Sam was a fighter pilot in Vietnam. Two years ago, when he was 77 years old, Sam developed a strangulated intestine that required emergency hernia surgery.
Sam already suffered from mild dementia, but when he came out of anesthesia something else was wrong. He was profoundly delirious. Sam thought he was back in the war—and the experience was awful.
Fortunately, Sam’s family stayed by his side. His hospital nurses checked on him frequently and protected his sleep so he could rest. The delirium abated in about a week.
I was Sam’s surgeon. His experience and those of older patients like him brings home for me the special vulnerabilities of geriatric surgical patients. Elderly patients like Sam are far likelier to experience complications such as post-operative delirium. And now in the era of COVID-19, they are especially vulnerable to severe illness. With the local population aging rapidly, we must bring these issues to the forefront of care and address them mindfully.
Aging population
People aged 65 and older are the fastest-growing segment of the U.S. population, expected to exceed 58 million by 2020, according to the American College of Surgeons. By 2030, people age 65 and older will make up 20.1 percent of the Monroe County population—up from 8.1 percent in 1940 and 13 percent in 2000, according to the Cornell Program on Applied Demographics.
The city of Rochester saw a 36 percent increase in its older adult population from 2007 to 2017—the highest rate of any major city in the state, according to a study by AARP and the Center for an Urban Future. Older adults now account for 12 percent of Rochester’s population, up from 9 percent.
More surgeries and more complications
Each person is an individual, with a unique health status. But older patients often are frailer, have chronic health problems, and take multiple medications. They also have more surgeries, with more risk of complications. People 65 and older make up 16 percent of the total U.S. population, yet account for more than 40 percent of inpatient surgeries, according to the ACS. After surgery, these patients are more likely to experience functional decline, falls, and extended hospitalizations. The risk of post-operative delirium jumps from 3.9 percent of patients aged 65-69 to 26.5 percent for patients over 85. For many types of procedures, morbidity and mortality increase steadily with age. (See chart.)
A study published in November in JAMA Surgery—and picked up by the New York Times—found that frail elderly patients have higher mortality after even minor surgeries.
Doing the right thing
Every day, I meet patients I worry about. When I ask how they’re doing, they say they are fine. But as we speak more, I learn they no longer can do their laundry. They don’t cook for themselves. They haven’t done their own grocery shopping for a long time. Their friends and family have been doing all this for them.
I ask myself how I, as a surgeon, can take that person who’s already on the edge and put them through an intervention that might tip them into a different life scenario. The patient might hope to return to life as they knew it before. I might see it as far likelier they’ll permanently need a higher level of care. Beyond the requirements of informed consent, I ask myself: What is the right thing to do?
New standards guide geriatric surgery
The ACS last year introduced 30 new surgical standards designed to systematically improve surgical care and outcomes for the aging adult population. The ACS Geriatric Surgery Verification Program addresses the care continuum from pre-operative planning through post-operative care. Rochester Regional Health’s Unity Hospital was one of eight hospitals nationwide to pilot implementation of these standards.
This approach to caring for older adults is simply the right thing to do. Some of the standards address issues of infrastructure, such as geriatric-friendly rooms with large clocks, names of care teams posted, and space for visitors. Others address screening for geriatric vulnerabilities, better medication management, and care-team coordination. For insight into patients’ wishes, advance directives and health care proxies are essential.
The advent of COVID-19 has brought a new host of concerns, from new infection-control protocols to communication challenges and visitor restrictions. Solutions include greater use of telehealth and connecting hospitalized patients with their families through iPads.
Like many surgeons, I tend to take an analytical approach to life: This is the problem, this is what I’ll do to fix it, and this is how long it will take.
These days, however, I focus more than ever on finding out how my patients define a good outcome. An operation might be a complete success and the patient might still have to move to a nursing home afterwards. Would he or she want that? Maybe what that person wants most is to return home, attend a grandchild’s graduation, or take a trip. I won’t know unless I ask.
All of this takes more time. In the fee-for-service model, productivity means seeing as many patients as possible. Now, we need to slow down and align our care with our patients’ goals for themselves.
People are accustomed to having their blood pressure and weight checked. They’re not used to talking about their memory, their at-home functioning, their support systems or long-term goals for themselves. Those conversations traditionally were not a routine part of surgical care. We must make sure they are. We can’t address problems we don’t see or talk about.
Sam, the Vietnam veteran, eventually recovered, but he remembers very little about the hospital experience. In conversations we’ve had over the years, he’s a strong advocate for veterans and for the aging.
Over the coming years, the needs of our aging population will become an issue of growing urgency for the Rochester region. Surgery is riskier for older people. The ACS standards give us a powerful framework for addressing this fact. Using the standards effectively requires us all to communicate better—as caregivers, as patients, as loved ones, and as a community.
Matthew P. Schiralli M.D. is chief of surgery for the Eastern Region of Rochester Regional Health; medical director of the RRH geriatric surgery program; and director of surgical quality with the American College of Surgeons National Surgical Quality Improvement Program.
So appreciate Dr Schiralli’s leadership in advancing these new approaches to surgery inclusive of what happens before and after the surgery! This will help so many people and, as he said, we can help even more by rewarding clinicians for value rather than volume services provided (Fee for Service).