Advancements in medicine have made it possible for people to live longer and healthier lives. However, for some older adults with multiple chronic conditions—such as diabetes, high blood pressure, and arthritis—surgery is sometimes still needed. These conditions can complicate having surgery, such as a knee replacement or gall bladder removal. And the thought of having surgery can be anxiety-provoking for most older adults, as they have repeatedly heard that one is “high risk” for surgery “when you’re old.”
More than one-third of all surgeries in the United States are now performed on people aged 65 and older. Those numbers are likely to increase as more people in this demographic consider surgery. So, how do older adults determine whether surgery is right for them? Following are a few points to consider.
Health vs. age
For an older adult considering surgery, it’s important to know that the healthier the senior, the better. Surgeons have realized that simply considering a person’s age is not always a good prediction of risk. Some older adults are physiologically younger than their chronological age because they are physically fit and lead very active independent lives. As a result, they may be strong candidates for surgery.
In contrast, others may be frailer, live with chronic conditions or advanced diseases, which can complicate surgery or slow down recovery. Older adults usually have more difficulty maintaining a physiological state of equilibrium, so it usually takes longer for them to recover. Some people have more advanced diseases, such as severe-stage dementia or end-stage-kidney disease, and have a very limited life expectancy, which is why surgical decisions should not be based solely on chronological age.
Additionally, if older adults are dependent on their families for help, this should also be part of the conversation when considering surgery.
Risks and benefits
When deciding whether surgery is the right treatment for an older adult, there are many considerations to discuss with your surgeon. First, you should consider whether the risks of surgery outweigh the benefits. Possible alternative treatment options, such as medication, physical therapy, and less-invasive procedures, should also be included in these conversations. For example, for an older adult with severe osteoarthritis of the knee, physical therapy may be better than knee replacement. Another older adult might choose to not have carotid surgery, fearing they may have a stroke.
Second, when considering the risks and benefits, it’s also a good time to discuss lifesaving or life-extending interventions. Some may opt-out, while others will choose interventions. Having these discussions will help older adults make the decision that is right for them. And if they are no longer able to make decisions for themselves, the designated durable power of attorney for health care should be engaged in these conversations.
Preparing for surgery
To ensure a successful surgery, there must be careful planning both before and after surgery with the family or care partner, as well as the interdisciplinary medical team. Those with diabetes should try to improve their blood glucose level prior to surgery, while obese patients should try and lose weight and those who smoke tobacco should try to quit.
Additionally, these groups should take a geriatric assessment before a surgical procedure. Specially trained clinicians should perform geriatric assessments, such as tests for cognition, mood, balance, weight changes, and frailty. Some older adults might benefit from a visit with a physical therapist for “prehab” to strengthen their muscles before the surgery. Depending on the level of cognitive and/or functional decline, older adults might need to hire a caregiver to help them with their daily activities as they recover. A social worker should discuss caregiving options, especially, if an older adult is at higher risk of developing delirium or functional decline, after the surgery.
If the proper health assessments are done and addressed prior to surgery, it increases the chances of a successful surgical outcome. Check with your healthcare provider to find out if it has a surgical support program for older adults. Kaiser Permanente has developed a senior surgical care program to ensure older adults and their families have the support they need to remain healthy before and after surgery.
Wynnelena C. Canio, M.D., is the Chief of Geriatric Medicine at Kaiser Permanente San Rafael
