Increasingly, surgeons are beginning to change the way they perform operations on elderly patients. They are coming to realize that almost everything is different about surgery on older people:  The patient’s goals, the likelihood of complications, and the entire process of treatment from pre-op through surgery itself to recovery.

As a result, doctors are learning that they not only need to adjust the way they perform surgery, but the health system needs to do all it can to be sure older patients are as healthy as possible before these procedures. Surgeons are also coming to understanding that while some procedures are absolutely appropriate for even very elderly patients, others are not.  

In one recent article, (behind a firewall) Johns Hopkins University professor Michael Zenilman said surgeons should not just aim for minimal complications and survival. Elderly patients, he wrote, may be more concerned with preserving their quality of life. Yes, even more than survival itself.  (Full disclosure: As regional director of surgery for Johns Hopkins Medicine, Zenilman manages surgeons at Suburban Hospital in Bethesda, MD, where I am a member of the board).

Over the past twenty years, surgeons have come to recognize that older patients are different than younger adults. But for much of that time, they misunderstood why. And they have been slow to adjust their practices to reflect those distinctions. Now, finally, that is beginning to change.

For many years, doctors thought the biggest difference between older patients and younger adults was simply that they were older. And as patients aged, their organs were less able to tolerate the shock of surgery. Like many simple explanations, it was wrong—or at least incomplete.

Zenilman, a practicing surgeon and author of a textbook on geriatric surgery, says key predictors of unsuccessful procudures are not age itself but factors such as a patient’s overall frailty and whether they suffer from dementia. And, importantly, outcomes also can be worse for those suffering from delirium (temporary confusion often caused by hospitalization), the effects of multiple medications, or cardiac and respiratory disease.  

In short, not every 90-year old is alike. Some will tolerate surgery well and others won’t.  New ways to measure frailty can help both doctors and patients recognize who is a good candidate for surgery.

And not every surgery is alike. It turns out, for example, that older patients do just as well with surgery for early stage pancreatic cancer as younger patients, according to Johns Hopkins research.

This means that surgeons need to learn how to carefully identify who is likely to have a good outcome and work with families, patients, and other medical practitioners to address those risk factors they can control.

For example, before surgery, doctors must make sure their patients are in the best possible physical condition. During surgery, they need to know the best techniques for operating on older patients. And after surgery, doctors should be aware of potential risks for delirium and bedsores.

Most important, families and physicians need to be clear about what a patient really wants from her treatment. Is her goal to maximize her lifespan, even if it means limiting her quality of life? Or is it maintaining independence and dignity, which may suggest less aggressive alternatives?

What Zenilman and other surgeons are learning is that knowing the answers to these questions is at least as important as their skill with a scalpel.