Larry McMahon is considering whether or not to have major surgery. His back pain has increased over the past five years. The only options for relief are physical therapy, injections, and muscle relaxants.
He said, “It’s an awful pain that makes it difficult to do anything.”
McMahon is an 80-year-old retired Virginia state trooper now living in Southport, North Carolina. Should he try spinal fusion surgery? This procedure can take as long as six hours. He had a lumbar fusion eight years ago. This was another difficult back surgery.
“Will my recovery take six months or a few years?” McMahon asked me, sharing his concerns with me over the phone.
Many older adults aren’t certain if they should undergo major surgery. Surgery can often save a senior’s life or improve their quality of life. People of advanced age are at greater risk for undesirable outcomes such as difficulty in daily activities, prolonged hospitalizations, mobility problems, and loss of independence.
In November, I wrote about a study that highlighted the risks seniors face during invasive procedures. Readers wanted more. How can one decide if major surgery is worth the risks? What questions should older adults be asking to help them figure this out? I sought out the opinions of several experts. Here are some of their suggestions.
What is the purpose of this surgery?
Ask your surgeon “How will this surgery make my life better?” Dr. Margaret Schwarze is an associate professor of surgery at the University of Wisconsin School of Medicine & Public Health. It will prolong your life by removing an aggressively growing tumor. Your quality of life will improve because it makes it easier to walk. It will prevent you from becoming disabled in a similar way to a hip replacement.
Ask your surgeon if he or she says that he needs to remove the growth or blockage. What impact will this have on your everyday life? Drs. said that just because a hernia was found does not mean that it must be treated. Robert Becher and Thomas Gill, both from Yale University, are the authors of this paper on major surgery for older adults.
What can I expect if things go according to plan?
Schwarze is a vascular surgeon who often treats patients with abdominal aneurysms. This is an enlargement of a major blood vessel that could prove fatal if it bursts.
Here is how she describes the “best case” scenario for this condition. “Surgery will take approximately four to five hours. After the surgery is complete, you will be admitted to the ICU and given a breathing tube for a few days. You’ll then spend another week in the hospital. You’ll need to return to rehab to regain your strength. However, I believe you can go home in about three to four weeks. It will take you between two and three months to feel the same as before surgery.
According to Schwarze’s patient brochure, there are many questions that patients might ask their surgeons. Three months later One year later? What will my needs be for help? Will I need to have drains or tubes inserted?
What can I do if things don’t go my way?
Schwarze suggests that this is the “worst-case” scenario: “You have surgery and then you go to ICU. You have serious complications. A heart attack occurs. Three weeks later, you are still in ICU with a breathing tube. You have lost all of your strength and cannot return home. You might have to go through this again if the surgery failed.
People often believe that I will just die on an operating table if something goes wrong,” Dr. Emily Finlayson, the director of the UCSF Center for Surgery for Older Adults in San Francisco, said. “But we are very skilled at saving people and can keep you alive for a long period. If things don’t go as planned, it can cause a lot of suffering and even feeding tubes and ventilators.
What is the most likely outcome based on my health, age, and functional status?
After your surgeon has shown you the various options, Finlayson suggested that you ask “Do I need this surgery?” and “What are your most likely outcomes for me?” Major surgery is more difficult for older people who are frail, cognitively impaired, or have other serious conditions like heart disease. Seniors in their 80s or 90s have a higher chance of major surgery going wrong.
Finlayson stated that it is important to have close friends and family members in the room when having conversations with high-risk patients. Many seniors may have cognitive problems and need help in making complex decisions.
What are the alternatives to this?
Finlayson advised that you make sure your doctor tells what nonsurgical options exist. For older men suffering from prostate cancer, Finlayson suggests “watchful waiting”, which is an ongoing monitoring of their symptoms, rather than having to undergo invasive surgery. If removing a small amount of breast cancer is considered risky, women in their 80s may choose to keep it as it is.
McMahon is over 50 and has underlying medical issues such as a 2021 knee replacement that hasn’t healed, arthritis, and high blood pressure. His neurosurgeon recommended that he consider other options, including more injections or physical therapy before undergoing surgery. McMahon stated that he told him, “I make my money through surgery, but that is the last resort.”
What can I do myself to be prepared?
“Preparing to have surgery is very important for older adults. If patients do a few simple things — quit smoking, lose weight and walk more — it can reduce the chance of complications and the time spent in the hospital,” Dr. Sandhya Lagoo -Deenadayalan, a director in Duke University Medical Center’s Perioperative Optimization for Senior Health (POSH).
Older patients are recommended to POSH to receive a complete evaluation of their medical, nutritional, mobility, ability to do daily activities, and support at home. Patients leave with a list of “to-dos” that they have been recommended to do, often starting weeks before surgery.
Finlayson stated that if your hospital does not have such a program, Finlayson suggested that you ask your doctor “How can my body and mind be prepared” before having surgery. Ask your physician: “How can you prepare your home ahead of time to ensure that I have everything I need for recovery?”
What will recovery look and feel like?
Consider the following: What is recovery at the hospital? Is it possible to be transferred to rehabilitation facilities? What will your recovery look like at home?
Ask how long you will be staying in the hospital. Are you likely to feel any side effects or pain from the anesthesia? It is important to preserve cognition after surgery. You might ask your anesthesiologist about what you can do to help. You will need to be informed about the type of therapy that you will require and how soon you can expect to get back to your previous level of functioning if you visit a rehabilitation center.
“A lot of older adults chose to go home during the Covid-19 pandemic and it’s really important that they have the appropriate support,” Dr. Rachelle Bernacki, director for care transformation and postoperative services at Brigham and Women’s Hospital in Boston, said.
Some older adults may lose their independence permanently after surgery. If this happens, be sure to ask about your options.