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How old is "too old" for elective surgery?

It’s something that I hear frequently: “I’m too old to have an operation!” But is this statement really true? How old is too old for surgery? Is 65 too old? What about 75, or even 80? Surely 100 is too old? Well as it turns out, just like so many other things in surgery: it depends!

Before we take a look at the evidence I’d like to introduce you to Mr Reginald “Swannie” Swanborough, who is a local celebrity in the Gawler region north of Adelaide, South Australia. Swannie has lived a very full and eventful life and he continues to be an active member in the community. He served in the Royal British Navy in World War II and has written a book about his experiences called A Life Well Lived. Swannie is a proud veteran and in 2019 he was the oldest walking Navy participant in the Adelaide ANZAC Day march. When I first met Swannie earlier this year he was 99 years old and only a couple of months shy of his 100th birthday, but by then he couldn’t walk anymore – not for the lack of a will, but because of severe nerve root compression in his lumbar spine. Swannie wanted surgery to fix this but I was sceptical that this was in his best interests, at least initially. As it happened his overall health was actually very good, his heart and lungs were in excellent condition most likely because he had stayed very active and regularly attended the gym, but he just couldn’t walk any more. My main concern originally was that if Swannie were to have a general anaesthetic he would have a bad complication or could even die. Swannie appreciated all my concerns but at the same time his quality of life was relatively poor because of his immobility, and he accepted all the potential risks of surgery in the hope that nothing bad would actually happen and that his walking ability would improve afterwards. I eventually agreed to operate on Swannie, but he had one condition: that his operation happen after his upcoming birthday party, there was nothing that was going to get in the way of that celebration!

Swannie had successful elective spinal decompression surgery the week following his 100th birthday, and I can honestly say that I had never operated on a centurion prior to that day. Following surgery Swannie could walk again with minimal pain, there were no surgical complications, and after a short stay in rehabilitation he went home to carry on with his life. I saw Swannie for his routine post-operative check-up about six weeks after his surgery, and the photographs above were taken on that day. His quality of life was excellent, his walking was back to normal, and he was almost ready to start playing golf again. He was very happy that he underwent surgery, and I was happy that I offered it to him and did not deny him the ability to live his life the way he wanted to live it.

As we age we accumulate degenerative conditions in our bodies: joints develop arthritis, arteries harden and our risk of heart attack increases, our lung capacity reduces, and we become more susceptible to infections to name just a few examples; in short, our bodies start to fall apart. The stress of surgery including the need for a general anaesthetic can sometimes be too much for the body to cope with, and the risks of surgery tend to increase with the number and severity of medical comorbidities. However, it is very much a generalisation to suggest that advanced age itself is a risk of having an adverse outcome with surgery: although it is true that degenerative diseases are more likely in older people, there are still a large amount of older people in the community, just like Swanny, who are considered elderly but who are in fact still in excellent general health.

We now know that what is more important than a patient’s age is their overall level of health, which we refer to as a patient’s physiological age (also known as biological age), as opposed to their chronological age (which is quite simply a person’s age measured in years). This understanding has resulted in fairer and more equitable access to health care: no patient should be denied life improving surgery based on their chronological age alone, and particularly when their physiological age is far younger than their chronological age suggests. A careful medical history is particularly important in older patients contemplating surgery, and when risks to health are identified then an adverse event can sometimes be avoided with meticulous communication between the surgeon, the anaesthetist, and the critical care physicians caring for the patient in the post-operative period. Advanced age is most definitely associated with an increased likelihood of needing inpatient rehabilitation following recovery from major Neurosurgical procedures including open spine surgery and brain surgery, but when it comes to the risks associated with the actual procedure age is far less important than physical health. In a 2018 study published in the Annals Of The Royal College of Surgeons of England Dr Alexis Sudlow demonstrated that in patients aged 90 years or over elective (planned) surgery had an acceptable risk profile for death and major disability when compared with younger patients, but there was an increased risk of death in the same older population for emergency (unplanned) procedures. The results of this study would support the theory that with careful planning the risks for elective surgery are no greater in older patients, and particularly in older patients in otherwise good general health.

So back to the original question then: how old is too old for elective surgery? As you can see, the answer to this depends a lot on each individual patient and their overall level of health. One patient may have a chronological age of 60 years but a history of advanced cardiac disease or diabetes and a physiological age of 85, and that individual would have a higher risk for having elective surgery than Swannie, who despite being 100 years old had a physiological age much closer to 70. No one should be denied the right to health care, but it is the responsibility of the surgeon to make sure all the perioperative risks are addressed and minimised as much as possible before surgery, and that all non-operative management strategies have been explored before committing to an operation. Even if you think you might be “too old” for surgery it is important to discuss your health with your General Practitioner, you might be surprised to find that your physiological age is much younger than you think!

When considering surgery in older patients:

· No one is “too old” for elective surgery, and no one should be denied life improving surgery based on their age alone

· Age is only one factor that should be considered when evaluating a patient’s risk for elective surgery

· Physiological age is more important that chronological age when assessing risks for elective surgery (free online biological age calculator can be found here)

· Expect a longer recovery time: the need for inpatient rehabilitation or help at home after recovering from elective surgery is more likely with advanced age, and this can be anticipated before surgery

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