When is too old to have surgery?
I get asked this a lot. “Am I to old to have a….” facelift, breast reduction, eyelid surgery. My answer? It depends. What is your health?
But how do we assess that health in older patients? It isn’t just your age. It is some kind of complex mixture of your age, your other health ailments (like diabetes or high blood pressure), your exercise level, your weight. Since most of the surgeries I perform are totally elective, and therefore not needed, safety is key. So how can we assess? I have in the past sent them to their primary care doctors to be screened with basic bloodwork, EKG, and sometimes stress tests if the patients are not able to exercise. But is there a better way?
The NY Times recently (December 2019) had an article about “Frail Older Patients Struggle Even After Minor Operations.” This study cites a study in from Journal of American Medicine JAMA in March 2017 entitled, “Association of a Frailty Screening Initiative with Postoperative Survival at 30, 180, and 365 Days.” STUDY LINK. NY TIMES LINK. There was data which led to this study that frailty is more important than age or cormorbidity alone.
Frail patients are less likely to be discharged to home, more likely to be readmitted to the hospital within 30 days, more complications, and higher mortality rate. Traditionally people have focused on cardiopulmonary testing and evaluation by anesthesia. Then the VA system in Nebraska (who did this study) implemented a frailty screening.
This sounded like important information, so I read on.
Study:
- 432 828 unique patients,
- 93% male
- Mean age 61
- The study was the Risk Analysis Index test. (a 14 item questionnaire that takes less than 2 minutes to complete. Scores range from 0 – 81.)
- They looked at all non cardiac surgeries.
- Frailty
- 8.5% were frail (RAI score greater or equal to 21)
- 2% were “very frail”
Findings:
- The 30-day mortality
- frail and low stress surgery (like a scope) 1.55%
- frail and moderate stress (like a laproscopic surgery) 5.13%
- very frail and low stress surgery 10.34%
- very frail and moderate stress surgery 18.74%
- mortality continued to increase at 90 and 180 days, reaching 43% for very frail patients after a moderate stress surgery
- Frailty was associated with increased 30-, 90-, and 180-day mortality across all levels of operative stress. Mortality among patients with frailty after low- and moderate-stress procedures was substantially higher than mortality rates usually associated with high-risk surgical procedures.
What does this mean?
This means even a simple surgery can be dangerous if you are frail. The frailty questionnaire is in the next blog, but know it is based on age, gender, if you have cancer, comorbidities (renal failure, hear failure, poor appetite, and shortness of breath), do you live by yourself, and if you have cognitive decline.
They used the RAI-C screening test, which takes 2 minutes to do, and it correlates with issues for the 6-12 months following the surgery.
As they state, “to our knowledge, the RAI-C is the first frailty index used explicitly for systemwide screening of surgical populations, taking only 1 to 2 minutes to complete as part of the standard intake interview and now prospectively validated in cohort of 6856 patients.”