Why Hospitals and Nursing Homes May Not Mix

You may have heard about some surgical procedures that are considered risky, but did you know that a number of surgical procedures are even riskier for nursing home residents than they are for non-institutionalized older adults? Research reported by Dr. Emily Finlayson, a surgeon at the University of California, San Francisco, and her colleagues in The Annals of Surgery says exactly that. If you are a caregiver to an older adult, particularly one who may now live in a nursing home, you need to be an informed advocate on behalf of that person.

Dr. Finlayson and her colleagues used data reported by Medicare on patients 65 and older to compare surgical patients who lived in institutional settings and those who did not. The samples for each group were impressively large - nearly 71,000 nursing home residents and over a million 65+ year olds who did not live in a facility. The doctor matched both samples on their actual ages and the numbers of other chronic medical conditions they had prior to their surgeries.

Across all surgical categories the mortality of the institutional patients was higher than for their counterparts. For instance, surgery to repair a bleeding duodenal ulcer showed 42% of nursing home older patients dying versus only 26% of their age peers who did not live in nursing homes. For an appendectomy the difference was 12% mortality for nursing home patients against only 2% for the population of older adults at large. Gall bladder surgery was similar with 11 percent of nursing home residents dying compared with 3% of the other population.

And surgery is not the entire story. For institutionalized patients there were proportionately more subsequent interventions than there were for their counterparts. These residents were more likely to need mechanical ventilation to help them breathe, feeding tubes in their abdomens or even venous catheterization to monitor their hearts. Each follow-on procedure introduced more risk on top of what the surgical procedure itself represented.

And as if the story could not get worse, you have to remember that hospitalizations, especially those for surgery, involve a lot of down time. Patients who spend more time in a hospital bed also are likely to be exposed to infections, some of which can lead to pneumonia. For those who dodge that bullet, they will still have their performance status diminished by that time on their backs. The rule of thumb is that for every day in a hospital bed, an older patient will need two days to recover their stamina.

So, the lesson for caregivers is fairly clear based on concrete data: When a provider recommends surgery for the elder in your charge, always ask about non-surgical options. And check out the article in The Annals of Surgery.