{"id":7304,"date":"2023-05-25T13:44:09","date_gmt":"2023-05-25T17:44:09","guid":{"rendered":"https:\/\/www.silvercentury.org\/?p=7304"},"modified":"2023-05-26T07:10:00","modified_gmt":"2023-05-26T11:10:00","slug":"should-older-seniors-risk-major-surgery","status":"publish","type":"post","link":"http:\/\/78.142.243.82\/~silvercentury\/2023\/05\/should-older-seniors-risk-major-surgery\/","title":{"rendered":"Should Older Seniors Risk Major Surgery?"},"content":{"rendered":"

Until recently, surprisingly little was known about probable outcomes when people have surgery late in life. Certain risks are becoming clearer now. Writing for <\/span><\/i>KFF Health News<\/span><\/a> journalist Judith Graham explains what new studies are finding and what some doctors and hospitals are doing to make major surgery safer for older people. Graham\u2019s article was posted on the <\/span><\/i>KHN<\/span> website on Nov. 28, 2022, and also ran on <\/span><\/i>CNN<\/span><\/i><\/a>. Funding from the Silver Century Foundation helps <\/span><\/i>KHN<\/span> develop articles (like this one) on longevity and related health and social issues. <\/span><\/i><\/p>\n

Nearly one in seven older adults die within a year of undergoing major surgery, according to an important <\/span>new study<\/span><\/a> that sheds much-needed light on the risks seniors face when having invasive procedures.<\/span><\/p>\n

Especially vulnerable are older patients with probable dementia (33 percent die within a year) and frailty (28 percent), as well as those having emergency surgeries (22 percent). Advanced age also amplifies risk: patients who were 90 or older were six times as likely to die [as] those ages 65 to 69.<\/span><\/p>\n

The study in <\/span>JAMA Surgery<\/span><\/i>, published by researchers at Yale School of Medicine, addresses a notable gap in research: though patients 65 and older undergo <\/span>nearly 40 percent<\/span><\/a> of all surgeries in the United States, detailed national data about the outcomes of these procedures has been largely missing.<\/span><\/p>\n

\u201cAs a field, we\u2019ve been really remiss in not understanding long-term surgical outcomes for older adults,\u201d said <\/span>Zara Cooper, MD<\/a>,<\/span> a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women\u2019s Hospital in Boston.<\/span><\/p>\n

Of particular importance is information about how many seniors die, develop disabilities, can no longer live independently or have a significantly worsened quality of life after major surgery.<\/span><\/p>\n

\u201cWhat older patients want to know is, \u2018What\u2019s my life going to look like?\u2019\u201d Cooper said. \u201cBut we haven\u2019t been able to answer with data of this quality before.\u201d<\/span><\/p>\n

Some older people are more likely than others to have a poor outcome from surgery.<\/b><\/p><\/blockquote>\n

In the new study, Thomas Gill, MD, and Yale colleagues examined claims data from traditional Medicare and survey data from the National Health and Aging Trends study spanning 2011 to 2017. (Data from private Medicare Advantage plans was not available at that time but will be included in future studies.)<\/span><\/p>\n

Invasive procedures that take place in operating rooms with patients under general anesthesia were counted as major surgeries. Examples include procedures to replace broken hips, improve blood flow in the heart, excise cancer from the colon, remove gallbladders, fix leaky heart valves and repair hernias, among many more.<\/span><\/p>\n

Older adults tend to experience more problems after surgery if they have chronic conditions such as heart or kidney disease; if they are already weak or have difficulty moving around; if their ability to care for themselves is compromised; and if they have cognitive problems, noted Gill, a professor of medicine, epidemiology, and investigative medicine at Yale.<\/span><\/p>\n

Two years ago, Gill\u2019s team conducted research that showed one in three older adults had not returned to their baseline level of functioning six months after major surgery. Most likely to recover were seniors who had elective surgeries for which they could prepare in advance.<\/span><\/p>\n

In <\/span>another study<\/span><\/a>, published last year in the <\/span>Annals of Surgery<\/span><\/i>, his team found that about one million major surgeries occur in individuals 65 and older each year, including a significant number near the end of life. Remarkably, data documenting the extent of surgery in the older population has been lacking until now.<\/span><\/p>\n

