Who Thrives After Surgery?

It has become increasingly acceptable to conduct major surgery on the elderly. With better techniques, safer anesthesia and, of course, more old people — half of all operations in the United States are performed on those over age 65. Surgeons routinely do elective surgery on people in their 80s and 90s.”

But how to decide who will recover and thrive and who will not? How very old patients respond to surgery has proved unpredictable. Surgeons usually eyeball their to try to evaluate whether they can recover well from the stress of an operation, but it’s an inexact science.

The usual tests surgeons use to try to predict how older patients will fare are crude, mostly based on cardiovascular strength. And standard estimates of mortality and length of hospitalization for specific operations are all but useless for patients who might be 30 or 40 years older than the norm.

But thanks to a recent study published in The Journal of the American College of Surgeons, Frailty as a Predictor of Surgical Outcomes in Older Patients, a rather elegant piece of research by a Johns Hopkins team, surgeons can give more informative answers when elderly patients in this situation, or their families, wonder what to do.

Laypeople tend to use the word “frailty” imprecisely to allude to fragility or vulnerability in old people, but for physicians and researchers, frailty is a specific medical syndrome with measurable criteria. They look for a series of declines that include weight loss (specifically, an unintentional loss of 10 pounds or more in the past year), a weaker grip, exhaustion and lack of physical activity, and a slower gait.

The assessment takes perhaps 15 minutes to conduct in an office. Then the doctors assign a score: 0 to 1 for those who aren’t frail, 2 to 3 for the intermediately frail. Patients who score 4 to 5 are frail. They tend to have much less reserve, a decreased ability to bounce back

Are frailty scores better at predicting how patients fare after surgery than the existing methods? The Johns Hopkins tracked nearly 600 patients over age 65 who had elective surgery in that hospital – from minor gallbladder removal to joint replacement and major abdominal surgery for a year. All lived independently.

The researchers assessed patients’ frailty before their operations: slightly more than 10 percent were adjudged frail (average age 76.3), and more than 58 percent weren’t frail at all (average age 71.3). The remainder were classified as intermediately frail.

The researchers found that people who are frail before surgery are at higher risk for poor outcomes afterwards. Those who were intermediately frail faced twice the odds of complications after surgery, compared to patients who were not frail, according to the study; frail patients had more than two and a half times the complication rate. Hospital stays were 44 percent to 53 percent longer for those intermediately frail, and 65 percent to 89 percent longer for the frail.

After the operation, the odds of a patient being discharged to a nursing home or to assisted living, instead of her own home, rose in proportion to her frailty. The intermediately frail were more than three times as likely to have to enter such a facility, compared with those who were not frail. The frail were 20 times as likely to go to a nursing home or assisted living — from which they may or may not have emerged.

“If the risks are likely to be higher, it changes the equation as to whether the surgery has benefit,” said one of the medical researchers.

Surgeons at Johns Hopkins have widely adopted the index to help make such pre-op decisions, and informal sharing indicates that surgeons at about a dozen other major medical centers are also using it. In some cases, patients may decline surgery. In many, they and their families will have a more realistic idea of how long recovery may take and how much help they will need. In the future, patients and their families want to ask their doctors for their frailty score when considering surgery.

For more go to: newoldage.blogs.nytimes.com

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