Seniors have a lot of surgeries! In fact, people 65+ years old account for over 40% of all surgical procedures in the US. In fact, researchers estimate that ever year, there are 1 million major surgeries performed on people 65+ years old. Unfortunately, older patients have a higher risk of complications and harm, even for procedures that most consider routine. Therefore, if you, or your loved one, are over 65, consider the pros and cons before agreeing to a procedure. To help you decide, use my questions seniors should ask before surgery, which you can find below.
Note that the minimum age of a “senior” is often considered 65. However, many of the issues raised in this post present more of a concern for patients in their 80s and 90s.
What do seniors hope to gain from surgical procedures?
Senior patients undergo a range of surgical procedures, from major operations that involve ICU stays and lengthy recoveries to minor procedures performed in a doctor’s office, such as the removal of nonfatal skin cancers.
The goals for senior patients may differ significantly 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.
Importantly, surgical procedures may not meet the long-term goals of senior patients, since many of us prefer to avoid difficult treatments that have a limited ability to maintain our functional abilities or improve our lives. In other words, although surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or return their quality of life.
Additionally, for senior patients with a slew of chronic conditions, a surgical fix for one ailment may not improve their overall quality of life.
Thinking about your goals, or the goals of your loved one, will help you make treatment decisions. Our list of questions seniors should ask before surgery can help you determine the best choice for you or your loved one.
Surgical procedures are risky for seniors.
Although plenty of people in their 80s and 90s have many years of life ahead of them, studies show surgery is also common among seniors who are frail.
Importantly, 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, increasing age itself can increase the risk of complications and deaths following surgery. Importantly, a recent study found that seniors may experience more problems after surgery if they:
- Have chronic conditions, such as heart or kidney disease.
- Are already weak or have difficulty moving around.
- Cannot care for themselves.
- Have cognitive problems.
Importantly, a 2022 study evaluated 7 years of data on invasive procedures on senior patients occurring in operating rooms with patients under anesthesia. Examples include hip replacements, gallbladder removals, and hernia repairs, as well as procedures to improve blood flow in the heart, remove cancer from the colon, and fix leaky heart valves. The results show that 13.4%. (almost 1 in 7) older adults died within a year of undergoing major surgery, with patients aged 90+ six times more likely to die than those 65 – 69 years old.
Another study evaluated 10 years of data for patients 65+ years old who had emergency major abdominal surgery. The researchers found that 20% died within 30 days, and 34% died within a year. Even worse, 50% of those 85+ years old died within 1 year of their surgery.
Procedures in ambulatory surgery centers also pose risks.
As Medicare removes procedures from the inpatient-only list, more and more seniors will undergo surgical procedures at freestanding ambulatory surgery centers. These surgery centers are not attached to a hospital or emergency department, and patients are expected to go home the same day.
One study evaluated outcomes for seniors undergoing procedures in ambulatory surgery centers and found that patients over 65 had an increased rate of same-day hospital admissions and complications after surgery, as compared to patients under 65 years old.
Similarly, another study found that seniors were 54% more likely to be admitted to the hospital within 30 days of surgery at an ambulatory center, as compared to patients under 65 years of age – regardless of their health status before surgery.
When patients go home the same day as their surgery, they, or their loved ones, must stay on top of care related tasks. For instance, they must follow medication instructions – which may include opioid painkillers. Additionally, patients must monitor themselves for issues requiring immediate attention, such as bleeding or infection.
Since seniors may have difficulty understanding medication dosing and discharge instructions, or may have cognitive impairments, it can be hard for seniors to get everything right, which can lead to complications and even hospitalizations.
Risks are worse for frail patients.
Studies show surgery is common among seniors who are frail, even though they face more risks than non-frail senior patients. For example, a 2016 study 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.
And a 2022 study found that older patients who are frail or who have probable dementia have a higher risk of death after major surgery.
Surgeries close to end-of-life are even riskier.
