Age is no longer the absolute barrier to undergoing surgery in the U.S. As the population gets older, and the number of older individuals increases, more people require interventions for a number of health concerns. Interventions include procedures such as valve-replacement surgery, hernia repairs, cataract removals or joint replacements, for example.
Internal medicine physicians and family practitioners are well-versed in “clearing” patients for surgery. This evaluation essentially determines the risk of adverse cardiovascular events (along with additional risks in individuals with specific conditions: pulmonary risks in individuals with chronic lung disease; risk of bleeding or blood clots in individuals on blood thinners) and communicates this risk with the surgeon.
[See: 11 Things Seniors Should Look for in a Health Provider.]
Determining risk is more pertinent in elective or planned surgeries, as there is time to implement an intervention for individuals who are at higher risk for these complications. Such interventions may include stress tests for people who may have symptoms of uncontrolled or unmanaged coronary artery disease. On the other hand, in emergency situations, determining risk can often be secondary when surgery must be done to save a person’s life. The risks remain, though, despite any urgency or need to immediately go to the operating room.
Recently, functional status has been increasingly predictive of how older individuals do after surgery. Individuals who are more functionally independent (e.g. able to do daily living activities independently) are usually more physically and cognitively intact, and those with more limitations are usually more physically and/or cognitively impaired. This functional status is a good marker of overall fitness for surgery, as it reflects the impact of aging along with a person’s medical problems.
Years ago, Dr. Linda Fried, a geriatrician, developed the “frailty phenotype” as a way to characterize and measure this concept. The term “frail” is often used when referring to individuals who are older, more disabled, more dependent on others for assistance or less able to do things independently. As a medical measurement, meeting criteria for frailty requires three of the following:
— shrinking/weight loss (10 pounds or more in one year)
— physical exhaustion (self-reported)
— muscle weakness (measured by weak grip strength)
— decline in walking speed
— low physical activity
This basic definition has been expanded and refined over the years to include other elements, but the underlying premise is the same: identifying individuals whose overall performance is associated with higher risk of complications when they undergo some sort of medical intervention. Individuals who are considered frail by medical criteria have higher risks of complications. This is being studied extensively and includes surgeries of various types, including joint replacement surgeries, cancer-related surgeries and cardiovascular surgeries.
[See: How to Help Aging Parents Manage Medications.]
I believe the discussion a patient and physician have about the risks of surgery should include more than looking at complications related to heart and lung issues. Frailty should now be a part of this discussion.
Patients often ask if they can do anything to help reduce frailty. Considering the frailty criteria above, several interventions could be studied to see if person’s frailty score could be reduced, potentially decreasing surgical risk. Interventions could involve some sort of physical therapy/exercise program to address muscle weakness, exhaustion and low physical activity. Perhaps an intervention to help stabilize weight or improve nutritional status could also be effective. It’s not clear at this time whether interventions implemented immediately before surgery will make a difference. The studies need to be conducted; the jury is still out.
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
So, what can patients do? What is interesting to me is lifestyle choices throughout one’s life that influence nutritional status and physical well-being have a significant impact on this risk score. Though we often think about diet and exercise as interventions to promote everyday life and healthiness alone, these lifestyle choices also influence the concept of frailty, its relationship to surgical risk and the ability to tolerate surgery later in life. By the time chronic illness develops and impacts physical and cognitive well-being, it’s often too late to reverse course.
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Preparing for Surgery? Frailty: a Special Consideration for Older Persons originally appeared on usnews.com
