PUMPING IRONY: Too Weak for Surgery?

Aunt Lois is 93 years old, lives independently in her own home and, last I heard, was still driving to her hospital volunteer gig once a week. So, I was taken aback the other day when My Lovely Wife mentioned that Lois had recently undergone surgery to implant a pacemaker.

“It’s risky business for someone that old,” I noted, more fretfully than I had intended. “I mean, surgery at that age can often be the beginning of the end.”

MLW glanced up from her newspaper, eyes narrowed.

“Oh, I’m sure nobody would’ve talked her into it if she didn’t want to do it,” I offered, backpedaling. “If her heart was really getting to be too weak, I suppose it would make some sense.”

The operation was successful, MLW reported, and Lois seemed to be doing fine. “Her doctor came in to discuss when she would be released from the hospital and Lois told him, ‘Go to your room.’”

Lois may be an outlier among the multitudes of elderly Americans who end up in operating rooms each year despite a level of frailty that makes survival — not to mention recovery — a dicey affair. As Paula Span reports in the New York Times, patients over the age of 65 account for more than a third of all inpatient surgical procedures in the United States. And about 15 percent of that group — plus a full third of those over 85 — are probably too weak to risk even routine surgical procedures.

“Researchers have shown that after major operations — including cardiac and colon cancer surgery and kidney transplants — frail older patients are more prone than others to longer hospital stays, being readmitted within a month of a procedure and winding up in nursing homes after they’re discharged,” Span writes. “They’re also more likely to die.”

If the anesthesia and inflammation don’t get you, University of California, San Francisco, surgeon Carolyn Seib, MD, tells Span, there’s always blood clots, infection, and muscle weakness to contend with. “The more frail a patient is, the higher the risk of complications.”

Some surgeons have responded by devising various methods to determine a patient’s level of frailty before deciding whether to operate. “We have to take frailty into account for any operation, big or small,” says Seib, though she admits that it’s not a widely accepted practice. “I wouldn’t say it’s routine yet.”

Part of the challenge, I suspect, lies in distinguishing the weak from the strong(er). Some doctors test their patients by measuring the time it takes for them to get out of a chair, walk 10 feet, and return to the chair. Others rely on tests of grip strength and walking speed, while still others look more generally at the presence of chronic illnesses and cognitive issues.

Span describes the case of an 86-year-old man with a troublesome gall bladder who failed the chair test. After discussing the risks of surgery, the patient decided to forgo the knife and try to avoid the foods that tend to cause his symptoms. It’s part of what’s called a “prehabilitation” program, which often includes lifestyle changes. Recent studies in Poland and Singapore, which suggest physical training and dietary changes can actually reverse frailty in the elderly, support this strategy.

“Surgical decision-making is not a binary choice between patients agreeing to the standard operation or doing nothing,” Span explains. “Alerted to frailty, a surgeon might opt for a less aggressive approach or a different kind of anesthesia. A patient, understanding that she may be looking at an altered future even if the surgery fixes the physical problem, will have her own priorities to weigh.”

Aunt Lois has never been shy about asserting her priorities. At her 90th birthday party, someone asked her what she wanted for her birthday. Nursing a cocktail, she smiled as she surveyed the room. “I’m just looking for a date,” she replied. I suspect, frail as she may be, the old girl was going to get her pacemaker no matter what anyone else said. Here’s hoping it’ll come in handy if she finds a fellow who manages to quicken her heartbeat.