Nov 15, 2022
Over the past five years, more than 20 million Americans aged 65 and over had elective surgery. This number is expected to grow to more than 27 million by 2030.
While elective surgery can be life-changing and even life-saving, it’s not without its risks. There are many things to consider before elective surgery – from the cost of the procedure to who will provide caregiving afterwards during recovery.
In addition to the normal conversations, exams, and tests that will be run to clear an older adult for surgery, there are ten additional things older adults and their families should know before heading into the Operating Room.
Most surgical offices will require thorough lab work, along with heart, lung, and kidney function tests; but if you are over 65 years old or the loved one of someone who’s going to have the elective surgery, be sure you—and those the surgical team — know the following because many of these have been linked to a higher risk of death or complications after an older adult has surgery. These recommendations are based on the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Developed Best Practice Guidelines recommend the following:
Key points covered in this episode:
✔️ #1: Know The Person’s Pre-Surgery Cognitive Ability
Though you may be an older adult, have been feeling great recently, and even played golf the day before surgery, things can take a turn for the worse post-operation. You can end up looking pretty sick to providers who don’t know you—and due to pervasive ageism, health care professionals can unfortunately make an assumption that you have a cognitive impairment (when you don’t!)
You want to be sure that your surgical team knows what the person's cognitive ability was before the surgery ~ because you should return to baseline with your thinking.
✔️ #2: Depressed Or Not?
Depression has been associated with a higher likelihood of dying after surgery and more days in the hospital after surgery. It is essential that the surgical team understands what the person’s emotional state was before surgery.
Older adults may not want to talk about it, but if a loved one is going in for surgery, please ask: “Have you been feeling down or depressed lately?”
✔️ #3: Any Alcohol Or Substance Abuse/ Dependence Issues?
While a glass of wine with dinner or a beer while watching the game may be part of your routine, there may also be some signs that alcohol use is more along the lines of alcohol dependency or abuse.
There are four questions that are asked, and we call it the CAGE questionnaire:
C: Have you ever felt the need to Cut down on your drinking?
A: Have you ever felt Annoyed by people criticizing your drinking?
G: Have you ever felt Guilty about your drinking?
E: Have you ever had an Eye-opener (a drink first thing in the morning) to steady your nerves or get rid of a hangover?
Substance abuse isn’t only about alcohol. It can includes taking other drugs. In either case, alcohol and substance misuse also puts the person at a higher risk for complications after surgery
✔️ #4: Know Your Risk Of Post-Surgery Delirium And How To Recognize It In A Loved One
Delirium is a change in mental status, and people can fluctuate in and out of it. They may be confused at times and then clearheaded at other times in the same day.
Being 70 or older and taking multiple medications increase a person’s risk for delirium. Before elective surgery, it is essential to let your loved one’s surgical team know about any medications they are taking and if they have had issues with delirium in the past.
The bottom line after surgery: If you have any feeling that your loved one “just isn’t right”, mention it to their medical team because it needs to be investigated.
✔️ #5: Know Functional Status And History/ Risk Of Falls
Can the person get dressed? Take a bath? Get out of a chair or the bed by themselves? Prepare own meals and/or do their own shopping ?
Have you fallen in the past year?
The answers to these questions give the surgical team a good idea of what level of care the person was prior to surgery and can discuss self-care goals post-surgery.
The risk of falling also needs to be discussed. A history of falls or any current balance issues puts someone at a higher risk for complications after surgery.
The surgical team can also administer the Timed Get UP and Go Test (TUG): This is when the older adult is asked to stand up from a chair, walk 5 or 6 feet, turn around and walk back to the chair, and sit down. Taking longer than 15 seconds to do this indicates an increased risk of falls.
✔️ #6: Is The Person Malnourished?
Older adults can lose weight for many reasons: changes in taste, dentition issues, and inability to cook for themselves. But whatever the reason, malnutrition puts someone at a higher risk for complications after surgery.
The best way to assess this is by asking if they had an unintentional weight loss of more than 10 pounds last year. A laboratory test of albumin and pre-albumin levels or calculating the Body Mass Index (BMI) based on Height and weight. It determines if a person is overweight or underweight, which can result in negative surgical outcomes.
✔️ #7: What Is The Person’s Frailty Score?
One indicator of frailty is an unintentional weight loss of more than 10 pounds in the past year. Another frailty indicator is decreased grip strength, which is the inability to open a jar of peanut butter or hold a cooking utensil. Slow gait speed (walking) is another indicator.
Self-reported poor energy or low endurance may also be seen. Or you may notice that they don't expend much energy during the week. So this is someone who may be doing a lot of sitting, and if they are up and walking, it will be slow.
✔️ #8: Take A Medication List With Diagnoses
I recommend the Brown Bag Approach: bringing all medications in a brown paper bag to each appointment. This allows the clinician or surgical team to go through everything and ensure that each one is still indicated.
Put all ALL medications - vitamins, over-the-counter, and prescriptions -into a ‘Brown Bag’ and take them all in to be reviewed with your provider. You should know the reason for taking each medication - the diagnosis it is treating. This allows the clinician to understand what other health problems the person may have and if any of those could interact with surgery or anesthesia.
Talk with your provider because any nonessential medications should be discontinued before surgery; know what medications can be taken on the day of surgery or be continued after surgery.
It would also be best to review your medication list against the Beers Criteria and be sure every medication has a supporting diagnosis. Otherwise, work with your provider to discontinue it.
The bottom line: The more information the surgical team has, the better they can assess and plan for the surgery
✔️ #9: Treatment Goals And Expectations
If a person thinks they will have a surgery to cure their pain and they don't get that result—that will be disappointing. So it's essential to manage expectations by getting a clear explanation of the goal(s) of surgery. The goal may be to decrease the pain but not necessarily get rid of it. It's also important to set realistic goals for post-operative function
Be sure to have a discussion about the patient’s preferences and expectations – and if there will be a need for rehabilitation after surgery, where is the preferred facility for that to take place, or can it be done at home?
✔️ #10: Take Paperwork: Who Will Be Involved In Care
Take copies of any and all legal paperwork that you may need – this includes the person’s advanced directive (code status: full code vs. no code) and who their designated decision-makers are in case they are needed – such as their healthcare power of attorney. Copies of these should also be in the person’s medical record.
If you have questions, comments, or need help, please feel free to drop a one-minute audio or video clip and email it to me at melissabphd@gmail.com, and I will get back to you by recording an answer to your question.
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About Melissa Batchelor, PhD, RN, FNP, FGSA, FAAN:
I earned my Bachelor of Science in Nursing ('96) and Master of Science in Nursing ('00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I genuinely enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home, and office visits), then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer. I obtained my PhD in Nursing and a post-master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11). I then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 which led to me joining the George Washington University (GW) School of Nursing faculty in 2018 as a (tenured) Associate Professor. I am also the Director of the GW Center for Aging, Health, and Humanities. Please find out more about her work at https://melissabphd.com/.