Evaluating harms and benefits of surgery for frail older adults
For a healthy 80-year old that has arthritis in their knee that affects their everyday activities, knee replacement surgery could improve their quality of life. But what about an 80-year old person with a cardiac condition and cognitive decline?
In the latest edition of the “Right Care Series” in the journal American Family Physician, Dr. Ann Lindsay from the Stanford University School of Medicine, and patient partners Helen Haskell and John James tackle the subject of evaluating older adults for frailty before recommending elective surgery.
Patients will often come to their primary care clinician to ask about surgeries they are considering. Thus, primary care clinicians play a key role in helping patient and families understand the risks of surgeries and figure out whether that surgery is appropriate for them. An important part of this process is evaluating patients for signs of frailty, a condition that greatly increases the risks of surgery.
Frailty is a term that describes patients, regardless of age, who have reduced physiologic reserve and are at increased risk of dying within five years. For frail patients, even procedures described as “low-stress” can lead to significant declines in function and cognitive decline. However, as Haskell and James write, patients and their families may not be aware that disability, impairment, and worsened function are among the risks of surgery.
Lindsay recommends that clinicians use the Risk Analysis Index to determine frailty, along with the Mini-Cog screening tool for dementia to supplement. Clinicians should also evaluate the patient’s living situation: Who will be taking care of the patient after the operation? Do they have adequate resources to do so? Is their home easy to navigate for someone recovering from surgery or are there fall risks? These factors greatly impact the ability for frail patients to recover.
Clinicians can use the preoperative evaluation to inform patients and families about alternatives to surgery, such as “physical therapy, working on pain management, additional durable medical equipment, and alternate modes of physical activity.” The patient’s life goals need to inform the decision about these options.