Elective Surgery in the Older Patient
A common and important aspect of healthy aging is having surgery to address a medical problem where there is no better medical management plan. A disproportionate number of surgeries are performed on people 65 years or older. This is because, as we age, the wear and tear begins to take its toll on our bodies and joints, tendons, eyes, and hearing, and whole organs no longer function well, as diseases like atherosclerosis and cancer occur. In some cases surgery can be restorative or, as we commonly say in the profession, palliative (meaning things can be improved if not completely fixed).
Making the Decision to Have Surgery
The decision to have an elective operation is generally arrived at by you, your family, your primary care doctor and the surgeon specialist. Your primary care physician will generally refer you to the surgeon after talking with you and your family, but the actual decision about a given surgical procedure is up to you, your family and the surgeon. There are no “geriatric” surgeons — it is not a medical specialty as geriatric internal medicine is. The surgical specialist to whom you are referred will be someone who does the operation you need to consider, and does it well, or you would not be referred to him/her.
Once you meet with the surgeon it is vitally important that expectations are made crystal clear. By expectations, we mean what is it that you want the operation to allow you to do that you no longer are able to do? As we age and enter the geriatric group, things change in surgical approach. A new variable related to age is that it often takes longer to recover from surgery than when younger people have it, and complications tend to be more common, including ones that can involve mental acuity and short-term postoperative delirium or confusion, even in the most alert of us. Thus, all the risks (which are greater the older we get) and the expected benefit must be clearly discussed and understood. This includes the real possibility that convalescence may be slow (sometimes months). In the end, you, the patient, have to make the decision.
Goals for the Surgery & Getting There
The goal is to improve or remove whatever is causing the need for surgery. A secondary, but very important, goal is to achieve a functional state better or at least as good as before the operation. Functional recovery is more important to us as we age than it may be to younger people who worry less about independence.
Before the Operation
In order to achieve this goal, the patient needs to be evaluated thoroughly and anything that can be improved should be before surgery. For example, blood pressure should be well regulated prior to surgery and the same goes for many things that can be improved prior to an elective operation. Your general internist or geriatrician is best able to make sure you are as ready as you can be for the surgeon. It is particularly important for the team to know if there is a history of falls, or alcohol or drug dependence. All chronic diseases need to be clearly understood and documented and disease management assessed. The surgeon undoubtedly will have some suggestions as well.
Others may be asked to get involved well before an elective operation such as an anesthesiologist, physical therapist or maybe dietitian. All will evaluate you from their perspective and optimize things before the operation.
There are administrative details that need to be dealt with, too, including making sure that you have a “living will” that deals with all the things nobody likes to think about. It should clearly outline your preferences for life-sustaining technology if you are faced with seriously impaired quality of life. Specifically it should address whether resuscitation, mechanical ventilation, feeding tube, intravenous nutrition, hemodialysis and blood transfusion are the types of interventions that should be addressed in the face of seriously reduced quality of life. For very high risk operations, a physician order for life-sustaining treatment (POLST) may be recommended. This set of medical orders on the hospital record will specify which interventions you have told your doctor you want or do not want.
During the Operation
During the operation, the patient should have confidence that the surgeon and anesthesiologist are mindful of the particular problems the older patient has. Some of the concerns that are greater for the older patient are careful positioning, maintaining temperature, and careful fluid administration since the heart and kidneys do not work as well as when the patient was younger. The anesthesiologist particularly has to reduce doses of certain drugs and avoid others that tend to cause delirium. If possible, regional anesthesia — as opposed to general anesthesia — seems to be better for older patients, and certainly short-lasting drugs are preferred to longer-action ones. The surgeon has to be gentle with the tissues and very fastidious about potential infections.
After the Operation
The older patient requires more care postoperatively. Pain should ideally be dealt with using multiple approaches and not solely relying on opioids. It is important to walk or move around as soon as possible and, if appropriate, discharge from the hospital. Family should visit and help keep the patient oriented. The patient and family can use the checklist below, along with the nurses and doctors, to prevent common postoperative problems.
Checklist: Some Things Patients/Family Should Be Mindful of to Prevent Adverse Events
Delirium/Cognitive Impairment Preventive Steps
- Satisfactory pain control
- Family presence
- Frequent orientation
- Hearing aid and glasses in use
- Early mobilization
- Wall calendar and clock
Fall Risk Preventive Steps
- Assisted walking
- Scheduled toileting
Pressure Ulcer Preventive Steps
- Reposition to avoid prolonged pressure
- Wound care
- Early mobilization
- Adequate nutrition
Modified from: Mohanty, S., et al., Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg, 2016. 222(5): p. 930-47
The Bottom Line
Surgery is common as we age. The indications are very diverse and have various goals, but all elective operations in the elderly can and should be approached differently than for the young. The reason is that the risks are greater and quality-of-life concerns are more important. Being clear about expectations and choosing doctors for the team that have experience and competence is important. However, you and your family play a vital role in making sure communication is clear and that you have done all you can to be in the best shape possible for the surgical procedure. As an anesthesiologist, I always knew that my patients would have preferred to be somewhere else, but often surgery is required for improved healthy aging.