A push to get older adults in better shape for surgery

Jan 25 2018

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."

At Michigan Medicine, an academic health center operated by the University of Michigan, a similarly intentioned but pared-down program focuses on four objectives before surgery: walking more, getting lungs ready through breathing exercises, eating well and relaxing (spending time with friends and family, getting enough sleep, minimizing stress). Participants get daily text reminders and can log their progress through a patient portal in the hospital's electronic health record.

Empowering older patients to take action before surgery instead of sitting around and worrying is the program's "magic sauce," said Dr. Michael Englesbe, a professor of surgery at Michigan Medicine who is involved with the program. Difficulties with billing Medicare for preoperative consultations and restructuring how physicians practice are the biggest challenges to implementing this kind of model widely. Still, "a lot of vendors are developing education and activity-tracking programs around surgery, and I expect these kinds of programs will become part of the standard of care in the not-too-distant future," Englesbe suggested.

At UCSF's Surgery Wellness program for older adults, patients are seen by a geriatrician, nutritionist, physical therapist, occupational therapist and a health coach. Consultations last about 90 minutes and result in concrete suggestions for seniors and their families as well as referrals, if needed, to specialists who can undertake more extensive evaluations.

Hoping to expand the reach of UCSF's approach, Finlayson and colleagues are developing a website and digital app, Prehab Pal, that will walk older adults and their caregivers through surgery prep. Created with input from seniors, it will have large-text fonts and easy-to-use design features. "We're putting the final touches on the first product and will pilot in March," Finlayson said.

For patients, knowing how to ask the right questions before surgery and appointing a surrogate to act on your behalf during and immediately after surgery is critically important, noted Rosenthal of ACS, who is also a professor of surgery and geriatrics at Yale University School of Medicine.

The Patient Preferences Project at University of Wisconsin School of Medicine and Public Health has developed and is testing a list of useful questions for older patients. Even if your local hospital doesn't have a program like those at Duke, Michigan Medicine or UCSF, you can ask your surgeon to address these questions:

• Should I have surgery? What are my options? What is likely to happen if I do have surgery? If I don't have surgery? In your opinion, will surgery make me feel better? In your opinion, will surgery help me live longer? If so, how much longer?
• What should I expect if everything goes well? What will my daily life look like after surgery? (Right after, three months later, one year later?) Will I have any tubes or drains put in during or after surgery and will I need them at home? In your opinion, how will this surgery affect my other health problems (such as diabetes or high blood pressure)? After I leave the hospital, what type of care do you think I will need?
• What happens if things go wrong after surgery? Can you describe serious complications and explain what those might mean for me? If I'm too sick to speak for myself, how can I make sure you know my wishes? If I decide to appoint someone to make medical decisions for me, what do I need to do to make those arrangements official?

KHN's coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.