Before deciding on whether a surgical procedure is necessary, the patient and surgeon should be discussing a pile of questions that could end up being thick enough to cut with a scalpel.

Is this the right time? What are the alternatives? What if you don’t get the surgery? Do the benefits outweigh the risks? How long will the recovery be? What is the long-term prognosis?  How important is my age?

And that’s just for starters. Some doctors say a patient should do thorough research on the Internet and make lists of questions before deciding on non-emergency surgery.

“I run into this issue a lot, and what I can tell you is patients need to speak up and not be afraid to talk to their doctor and bring up questions,” says William Mihalko, MD, professor and J.R. Hyde Chair of the Joint Graduate Program of Biomedical Engineering at the University of Tennessee Health Science Center. “In our elderly population when they get into their 70s a lot of times they’re not always proactive in asking the questions they may have."

Mihalko, who also is in the Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, adds, “My advice is that if something doesn’t seem right or they don’t understand something they need to speak up and ask their doctor. There are no stupid questions from a patient. Sometimes there’s that white-coat syndrome or patients get the deer in the headlights feeling or they just forget the questions. I tell patients on of the best things to do is make a list of questions.”

Surgery for an older patient carries some special considerations, but doctors say every case is different and decisions must be tailored to the individual.

“It’s not so much the chronologic age as it is the physiologic age,” says Timothy Fabian, MD, the Harwell Wilson Alumni Professor and chair of the Department of Surgery at UTHSC. “You can have some 50- or 60-year-olds who are going to do worse than some 90-year-olds because they haven’t taken care of themselves. They might have heart disease or they’ve smoked all their lives.

“Is anyone ever too old for surgery? Not really, but it would depend on what the surgery is. If it’s someone 90 years old with the same inguinal hernia he had for 50 years, that would be someone you wouldn’t want to operate on. But if they’ve got an abdominal aortic aneurysm that’s getting bigger in size that’s documented and they’re in reasonably good health regardless of their age, then you operate on them."

Mihalko’s specialty is hip and knee replacement surgery, an elective procedure that he says calls for some practical as well as medical decisions. Some patients start thinking about surgery before they actually need it.

He once did a hip replacement for an otherwise healthy 92-year-old man whose alternative was moving to a nursing home because of his arthritic hip. The surgery allowed the patient to live independently for several more years.

But the surgeon emphasizes to patients that surgery is not always the answer.

“Just because their X-rays say they have bad arthritis doesn’t mean they have to undergo hip or knee replacement,” Mihalko explains. “It all depends on how it’s affecting their life and everyday activities. If they’re still able to take a walk and get in enough exercise to keep their heart and their lungs fit, then it’s probably not time to be thinking about that hip or knee replacement.”

Another reason a patient might want to at least delay such surgery is that the advancements in surgery over the past 15 or 20 years have been unprecedented. There may be a better procedure just ahead.

“Surgery is radically different over the last 15 years in almost all areas, and the technological advances have been incredible,” Fabian says. “Almost every area now has some element of minimal invasive approaches to surgery, be it heart surgery, neuro surgery, orthopedics or general surgery. That’s completely revolutionized all of surgery.

“It’s happened at some expense,” he continues, “but in most circumstances through studies of procedures it’s found to be as effective and safer.  In follow-up surveys, in the overwhelming majority, there’s better patient satisfaction with these minimally invasive approaches.”

Mihalko adds that the best is yet to come.

“Progress in medicine is moving much faster, so if you wait three or four years until it is bad enough to be impacting your life there may be a new procedure out or a new treatment that’s going to significantly benefit you,” the doctor says. “We may have a new treatment we didn’t have when all this started, and once you do a hip or knee replacement you burn the bridge. You can’t go back.

“I think too many times a lot of patients get into the mindset that, ‘Well, if I’m going to need it eventually I should just do it now.’ That’s not necessarily the right mindset. There are many 65-year-olds who are not as fit as some 75-year-olds. There are some 75-year-olds who are out there running half-marathons. It really comes down to the individual patient, and we need to treat them that way.”