Introduction

In the mid-1900s, surgeons often hesitated to perform even simple operations on people over age 50. Times have changed! Now, more than one third of all operations in the United States are performed on people 65 or over.

Despite an increased willingness to perform surgery on older people, aging does increase the risk of complications during and after surgery. For example, older people are much more likely than younger people to develop delirium after surgery. They are also more likely to experience complications from bed rest that might occur after surgery. The risk of death during or after surgery also increases with aging. More than three quarters of deaths in the period immediately after surgery occur in older people. Further, when emergency surgery is performed or when surgery involves the chest or abdomen, the risk of death goes up in all age groups, but much more so for older people.

Although age itself is a risk factor, overall health and the presence of certain disorders increase surgical risk far more than age. Having had a heart attack within 6 months is a particularly high risk factor, as is poorly controlled heart failure. Coronary artery disease, certain abnormal heart rhythms, and poorly controlled high blood pressure increase the risk of surgery in older people. Lung problems, such as chronic obstructive pulmonary disease, are of some concern when determining the risks of surgery, particularly in smokers. Impaired kidney function and problems with mental function, such as dementia, may also increase the risk.

Certain surgical procedures pose more risk than others. For example, surgery involving the abdomen or chest ranks high on the list of risky procedures. Many procedures that older people commonly undergo, such as cataract surgery and joint replacement surgery, pose lower risk. If an older person is generally well, most operations, including ones considered to be higher risk, can be performed safely.

When the risks of surgery are high, they still may be outweighed by the potential benefits. For example, surgery that involves some risk of death, such as repair of a large aortic aneurysm, should be considered if the person is expected to live for another 8 to 10 years, because such aneurysms increase the risk of death if they are not repaired. However, such surgery should probably be avoided if other illnesses limit life expectancy to only 1 to 2 years. When the risks of surgery are low, the low risk may be outweighed by a lack of benefit. For example, some people believe that the risk of tooth-extraction surgery, which usually is very low, is still much too great to justify putting a person with advanced dementia through such an operation.