October 10, 2013
News Review From Harvard Medical School – Past Falls Linked to Post-Surgery Complications
Older patients who fall in the 6 months before major surgery are more likely to have complications after surgery, a new study finds. The study included 235 people – mostly men -- ages 65 and older. All had elective heart or intestinal surgery. Thirty-three percent had reported falling in the 6 months before surgery. Researchers compared the number of complications among patients who had fallen to patients who hadn't fallen. Complications included heart attacks, infections, strokes and blood clots. They found that 59% of patients in the intestinal surgery group who had fallen experienced complications, compared with 25% of patients who hadn't fallen. Among heart surgery patients, 39% of people who fell had complications, compared with 15% of those who didn't fall. Readmission to the hospital or placement in a rehab or nursing facility within 30 days of discharge was also more likely among people who had fallen. The authors of the study say that falls are a good indicator of frailty. Asking about previous falls may help doctors identify patients at risk of complications after surgery. JAMA Surgery published the study. HealthDay wrote about it October 10.
By Robert H. Shmerling, M.D.
Harvard Medical School
What Is The Doctor's Reaction?
I frequently see patients who could benefit from surgery. Many are understandably reluctant. With any major surgery there are risks. Bleeding, infection, and a long recovery are among the most common.
And, what if the person considering surgery is elderly? In general, the risks tend to be higher. The reasons for this vary. For some, it's the presence of medical problems, such as heart or lung disease, that increases the risk of surgery. For others, a person's condition or medications may make a post-operative infection more likely. Also, some surgeries are followed by physical rehabilitation programs. Elderly people may not have the strength or endurance to follow these programs. This reduces their chances of a complete recovery.
Doctors often evaluate patients scheduled for surgery to determine whether they are at higher than average risk. This "pre-operative risk assessment" can guide preventive measures and treatments to reduce these risks. Sometimes, additional testing, such as a stress test, is recommended before elective surgery.
A new study suggests that this simple question should be added to routine preoperative risk assessments: Have you fallen in the last 6 months?
In this new study, researchers enrolled 235 people scheduled for elective major intestinal or heart surgery. Their average age was 74; one-third of them reported having fallen over the prior 6 months.
The researchers found that:
- For those having intestinal surgery, 59% of those who had fallen suffered complications. The rate was 25% for those who had not fallen.
- For cardiac surgery, the complication rate was 39% for those who had fallen and 15% for those who had not.
- Discharge to a care facility (rather than returning home right away) and readmission within a month were also more common among those who had fallen.
The authors did not compare questions about falling with other measures of frailty in predicting complications. In addition, most of the study subjects (98%) were men. We don't know if the results would be different for women. Still, the findings are important because they suggest that a simple assessment of frailty - falling - might be as good as (or better than) focusing on a person's past medical problems.
It's likely that doctors reading this study won't be surprised by the findings. The frail elderly are already known to have a higher surgical risk than others. Falling is simply an indication of frailty. Yet, there is no standard way to measure frailty. So, this study could change the way doctors assess elderly people before surgery.
What Changes Can I Make Now?
If you are planning to have surgery, consider the steps you can take to increase the chances of a good outcome. For example:
- Understand your surgery – You should have a good grasp of the reason for surgery, how it is done and what to expect afterwards. It's also important to know the pros and cons of not having surgery.
- Get in shape - Getting regular exercise, losing excess weight and participating in pre-operative physical therapy are ways to have surgery while at your best.
- See your primary care physician – This should happen at least a week or two prior to the operation. This will allow your doctor to review your medical problems and whether any of your medicines need to be stopped or changed.
- Make sure you understand the pre-operative instructions - For example, if you were advised not to eat anything after midnight, you may need to ask about liquids. (Some surgeons allow clear liquids up to 2 hours before the operation.)
- Follow the post-op plan – For example, after the operation, getting up and moving are important. But wait for your doctor to give you the go-ahead.
- Get some help – Having social and emotional support may be just as important (or more so) than the physical help you may need from friends and family.
These measures won't guarantee a successful operation. But they can reduce stress and reduce the chances that your surgery will be delayed or cancelled. And they may lessen the chances of complications.
The findings of this study do not mean that preventing falls – though a worthy goal - will improve surgical outcomes in the elderly. When it comes to predicting complications of surgery, it's likely that falling isn't the primary problem - frailty is. And falling is just an indication of frailty. Preventing frailty as we age is an even tougher challenge - and an even worthier goal.
What Can I Expect Looking To The Future?
In the future, you can expect researchers to confirm (or discount) the findings of this latest study and to sort out why falls predict worse outcomes for older people having surgery. This should guide preventive care that may reduce the risks of surgery. At the very least, these studies should clarify which people need more attention as they head into surgery.
Currently, more than one-third of surgeries in U.S. hospitals are performed on people who are at least age 65. As our population ages, this proportion is likely to increase. So, improving the safety of surgery for older individuals is important. And it's getting more important all the time.