The cohort of older Americans ages 65 or older is the largest it has ever been in history, at least in part due to advances in medicine and significant improvement treating and managing common illnesses³. However, older adults are also increasingly needing surgical treatment; more than half the surgeries performed in the US are performed on this patient population³. Surgery puts an immense amount of stress on the body, and thus the surgeon and the patient need to have conversations discussing surgery risk in older adults and weighing individual need prior to intervention³.  

As age increases, patients tend to experience faster physiologic decline and higher sensitivity to stressors such as surgery, a phenomenon referred to in the literature as frailty³. Frailty evaluation can be a helpful tool in stratifying surgery risk in older adults and providing patients with accurate counseling on postoperative outcomes³. The Fried frailty phenotype, comprising criteria such as unintentional weight loss, weakness, exhaustion, slow walking speed, and low physical activity, is commonly used to assess frailty³. A 2015 study in the Journal of the American College of Surgeons showed that higher frailty scores were associated with increased risk of preoperative complications and length of stay, as well as an increased risk of being discharged to an assisted living or skilled facility when the patient was previously living at home³.   

However, age alone is not an absolute contraindication for surgery; the presence of medical comorbidities and a comprehensive evaluation of physiologic reserve may be a better predictor for adverse surgical outcomes². This is evidenced by a study published in Medicina investigating postoperative complications after major GI surgery². The mean age of patients in this retrospective study was 68, and they classified patients as high-risk or non-high-risk based on their American Society of Anesthesiology and Revised Cardiac Risk Index scores, which include medical, functional and cardiac comorbidities². While both high-risk and non-high-risk patients had similar in-hospital mortality rates, high-risk patients had significantly higher 30-day, 90-day and 1-year mortality rates². Age greater than 70 years old was also identified as an independent risk factor for postoperative complications, especially when combined with these risk-stratification scores².  

Weighing and minimizing surgery risk in older adults requires comprehensive medical evaluation, medication reconciliation, and management of chronic conditions. Multidisciplinary approaches involving geriatricians, anesthesiologists, and surgeons can help in individualizing surgical plans. Furthermore, current guidelines for enhanced surgery recovery protocols are safe and appropriate to use in elderly patients; a 2021 study found that both ERAS protocols and a laparoscopic approach were not only associated with decreased lengths of stay and lower complication rates in patients under the age of 80 undergoing colon resection, but also did not carry an increased morbidity and mortality rate¹. Even after considering these strategies to optimize surgical care in older patients, providers should always engage in decision-making with patients when coming up with a patient-centered treatment plan.  

References 

1. Boon K, Bislenghi G, D’Hoore A, Boon N, Wolthuis AM. Do older patients (> 80 years) also benefit from ERAS after colorectal resection? A safety and feasibility study. Aging Clin Exp Res. 2021 May;33(5):1345-1352. doi: 10.1007/s40520-020-01655-4 

2. Jakobson T, Karjagin J, Vipp L, Padar M, Parik AH, Starkopf L, Kern H, Tammik O and Starkopf J. Postoperative complications and mortality after major GI surgery. Medicina, 2014, 50(2): 111-117. https://doi.org/10.1016/j.medici.2014.06.002 

3. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010 Jun;210(6):901-8. doi: 10.1016/j.jamcollsurg.2010.01.028