Frail Older Patients Struggle After Even Minor Operations

By | December 14, 2019

The patient, a man in his 70s, had abdominal pain serious enough to send him to a VA Pittsburgh Healthcare hospital. Doctors there found the culprit: a gallstone had inflamed his pancreas.

Dr. Daniel Hall, a surgeon who met with the patient, explained that pancreatitis can be fairly mild, as in this case, or severe enough to cause death. Recovery usually requires five to seven days, some of them in a hospital, during which the stone passes or a doctor uses a flexible scope to remove the blockage.

But “because it can be life-threatening, after patients recover, we usually take out the gall bladder to prevent its happening again,” Dr. Hall said.

A cholecystectomy, as that operation is known, isn’t high-risk surgery. When done with a laparoscope to avoid large incisions, it’s usually an outpatient procedure.

But Dr. Hall advocates screening all older patients for frailty, and this patient met the criteria. He had coronary artery disease and liver disease, had lost weight and took multiple medications.

“He was sunken behind the eyes, skinny, unsteady on his feet,” Dr. Hall recalled.

Dr. Hall’s research, recently published in JAMA Surgery, has found that frail, older adults are more likely than other patients to die after even supposedly minor procedures — and even when the surgery goes well, without complications.

Frail, older patients frequently undergo such operations, which surgeons tend to see as routine, simple fixes — but may not be. “Our data indicate that there are no low-risk procedures among patients who are frail,” Dr. Hall and his co-authors concluded in their study.

So he had a lot to talk over with this patient and his son, who joined the discussion by phone.

What’s frailty? “It’s an accumulation of problems that leave the patient vulnerable to stressors,” said Dr. Ronnie Rosenthal, a surgeon at the Yale School of Medicine. “And surgery is a big stress.”

Even in healthy patients, surgery “demands a lot of reserve from your body,” she added. But when they become frail, “people already use whatever reserve they have just to maintain their daily lives.”

After operations, frail patients find it harder than others to regain strength and mobility, and to return to independent lives.

Doctors and researchers assess frailty in a variety of ways. Geriatricians often measure things like gait and grip strength, and look for unintended weight loss and exhaustion.

That face-to-face approach doesn’t work well for researchers examining large populations, so Dr. Hall and his colleagues developed a tool they called the risk analysis index. It allows them to calculate frailty based on illnesses, cognitive decline, ability to perform activities of daily living and other factors derived from medical records.

They applied that index to about 433,000 patients (average age: 61) undergoing common surgeries — categorized as low-, moderate- or high-stress procedures — at VA hospitals from 2010 to 2014. Then the team looked at the patients’ subsequent mortality rates.

In this mostly male sample, 8.5 percent of patients were deemed frail and another 2 percent very frail. (At older ages, the proportion would almost certainly be higher; a 2012 review found that depending on definitions, frailty affects 14 to 24 percent of the over-65 population.)

Previous studies have shown that surgery poses higher risks for such patients, but “does frailty only matter for the big operations?” Dr. Hall wondered.

Results from the new study, limited to non-cardiac procedures, appear to answer that question.

Surgeons consider operations high-risk if their 30-day mortality rate exceeds 1 percent. But for frail patients, even the lowest-risk procedures — including removing a cyst from the hand or wrist, repairing a hernia or removing an appendix — had a 1.5 percent mortality rate within 30 days. For the very frail, the figure was more than 10 percent, Dr. Hall and his colleagues found.

A moderate-risk procedure like gall bladder removal or joint replacement involved a risk of death that was higher than 5 percent within a month for frail patients, and a nearly 19-percent risk for the very frail.

Those numbers rose over time. By 90 days, mortality after supposedly low-risk surgery climbed to 5 percent in the frail and about 23 percent in the very frail; for moderate-risk operations, the rates were about 11 percent and 34 percent, respectively.

After six months, roughly 9 percent of frail patients who’d had the lowest-risk procedures and 16 percent of those undergoing moderate-risk surgeries had died. So had 35 to 43 percent of the very frail.

It might not be the hernia repair or cyst removal, or complications thereof, that caused their deaths, of course. Those patients have shortened life expectancies, with or without surgery.

“Frailty means you’ve probably entered the last season of your life,” said Dr. Hall (who is also an Episcopal priest).

Moreover, living longer is not older people’s only concern, or even their primary one, Dr. Rosenthal pointed out. “We don’t ask patients often enough, ‘What’s important to you?’”

A frail patient, she noted in an editorial published in JAMA Surgery, may opt for an operation that increases comfort or mobility, even if it also raises the odds of dying.

Screening patients for frailty may allow those facing greater risk to begin several weeks of so-called pre-habilitation, to improve their nutrition and endurance.

But frailty also brings greater urgency to the discussions surgeons have with patients and families, who need to understand not only surgical risks, but what their lives may be like after surgery.

“It might not dominate the decision, but it could engender a few more questions,” Dr. Hall said.

Unhappily, another recent study in JAMA Surgery shows how difficult it remains to pose these questions.

Dr. Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison who studies doctor-patient communications, has too often heard patients say they had no choice but surgery, or were blindsided by how debilitated they felt afterward.

So she and her colleagues recently developed an 11-question brochure for older adults considering major surgery. Working with surgeons at five hospitals, the team sent it to 223 patients before their consultations.

Did those patients, who all had other serious illnesses, ask their surgeons more questions than a control group who didn’t receive the brochure? The team recorded everyone’s visits and learned that no, they didn’t. About half hadn’t even read the brochure.

“If you want to change communications, you probably have to work on the surgeons” more than the patients, Dr. Schwarze concluded.

But she noted that such questions will serve any older patient contemplating surgery, minor or major: What are my options? Will surgery make me feel better? Help me live longer? How much longer?

What will daily life look like right after surgery, or three months or a year later? What serious complications might arise? What will those mean for me?

When Dr. Hall discussed such matters with his frail patient, whose pancreatitis might never return, the man decided against gall bladder surgery. Time spent in the hospital, possibly in intensive care, and the potential need for recovery in a nursing home sounded unappealing.

From the patient’s perspective, “the risks of doing the surgery were greater than the risk of recurring pancreatitis,” Dr. Hall said. “We chose not to do the operation.”

Well