How old is too old to be a patient? Providers weigh in on controversy
By Joy Daughtery Dickinson
As the number of aging patients having outpatient surgery continues to increase, patient fitness is more important than chronological age, according to researchers.
- Outpatient surgery programs need to provide more comprehensive preoperative evaluations for geriatrics.
- Consider these evaluations: frailty, mini-COG cognition test, hearing, activities of daily living, nutrition, current medications, fall risk, and risk for pressure ulcers.
Financial Disclosure: Executive Editor Joy Dickinson, Board Member and Nurse Planner Kay Ball, and Board Member and Columnist Stephen W. Earnhart report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Mark Mayo, Consulting Editor, reports that he is director of ambulatory services, Ambulatory Surgical Care Facility, Aurora, IL. Steven Schwaitzberg, MD, Physician Reviewer, discloses that he is on the speakers bureau for Stryker Corp. and Merck & Co., he is a medical advisor to Surgiquest, and he is a stockholder in Starion Instruments.
Should age be a barrier to having outpatient surgery? Not according to recent research and to sources interviewed by Same-Day Surgery, some of whom report conducting surgery on centenarians.
"More important that chronological age is physiological age," says James E. Zins, MD, chairman of the Department of Plastic Surgery at the Cleveland (OH) Clinic. Zins recently conducted a study that showed when elderly facelift patients are carefully selected, their complication rates are not statistically different from those in a younger control group.1
"I have operated on many patients for facelifts who are over 65, operated on patients over 75, and given facelifts to patients over 80, but they were physically healthy patients," Zins says. These patients stay overnight in a hotel next to the surgical facility, and Zins sees them the next morning, he says.
His views on appropriate selection are echoed by Mark R. Katlic, MD, MMM, FACS, chairman of the Department of Surgery at Sinai Hospital in Baltimore, MD. Katlic is author of several books and numerous peer-reviewed journal articles on geriatric surgery. "I can tell you I’ve done outpatient chest surgery, video-assisted, on 100-year-olds," Katlic says. He also is the surgeon-in-chief and director of the Center for Geriatric Surgery at Sinai Hospital. "This is only center for geriatric surgery anywhere in the world to my knowledge," Katlic says.
Outpatient surgery managers would be well-advised to pay attention to what these pioneers have to say. The US Census Bureau predicts number of people over 65 years will double between 2000 and 2050. Zins says, "Probably more important from a surgeon’s standpoint is that although patients 65 and older account for 12% of population, they have 40% of the surgical procedures performed in the U.S." Also, the American Society for Aesthetic Plastic Surgery says that more than 700,000 procedures were performed in 2007 on patients over age 65. "That represented a six-fold increase from 1997 to 2007," Zins says.
Research backs up safety
Age is not the key measure in deciding whether elderly patients should have outpatient surgery, research contends.
In a study just published in the Annals of Surgery, researchers from Newcastle University in Newcastle upon Tyne, United Kingdom, found that fit older people had a lower risk of dying, recovered better after surgery, and had a shorter stay in hospital than unfit younger people.2
Professor Mike Trenell, a senior fellow at the National Institute for Health Research at Newcastle University and director of the MoveLab, who led the study, said, "To ensure the best possible outcome after surgery, we have found that it doesn’t matter how old you are; it matters how fit you are." The study involved 389 adults who underwent elective liver surgery at the Freeman Hospital in Newcastle upon Tyne over three years. Older people who were described as fit spent the same number of days in hospital as fit younger people.
"This data reinforces how important it is to be physically fit before surgery, no matter how old you are," Trenell says. "We’re not talking about being an athlete, but fit enough to ride a bike."3
Chris Snowden, consultant anaesthetist at the Newcastle Hospitals NHS Foundation Trust and senior lecturer at Newcastle University, said, "Optimistically, it means that there is an exciting opportunity to improve surgical outcome, across all age groups, but especially in the older person, by improving preoperative fitness."3
What geriatric patients need in preop?
While some hospitals have excellent results with elderly surgical patients, those good outcomes aren’t uniform across the United States, Katlic says.
Elderly patients need a more comprehensive preoperative evaluation, he says. The American College of Surgeons and The American Geriatrics Society developed a list of recommended preoperative tests for geriatric patients. (See resources at end of this story. For more information, see "Preop guidelines published for geriatric surgery patients," Same-Day Surgery, December 2012.)
The theme is to treat each geriatric patient as an individual, Katlic says. "Not every 80-year-old is the same," he says. "Some can’t walk to mailbox, while others can play a vigorous game of tennis."
At The Sinai Center for Geriatric Surgery, clinical coordinators and a full-time nurse practitioner perform a 20-minute evaluation that includes the following:
• Mini-COG cognition test. Patients are asked to remember three words, and they are asked to draw the hands of a clock. "That’s a test of brain function," Katlic says.
Patients who fail the mini-COG test are at risk for postop delirium, he says. In those cases, nurses and social services staff are alerted that the patients should be watched closely after surgery to see if they have delirium. Also, they might need rehabilitation after the surgery rather than returning home, Katlic says.
At the Center for Geriatric Surgery, 20% of geriatric patients have failed the cognition test, he points out. "We wouldn’t have known that if we hadn’t done that simple test," Katlic says.
• Frailty. This evaluation includes hand grip strength and gait walking speed, as well as questions about energy level and unintended weight loss, Katlic says.
It’s important to notify patients if they are hard of hearing, Katlic says. "We’re trying to facilitate better care of these people in the hopes we’ll get shorter length of stay and better surgical results," he says.
Other areas that are assessed include hearing, activities of daily living, nutrition, current medications, fall risk, and even risk for pressure ulcers, Katlic says. "You wouldn’t do on every person coming in, but on the elderly, you don’t want to miss anything," he says. The risk factors, along with the medical illness, are used to determine a Charlson Commorbidity [Index] score.
The geriatric center also performs a specialized evaluation for the primary caregiver. The burden placed on the patient’s caregiver is assessed before the operation and at some point after to determine if the operation made the burden less or more, Katlic says.
That evaluation includes 20 questions, such as "Do you ever feel you don’t want to have friends over because of your loved one?" The responses include "always," "sometimes," and "never." Such evaluations of patients and caregivers are becoming increasingly important as the amount of surgery performed on aging patients increases, Katlic says.
"It’s the greatest force affecting healthcare in our lifetime: aging patients," he says. "Cancer, cataract, prostate disease, almost everything is more likely, the older you get. We all need to be geriatric surgeons."
REFERENCES
- Martén E, Langevin CJ, Kaswan S, et al. The safety of rhytidectomy in the elderly. Plast Reconstr Surg 2011; 127(6):2455-63; doi: 10.1097/PRS.0b013e3182131da9.
- Snowden CP, Prentis J, Jacques B, et al. Cardiorespiratory fitness predicts mortality and hospital length of stay after major elective surgery in older people. Annals Surg 2013; 257(6):999-1004; doi: 10.1097/SLA.0b013e31828dbac2.
- Newcastle University. Fit for surgery? June 11, 2013. Accessed at http://bit.ly/16clFYl.
RESOURCES
- The American College of Surgeons National Surgical Quality Improvement Program and The American Geriatrics Society have a free Best Practice Guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient. Web: http://bit.ly/RnJPaF.
- The American Geriatrics Society has a free Geriatrics for Specialty Residents Toolkit. Web: http://bit.ly/15bxWMo.
- Sinai Center for Geriatric Surgery. Web: http://bit.ly/1b8O9Ym.
