Surgery can be hard on older adults, resulting in serious complications and death far more often than in younger patients. But many seniors aren't adequately prepared for the risks they might face.
Innovative hospitals such as Duke University Medical Center, the University of California-San Francisco Medical Center and Michigan Medicine are working to change that. In the week leading up to surgery, they prescribe exercise to seniors, make sure they're eating healthy foods and try to minimize anxiety and stress, among other initiatives.
Research suggests these interventions can enhance seniors' readiness for surgery and potentially lead to improved outcomes. "Changing how we approach older patients is really an imperative," said Dr. Emily Finlayson, director of the Center for Surgery in Older Adults at UCSF.
In that vein, next year the American College of Surgeons (ACS) plans to launch a national effort to improve surgical care for seniors, after defining a broad array of standards that hospitals should meet. The goal is to promote and recognize "centers of excellence in geriatric surgery" across the U.S., said Dr. Ronnie Rosenthal, chair of ACS' geriatric surgery task force.
New evidence from Duke's POSH (Perioperative Optimization of Senior Health) program demonstrates the value of prepping at-risk seniors for surgery, a strategy endorsed by the newly published standards.
In January, researchers reported that older adults who went through the POSH program before major abdominal operations spent less time in the hospital (four days versus six days for a control group), were less likely to return to the hospital in the next 30 days (7.8 percent vs. 18.3 percent), and were more likely to return home without the need for home health care (62.3 percent vs. 51.1 percent). They also had slightly fewer complications.
POSH is an interdisciplinary model of care, bringing together surgeons, geriatricians, anesthesiologists and social workers while actively engaging older patients and their families. Seniors referred by surgeons attend one- to two-hour appointments at Duke's Geriatric Evaluation and Treatment Clinic, where they receive a comprehensive geriatric assessment focused on their functioning (what they can do, with what degree of difficulty), mobility, cognition, medications, nutrition, existing medical conditions and support at home from family or other caregivers, among other factors.
Making sure that older patients understand what surgery might mean for them -- the potential benefits as well as harms -- is a primary objective. "We ask 'What do you really want to do in the future?' and then spend a good amount of time explaining if surgery will actually help a patient meet that goal," said Dr. Sandhya Lagoo-Deenadayalan, an associate professor of surgery at Duke, who helped launch POSH in 2011.
"When patients leave our clinic, they have a very detailed to-do list," said Dr. Shelley McDonald, an assistant professor of geriatrics who helps run POSH. Although the plan is tailored to each patient, she often recommends: Start walking 20 minutes a day, five days a week; do core-strengthening exercises three times a week; practice deep breathing three to four times a day; stop taking medications that can interact poorly with anesthesia, such as antihistamines and benzodiazepines; eat 30 grams of protein three times a day; drink lots of fluids starting three days before surgery (your urine should be light yellow to clear); and make sure you have someone to sit with you in the hospital and be with you when you return home.
Ralph "Benny" Suggs, 70, went through the POSH program last summer, before surgery to repair a large hernia. "I hadn't had any major surgery, ever," said this retired Navy rear admiral, who's now associate vice chancellor for alumni relations at North Carolina State University. "They went to great lengths to brief me on every little thing -- not only the medical procedure itself, but what I could expect physically and emotionally afterwards. That really gives you a sense of confidence that things are going to go well."