Warren Buffett, believed to be the world’s greatest investor says, “Risk comes from not knowing what you’re doing.”
Risk in surgery also comes from not knowing what you’re doing. But in this case rather than losing money you can lose a life. This week, how the fragility test saves lives.
A report from Johns Hopkins University says that 50% of people over 65 will undergo surgery. It’s therefore a forgone conclusion that aging parents and their children will be asking, “Do you believe he or she is well enough to undergo an operation?”
Sometimes the answer is as easy as falling off a log. The parent simply does not need surgery. After all, why submit a 70-year-old with only mild discomfort, that’s not life-threatening to a major operation? The benefit does not warrant the operative risk.
But suppose an elderly parent’s quality of life is severely affected. How then do you assess the risk of surgery? In the past there were several ways to evaluate it.
The ‘Lee Cardiac Index’ looks at the possibility of cardiovascular problems based on the type of operation, the degree of cardiovascular disease, whether the patient suffers from diabetes and how good kidney function is.
There’s also a tool used by the American Society of Anesthesiologists, called the ASA score.
Anesthetists and surgeons estimate the patient’s health using a scale of one to five. A score of one says that in all probability the patient is fit for the operation. A score of five indicates an unfit patient who is unlikely to survive surgery.
But it’s been long recognized that some patients with a score of one may do poorly and those with a score of five may thrive after surgery. So these tests are unreliable and may be little better than tossing a coin.
Dr. Linda Fried, founder of the Johns Hopkins Center on Aging and Health, has been working on this dilemma for 10 years.
She says that 20% of those over 80 are frail, women more so than men because they start life with less muscle.
Sometimes their fragility results from a triggering event such as sudden illness or injury that leads to loss of appetite, weight and muscle mass. Or more often it’s a combination of the ravages of time along with decreased physical activity that decimates muscle mass.
Dr. Fried’s research has developed what’s called the ‘Fragility Test’ which evaluates five aspects of the patient’s health.
If an elderly person suffers from two or more of the following problems they must be classified as frail.
First, unintentional weight loss of 10 pounds or more in the last year accompanied by loss of muscle mass, called sarcopenia.
Second, weakness demonstrated by poor grip strength. Three, a feeling of exhaustion causing the remark “I feel I cannot get going most days of the week.”
Four, less physical activity where they’re only using 2,700 to 3,380 calories for the entire week (compared to a need of 1,600 calories a day).
Five, a slow walking speed in which men over 5’ 7” and women over 5’ 3” take seven or more seconds to walk 15 feet.
To test its accuracy Hopkins researchers assessed 564 patients 65 years of age or older before they underwent major surgery.
Prior to their operation they were classified by the fragility test as either frail, moderately frail or not frail.
The results were published in the Journal of the American College of Surgeons. It showed that the moderately frail and the frail were twice as likely to suffer post-operative complications such as infection, respiratory distress or poor wound healing.
The moderately frail were also three times more likely and the frail 20 times more likely to require a nursing home when they were discharged from hospital.
It’s said that “The race is not to the swift nor the battle to the strong.”
But keeping in good shape certainly improves survival after surgery.
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