Surgery can have dangerous effects on older adults—even leading to death for roughly one in seven older adults in the U.S. within a year after major surgery. However, the risk of death increases significantly among adults over age 80 – as well as among those considered frail or who had probable dementia – according to a new study published in JAMA Surgery.
The findings were based on data from nearly 1,000 community-living Medicare beneficiaries aged 65 and older who had major surgery between 2011 and 2017. The participants were also enrolled in the National Health and Aging Trends Study.
Researchers from Yale University say the findings have major implications for the way providers and policymakers in the U.S. think about major surgery in older populations and how pre- and post-operative care should be managed for people over 65.
“The key takeaway is that older persons who have major surgery should be assessed before their surgery for indicators of geriatric vulnerability,” Robert Becher, MD, MS, senior author of the study and assistant professor of surgery at Yale School of Medicine, told Seasons. “Those who are vulnerable because of frailty and/or dementia warrant special attention to improve their long-term outcomes after surgery.”
Becher said while he and his colleagues expected that frailty and dementia would increase mortality in the year after surgery, the magnitude of these effects was much larger than they anticipated. They found that more than 25% who were frail and nearly 33% who had probable dementia died in the year after major surgery, which Becher claims has never been shown in a nationally representative study investigating the entire spectrum of geriatric surgery. In addition, the expected one-year mortality rate for the participants was less than 5% had they not undergone major surgery.
“We are not saying that frailty caused someone to die,” Becher said. “Rather, people with frailty have much poorer outcomes after surgery than those without frailty.”
The researchers also found the following:
- Overall mortality within one year of surgery was 13.4%.
- One-year mortality for patients who underwent elective surgeries was 7.4% compared to 22.3% for nonelective surgeries.
- Mortality risk was higher for patients in the oldest age groups, including those aged 80 and older.
Kuljit Kapur, DO, chief medical officer at Transitions Care (who was not involved with the study), said these findings are important because they bring awareness to factors that make a person vulnerable if they plan to undergo surgery, can help people decide whether or not to have a major surgery at an old age, and emphasize the importance of care after surgery.
“Although complications are much more likely to occur after a nonelective procedure, it is still something that merits an open discussion between families and patients when thinking about an elective procedure,” Kapur said. “An additional reason that these findings are important is that they emphasize the importance of palliative care services in a post-operative setting.”
Why frailty and probable dementia increase the risk of death after major surgery
The major reason frailty and dementia may increase an older person’s risk of death after major surgery, Becher said, is that both of these factors increase a person’s susceptibility to adverse health outcomes.
“So, when someone with frailty, for example, undergoes the stress of major surgery, they have a significantly decreased ability to recover,” he said.
In terms of an underlying diagnosis of dementia, Jennifer Prescott, RN, MSN, CDP, founder of Texas-based Blue Water Homecare and Hospice, told Seasons people don’t usually die from dementia itself but instead from complications of the disease.
“Somebody who has memory impairment or is mildly cognitively impaired, their recovery is not going to be as stellar as someone who is in their 50s and is able to get back to their rehabilitation very quickly,” she said. “They’re able to do the exercises and follow the proper protocols – eating right, exercising, going to physical therapy – very quickly, but people who have dementia are not going to be able to do that or be as aggressive with their post-operative care as they would be if they were younger.”
Additionally, some older adults have common health problems related to aging – such as clogged arteries, heart disease, lung disease, hypertension, cholesterol and diabetes – that can impact healing after surgery and make it more likely an older adult will experience side effects or complications during or after surgery.
Certain medications can also impact the healing process before, during and after surgery, Prescott said.
“When we have surgery, a lot of times we have to stop taking certain medications and potentially vitamins as well because that can make changes to a body’s ability to clot the blood,” she explained. “If you’re having surgery, it’s important that you go to your physician or practitioner with all the things that you take, including both over-the-counter as well as prescription medications because both make an impact on healing and your body’s ability to clot the blood after a surgery.”
What can I do to support my loved one who needs surgery?
Kapur said while avoiding a major surgery and finding a less invasive way to treat the issue may be beneficial, it’s not always possible.
If your loved one has to undergo surgery, Kapur recommends caregivers connect with health care providers to ask questions and have a full understanding of the procedure (and what can be expected once the surgery is over). It’s also important to speak with a health care provider about the risks and benefits of surgery to help determine if surgery is even necessary.
“The better you understand the procedure and what can be expected post-op, the more confident you will be in knowing how to support your patient,” Kapur said. “This will also allow you to know what to look for if any negative side effects result from the procedure.”
In addition, Kapur said caregivers can plan ahead by preparing their patient’s or loved one’s schedules in advance, scheduling ahead for follow-up visits, including physical therapy, speech therapy and others depending on the type of surgery, organizing prescription pickup and refills, meals and time off.
Furthermore, caregivers should also plan ahead for more assistance in caring for their older adults, if that’s needed.
“You can’t provide the highest quality of care if you yourself are burnt out,” Kapur added. “Know that it is OK to have support and other caregivers as part of the recovery process.”