How old is too old for surgery
You are never too old for good medical care and surgery.
Is it safe for elderly to have surgery? YES it is if they are carefully assessed and managed.
Can you be too old for surgery? The simple answer is NO!
Can 80 year old have surgery? The answer is YES!
Can a 90 year old have surgery? The answer is YES!
Even elderly patients with dementia can still have surgery if they need it. For example, if the dementia patient is independently mobile and has good quality of life they may need surgery for-
knee replacement for severe, painful osteoarthritis of the knee causing distressing pain, limiting mobility and suffering pain killer drug side-effects.
back surgery for severe lumbar back pain with sciatica limiting mobility and not responding to pain medications or getting pain killer drug side effects.
Acute bowel obstruction- emergency surgery.
Hip joint replacement surgery for severe painful osteoarthritis of the hip limiting mobility and not responding to pain medications.
Patients with dementia have high risk of post operative delirium that requires holistic multidiscilpinary medical care.
My oldest surgical patient was 106 year old man who had a fractured hip after a fall and successfully went on to have total hip replacement surgery and return home.
Doctors commonly use “old age” as an excuse not to treat and operate on older patients.
Successful surgical outcomes and complication rates depend on the co-morbidities and general state of health of the older person.
Carefully selected older patients can still successfully undergo major surgery such as cardiac valve replacements, hip replacements, neurosurgery on spine and cancer surgery- ie. bowel.
Surgical risks increase in those older patients with-
malnutrition
low blood pressure which usually means they are quite frail and unwell
dementia
heart failure
chronic lung disease
severe kidney failure
Preoperative need for transfusion, emergency surgery and recent weight loss are good predictors of morbidity and mortality for those 80 years of age and older.
Increasing age itself remains an important risk factor for postoperative morbidity and mortality.
Therefore older surgical patients need a thorough pre-op work up and comprehensive geriatric assessment to maximise their fitness for surgery and minimise post-op complications.
Major Geriatric Syndromes such as cognitive impairment are important prognostic factors for postoperative complications.
Postoperative delirium and cognitive decline are are risk for those elderly with pre-exisiting dementia and cognitive impairment.
Older surgical patients need very good peri-operative care-
So what is peri-operative care?
· pre-operative comprehensive medical assessment, focusing on management and appropriate optimising of treatment of the intercurrent chronic active medical problems.
· pre-operative cognitive assessment.
· screening for delirium.
· minimising post-operative delirium and post-operative cognitive decline.
· reviewing all their medications.
· assessing their nutrition to prevent post-operative malnutrition.
· early mobility post-op.
· safe and adequate pain management.
· to allow for the best surgical and medical outcome following the surgery.
The days when complex frail older patients can be operated on by a Surgeon alone, independently without being part of a multi-disciplinary medical team with the Geriatrician are rapidly fading.
Surgeons must screen for cognitive impairment and post operative delirium risk before they operate on patients over 70 years.
Current evidence-based medicine tells us that Geriatrician-led peri-operative care reduces post-operative complications and mortality and results in a shorter length of hospital stay, less health care costs, and positive surgical and medical outcomes for the patient.
For more information read Dr Peter Lipski’s book “Your Elderly Parents Failing Health. Is It Ageing Or A Treatable Condition”.