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Seeking Better Ways To Tell If Surgery Is Too Risky

Just because surgery is possible doesn't mean it's a good idea, especially for frail older people.
Sam Edwards
Getty Images/OJO Images RF
Just because surgery is possible doesn't mean it's a good idea, especially for frail older people.

Older people face higher risks in surgery, but not all 85-year-olds are alike. One may celebrate his birthday skydiving, like former president George H.W. Bush, while another may be unable to stand without help.

Since half of all surgery in the United States is performed on people 65 and older, figuring out an individual's risk is key. Measuring frailty beforehand more accurately predicts who will do well after surgery, according to a study published Wednesday in JAMA Surgery.

"We're now entering a new era of prediction of risks for surgery," says Dr. Michael Zenilman, a professor of surgery at Johns Hopkins School of Medicine who wrote a commentary on the study. "Surgeons were never trained in recognizing frailty."

For decades, surgeons have relied on the American Society of Anesthesiologists' Physical Status Classification System, with six categories ranging from "a normal healthy patient" to "a declared brain-dead patient whose organs are being removed for donor purposes." It works well, but relies on doctors' judgment to decide how a person's age or physical strength affects their ranking.

In this study, researchers in Korea used widely recognized measures of frailty to test 275 patients before they had surgery. About half had surgery for cancer.

One year later, 9 percent of the patients had died, and 8 percent were sick enough that they went from the hospital to a nursing facility, rather than home. Slightly over 10 percent had at least one medical complication while in the hospital, such as pneumonia or delerium.

The people who fared best were more likely to have scored higher on tests of physical function, such as being able to bathe and dress themselves, cook, or manage their finances. And they were less likely to have multiple health problems.

They also tended to be better nourished, heavier, have a normal blood albumin test, and do well on tests of cognitive function. Yet depression and taking too many medications, or inappropriate ones, turned out not to be a factor.

Surgeons know that some older people don't have the physiological reserves to withstand surgery, the authors write, "but many physicians measure the patient's reserve subjectively, or even worse, disregard it."

Since there are now good measures for frailty, the authors conclude, doctors no longer have that excuse.

"I just operated on someone who's 95 years old who had gastric cancer," Zenilman, who wasn't involved in the study, tells Shots. "The mission is not to cure people at that age, but get them to the point where they can function and have good quality of life."

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