May 9, 2014
News Review From Harvard Medical School -- Predicting Risks of Surgery in Older Adults
A "frailty score" may help doctors predict which older patients are most likely to have serious problems after surgery, a new study says. Researchers developed the scoring system based on a series of questions about people's everyday life and state of health. They tested it on 275 patients, age 65 or older, who were scheduled for surgery. After surgery, 10.5% had at least 1 serious problem (complication). These included blood clots in the lungs, infections, pneumonia and delirium. After hospital discharge, 8.7% needed to spend time in a nursing home. In the year after surgery, 9.1% died. People with higher frailty scores were more likely to die or have complications. They had longer hospital stays. They also were more likely to need nursing home care. Researchers said the frailty score was more accurate than another scale used now to predict surgical risk. The journal JAMA Surgery published the study. Medscape Medical News wrote about it May 8.
By Mary Pickett, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
I am all for fixing things. But sometimes I advise my patients not to have surgery. An example is my patient with a bulging abdominal hernia. She has a heart condition. To me, it seems she is better off without an operation. It has taken me a lot of effort to convince her of this.
No one expects problems (complications) when they have surgery. But they do occur.
Two years ago, researchers looked at death rates after surgery in 500 hospitals in Europe. None of the surgeries involved the heart. The death rate in the first 60 days after surgery was 4%. Certainly, not all of these deaths were caused by surgery. All of these people had medical problems that led to surgeries in the first place. But it is worth considering surgical risk.
In the United States, more than half of all operations are done on people 65 and older. Most complications also happen in this group. So a group of researchers wanted to predict the safety of surgeries in these older patients. They looked at 275 older patients having operations. Low-risk surgeries (such as cataract surgery) were excluded. They published their findings this week.
In this study, 9.1% died in the year after surgery. Another 10.5% had a major complication, such as pneumonia, urinary tract infection or abnormal confusion called delirium. And 8.7% needed to spend some time at a nursing facility after surgery.
But these researchers also found a way to help doctors predict risk. They answered a series of questions for each patient before surgery. They used the answers to assign everyone a "frailty score." Here are some of the most important things that led to a higher frailty score:
- Dependency in activities of daily living (such as dressing and bathing)
- Dementia or milder memory loss
- Not eating well, recently having lost weight, or having other signs that suggest malnutrition
Having a higher score predicted a greater risk of death. People with higher scores also tended to have longer hospital stays and were more likely to need nursing home care after surgery.
Why does surgery put people at risk? We used to speak about the risks of anesthesia. In truth, close monitoring and skilled medical care have made this risk very low.
Being bed-bound and taking strong pain medicines can lead to some complications. The most severe events after surgery are caused by blood clots. Heart attack, stroke, pulmonary embolism, sudden death -- these big events all are the result of blood clots.
After surgery, blood vessels that have been cut send a chemical message into your bloodstream. Your body needs to stop bleeding from places where you have been cut. It is a brilliant thing that your body can start the healing process after injury. But this shift in priorities -- clot, so you will not bleed -- makes the weeks of healing from surgery a time of real risk.
What Changes Can I Make Now?
Some surgeries are considered low-risk. These include cataract surgery, breast surgery or surgeries that are superficial (only skin-deep).
Low-risk surgeries very rarely result in medical complications. In fact, the Society for General Internal Medicine says that being evaluated by a medical doctor is probably not needed before cataract surgery.
But more significant surgeries have risk. Most people will get through the operation and the recovery with no major problems. Still, be informed about the risks. Do what you can to stay safe.
- Pass up surgeries that are not essential. Ask about other options for treatment. No surgery is free of risk.
- Put your health in order first. Your risk will be lowest after surgery if chronic illnesses are in good control. Your risk can be increased by high blood pressure, poor diabetes control or thyroid disease that hasn't been recently monitored.
- Get back on your feet. Staying in bed after surgery may seem to make sense, but it is not good for you.
- Be a nonsmoker. Smoking increases clot risk. Avoid smoking in the week that leads up to surgery and in the month that follows. Surgery is a great opportunity to quit smoking.
- Restart aspirin. Aspirin does not always need to be stopped before surgery. Most people who have a strong need for aspirin should continue it before surgery. This can include people with a history of heart attack or a stent in an artery. Aspirin must be stopped for surgeries in the brain, the spine, the middle ear, some bladder operations and some deep eye operations (but not cataract surgery). The American College of Chest Physicians recommends that patients restart their usual aspirin the morning after surgery, as long as there are no signs of bleeding.
What Can I Expect Looking to the Future?
Up to now, doctors have considered a patient's frailty only in an indirect way when they are predicting the risk of surgery. This study may cause frailty to be considered in a more methodical manner. Considering frailty as a predictor of surgical risk will help doctors to better advise patients who are thinking about optional surgeries.