Frail Older Patients Struggle After Even Minor Operations

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.

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.

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.”

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