Importantly, older patients who have surgery within a year of death spent 50% more time in the hospital than younger patients, and nearly twice as many days in intensive care units. Yet almost 1 in 3 Medicare patients have surgery in their last year of their life, even though evidence shows many are more likely to be harmed than to benefit from it.
These findings underscore the importance of seniors and their loved ones asking questions before surgery that focus on the needs and desires of the patient.
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.
Post-surgical 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.
Surgical 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 lives in a nursing home, talk to the doctor specifically about this issue and carefully consider risks before deciding on surgery.
Why do seniors undergo surgical procedures they might not benefit from?
There are many reasons why seniors can undergo procedures that provide little or no benefit.
Firstly, surgeries among seniors are partly driven by financial incentives that rewards doctors for performing procedures. These financial rewards can encourage a doctor to recommend a procedure that a patient might not benefit from. And with diminished cognitive abilities, and an old-fashioned respect for the medical profession, some senior patients may receive unwanted interventions because they are unable or unwilling to voice their opposition.
Additionally, in the US, our culture believes in aggressive care, often without considering the pros and cons of surgical procedures, or the priorities of patients. And, as a society, we are not comfortable having conversations about choosing who should, or should not, receive surgical interventions.
How do surgeons and hospital address the needs of seniors before, during, and after 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 they only evaluated how well the patient understood what the 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.
One Boston hospital leads the way.
The Center for Geriatric Surgery at Brigham and Women’s Hospital is one of the most advanced systems in the country for geriatric surgical care. They conduct frailty screenings on seniors who are candidates for surgery. When they identify a patient as frail, the patient then sees a geriatrician, undergoes a thorough geriatric assessment, and meets with a nurse who helps coordinate care after hospital discharge.
Additionally, they instituted “geriatric-friendly” orders for post-surgery hospital care with a goal of minimizing the harms of hospitalization. As part of this program, they assess older patients three times a day for delirium. They also get patients moving as soon as possible, and use non-narcotic pain relievers.
What questions should seniors ask before surgery?
Importantly, you should have an honest conversation with your doctors. Clearly state your priorities (such as quality of life versus life extension) and describe your near and long-term goals. And be sure to 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.)
Here are the questions should seniors ask before surgery:
In addition to the questions patients of any age should ask before surgery, be sure to use these questions seniors should ask before surgery:
- What are the goals for this procedure?
- What are the best, worst, and most likely outcomes, given my age, health, and functional status right now?
- What will life “look like” in the worst-case scenario?
- What are the expected impacts on my physical and cognitive health?
- How will surgery impact the quality of my life immediately after surgery? After 3 months? After 1 year?
- Is a loss of independence expected? If so, for how long?
- 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?
- Will the anesthesiologist be a doctor who has experience with senior patients?
- What steps can I take before, during and after surgery to help reduce my risks of age-related problems from anesthesia and to help me recover?
- How likely is it that I will need an invasive intervention, such as a feeding tube, drains, respirator, or central line? For how long?
- 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?
- 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?
If you decide to schedule a procedure, ask for a copy of typical discharge instructions – before your procedure. These instructions will give you a chance to make sure you understand what will be required. And it will help you prepare for what lies ahead.
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 keep your dentures in as you enter the OR, remind your medical team you have them on!
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 years since you created an advance directive, review it since your needs and desires may have changed. 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. Then make sure the information is kept with you and in your medical records whenever possible.
Read How to Get the Medical Care You Want for more information.
Your choice of hospital can impact your health.
A stay in the hospital is a risky time for seniors. Medication issues, sleep disruptions, too much time in bed and other issues can increase the risk of health issues. For more information, read Risks for Seniors in the Hospital.
Want more information?
In addition to using my questions seniors should ask before surgery, read these posts to reduce your risk of harm:
- Questions to Ask Before Surgery.
- You Can Improve Your Surgical Outcome.
- How to Recover Faster After Surgery.
- Surgical Dangers – What You Need to Know.
- How Safe Are Surgery Centers?
NOTE: I updated this post on 1-30-23.