the Geriatric Surgery Verification (GSV) Program. The GSV program, which is currently in the pre-enrollment stage, outlines 30 new surgical standards designed specifically to improve the care and outcomes of older surgical patients.
The GSV Program will help all hospitals perform operations effectively, efficiently, and safely in older patients with a thorough and individualized approach. Importantly, these standards consider the distinct physical and social vulnerabilities of older patients, and the unique goals for their care.
The standards outline processes for improving surgical care for older adults, including, but not limited to:
- Improving communications with patients before surgical procedures to focus on outcomes that matter most to the patient
- Screening for geriatric vulnerabilities
- Better management of medications
- Providing geriatric-friendly rooms
- Ensuring proper staffing is in place
What can you do?
First, have an honest conversation with your doctor(s). Be sure to clearly state your priorities (e.g. quality of life versus life extension). Describe your plans for the near and long-term future. And participate in the decision-making process. It’s always a good idea to bring a loved one who can help you make decisions with you to appointments. Additionally, the hospital’s palliative care team might be able to help you with decision-making. (Read my post on palliative care to learn more.)
Legal documents help you get the care you want.
All people, particularly seniors, should have advance directives. This document outlines your wishes and instructions for the care you desire in case of a life-threatening event during which you cannot speak for yourself. You can include your desires regarding CPR, ventilators, feeding tubes, blood transfusions and more. Visit the US National Institute on Aging for more information. If it’s been a while since you created an advance directive, it’s a good idea to look it over since your needs and desires change over time. Talk to a lawyer if you have questions or concerns.
Additionally, complete a health care proxy form to assign who can make medical decisions if you are not capable. Download a health care proxy form for your state, fill it out and have it signed by witnesses.
Complete these documents prior to any surgery and make sure the information is kept with you and in your medical records when possible.
What are the questions seniors should ask before surgery?
In addition to the questions that patients of any age should ask before deciding on surgery, seniors should be sure to ask these as well:
- What are the best, worst and most likely outcomes?
- What are the expected impacts on my physical and cognitive health?
- How will surgery impact the quality of my life?
- Is a loss of independence expected?
- Are there things I can do before my surgery to make recovery easier and/or faster?
- What kinds of things can go wrong and how likely is each potential complication?
- What will life “look like” in the worst-case scenario?
- Will the anesthesiologist be a doctor who has experience with senior patients?
- What steps can we take before, during and after surgery to help reduce my risks of age-related problems from anesthesia?
- How long will recovery take? How long will I be in the hospital? Will I need a rehab facility? For how long?
- Will I need nursing care or other help at home? For how long?
- How likely is it that I will need an invasive intervention, such as feeding tube, respirator or central line? For how long?
- Are there any possible treatments other than surgery, and what are the likely outcomes for any non-surgical options?
- What would my future look like if I do nothing?
- Will palliative care help me?
One more thing…
If you have dentures, ask your surgeon if you should remove the dentures before you enter the operating room since the insertion of the breathing tube can dislodge dentures, potentially causing serious health issues. But in some cases, keeping dentures in until the last minute helps anesthesiologists administer medications. If you decide to keep your dentures in as you enter the OR, remind your medical team that you have them in your mouth!
Want more information?
For more information on reducing the risk of surgical complications and harm, read these blog posts:
- Questions to Ask Before Surgery
- You Can Improve Your Surgical Outcome
- How to Recover Faster After Surgery
- What Kinds of Things Can Go Wrong During Surgery?
- Is Nighttime Surgery Safe?
- Is it Safe to Have Surgery in a Surgery Center?