\u201cThis opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient\u2019s priorities and determining whether surgery would achieve them?\u201d said <\/span>Clifford Ko, MD<\/span><\/a>, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.<\/span><\/p>\n

As the older population grows, paying for major surgeries will be a challenge for Medicare. <\/b><\/p><\/blockquote>\n

As an example of this kind of decision-making, Ko described a patient who, at 93, learned he had early-stage colon cancer on top of preexisting liver, heart and lung disease. After an in-depth discussion and being told that the risk of poor results was high, the patient decided against invasive treatment.<\/span><\/p>\n

\u201cHe decided he would rather take the risk of a slow-growing cancer than deal with a major operation and the risk of complications,\u201d Ko said.<\/span><\/p>\n

Still, most patients choose surgery. <\/span>Marcia Russell, MD<\/span><\/a>, a staff surgeon at the Veterans Affairs Greater Los Angeles Healthcare System, described a 90-year-old patient who recently learned he had colon cancer during a prolonged hospital stay for pneumonia. \u201cWe talked with him about surgery, and his goals are to live as long as possible,\u201d said Russell. To help prepare the patient, now recovering at home, for future surgery, she recommended he undertake physical therapy and eat more high-protein foods, measures that should help him get stronger.<\/span><\/p>\n

\u201cHe may need six to eight weeks to get ready for surgery, but he\u2019s motivated to improve,\u201d Russell said.<\/span><\/p>\n

The choices older Americans make about undergoing major surgery will have broad societal implications. As the 65-plus population expands, \u201ccovering surgery is going to be fiscally challenging for Medicare,\u201d noted <\/span>Robert Becher, MD<\/a>,<\/span> an assistant professor of surgery at Yale and a research collaborator with Gill. Just over half of Medicare spending is devoted to inpatient and outpatient surgical care, according to a <\/span>2020 analysis<\/a>.<\/span> <\/span><\/p>\n

What\u2019s more, \u201cnearly every surgical subspecialty is going to experience workforce shortages in the coming years,\u201d Becher said, noting that in 2033, there will be nearly 30,000 fewer surgeons than needed to meet expected demand.<\/span><\/p>\n

The goal is to minimize the harms of hospitalization.<\/b><\/p>\n

\u2014Zara Cooper, MD<\/b><\/p><\/blockquote>\n

These trends make efforts to improve surgical outcomes for older adults even more critical. Yet progress has been slow. The American College of Surgeons launched a major quality improvement program in July 2019, eight months before the COVID-19 pandemic hit. It requires hospitals to meet 30 standards to achieve recognized expertise in geriatric surgery. So far, fewer than 100 of the thousands of hospitals eligible are participating.<\/span><\/p>\n

One of the most advanced systems in the country, the Center for Geriatric Surgery at Brigham and Women\u2019s Hospital, illustrates what\u2019s possible. There, older adults who are candidates for surgery are screened for frailty. Those judged to be frail consult with a geriatrician, undergo a thorough geriatric assessment and meet with a nurse who will help coordinate care after discharge.<\/span><\/p>\n

Also initiated are \u201cgeriatric-friendly\u201d orders for post-surgery hospital care. This includes assessing older patients three times a day for delirium (an acute change in mental status that often afflicts older hospital patients), getting patients moving as soon as possible and using non-narcotic pain relievers. \u201cThe goal is to minimize the harms of hospitalization,\u201d said Cooper, who directs the effort.<\/span><\/p>\n

She told me about a recent patient, whom she described as a \u201csocial woman in her early 80s who was still wearing skinny jeans and going to cocktail parties.\u201d This woman came to the emergency room with acute diverticulitis and delirium; a geriatrician was called in before surgery to help manage her medications and sleep-wake cycle and recommend nonpharmaceutical interventions.<\/span><\/p>\n

With the help of family members who visited this patient in the hospital and have remained involved in her care, \u201cshe\u2019s doing great,\u201d Cooper said. \u201cIt\u2019s the kind of outcome we work very hard to achieve.\u201d<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

Nearly one in seven older adults die within a year of undergoing major surgery, according to an important <\/span>new study<\/span> that sheds much-needed light on the risks seniors face when having invasive procedures.<\/span><\/p>\n

Read more Should Older Seniors Risk Major Surgery?<\/span> ›<\/span><\/a><\/div>\n

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