Surgical patients who experience preoperative distress and anxiety might face worse postoperative recovery. Research has suggested that preoperative stress impairs immune function and increases inflammation.

New research published in the Anesthesiology found that 40% of older surgical patients had high levels of distress. The study included129 older adults who were given a brief, 3-minute digital distress test. Having more preoperative stressors, but not the stressor intensity, was associated with an increased risk for postoperative delirium, poor pain control, and longer hospital stays.

“This isn’t purely about how the patient feels — it is a metric of their risk for poor surgical outcomes along the dimensions that healthcare providers are really concerned about when they think about the quality of the care that they’re providing,” Leah C. Acker, MD, PhD, senior study author, an attending anesthesiologist, and an assistant professor of anesthesiology and neurobiology at Duke University School of Medicine in Durham, North Carolina, told Medscape Medical News.

The researchers used a digital version of the NCCN Distress Thermometer to quantify distress. This screening tool, developed for cancer patients, allows respondents to rate overall stress on a scale of 0-10, identify the number of stressors they have, and write about specific stressors in a free-text section.

In a real-world setting, surgical patients could complete this, or a similar digital distress test, at home or in the waiting room. Clinicians could then use the patient’s responses to tailor preoperative conversations to address what matters most to the patient. This would help personalize care and make patients feel better going into surgery, Acker said.

While addressing stressors could help surgical patients experience less pain and leave the hospital sooner, more research is needed to determine if preoperative distress interventions will actually improve postoperative outcomes.

Overwhelmed Phenotype Identified

The study labeled surgical patients with a higher stressor count as an “overwhelmed phenotype.”

Flagging these patients before surgery could help the care team determine who would benefit most from tailored conversations or stress-reduction strategies.

“We’ve known for a long time that stress affects every organ system in the body, the immune system, and our ability to problem solve,” Andrea Bradford, PhD, a clinical health psychologist and associate professor at Baylor College of Medicine in Houston, told Medscape Medical News. “The more stress we have, the fewer resources we can devote to recovery and healing, both on a physiological and cognitive or problem-solving level. Understanding the context of what patients are dealing with outside of the context of surgery is always going to be important.”

While this study does not prove that addressing stressors with these patients will decrease hospital length of stay or postoperative pain, it highlights the importance of recognizing each patient’s humanity.

“I think what’s really critical to learn from this is that our patients are experiencing a high level of preoperative distress, some really quite extreme. And we all have that feeling because these are the people who break down crying when you start to talk about normal anesthesia stuff,” Elizabeth Whitlock, MD, MS, an anesthesiologist at University of California San Francisco Health and vice chair in the American Society of Anesthesiologists’ Committee on Geriatric Anesthesia, told Medscape Medical News.

Perioperative care clinicians should consider factors affecting the patient’s quality of life rather than just the patient’s immediate pathology, she added.

Addressing the Risk for Delirium

Although the findings still need validation, the research underscores the importance of addressing the risk for delirium.

“Once a patient tips into delirium, it’s horrible for everybody. It’s horrible for the patient, obviously, and it’s horrible for families,” Daniel Chen, MD, a hospitalist who is board-certified in geriatrics at Cambridge Health Alliance in Cambridge, Massachusetts, told Medscape Medical News.

Postoperative patients with delirium tend to stay in the hospital longer because they often don’t participate in their physical therapy evaluation, which is needed for a nursing home referral or a sign-off to go home and continue physical therapy outside of the hospital, Chen added.

Importantly, this study did not exclude patients with cognitive impairment, which may have affected the findings since older adults with dementia and other cognitive disorders have an increased risk for delirium.

However, if additional studies confirm that having more preoperative stressors increases the risk for delirium, clinicians could use a screening test to identify at-risk patients and work to lower their chances of developing delirium.

Anesthesiologists can already do some things differently if a patient has a higher risk for postoperative delirium due to baseline cognitive impairment, Whitlock said.

If we can identify cognitive distress as an independent predictive delirium risk factor, clinicians could use concrete strategies to also intervene on that, she added.

Make Patients Feel Heard

The new study was a wonderful opportunity to remind clinicians that coming in for any kind of procedure is very stressful, Caron Hong, MD, CRSP, MSc, MBA, chair in the anesthesiology at MedStar Washington Hospital Center and professor of anesthesiology at Georgetown University School of Medicine, both in Washington, DC, told Medscape Medical News.

Previous research has shown that holistic patient care, which incorporates body, mind, spirit, social, and cultural factors, improves patient satisfaction and recovery rate.

Here are a few ways clinicians can practice holistic care with surgical patients to make them feel heard:

Use active listening. Hong said she has about 10 minutes to speak with a patient before surgery, so she goes in “with a script that gets modified based on how the patients want to drive the conversation.” When engaging in active listening, try to really hear and understand the speaker’s perspective. Ask open-ended questions, paraphrase their responses, and reflect what they said back to the patient to show that you are listening and comprehending. 

Engage the patient’s loved ones. The study showed that many patients felt concerned about how their loved ones would cope during the patient’s recovery period. As patients often have a loved one in the preoperative room, this is a nice opportunity to help alleviate some of that stress. Hong said she always asks the loved one if they have any questions, including about the anesthesia or procedure. “I think what’s most important are the moments that we have with the patient and the families to make them feel they’re heard and to make them feel that they’re being taken care of,” Hong said.

Make patients aware of well-being support. Before implementing distress screening, the care team needs to develop a plan for how to help patients who need referral to a mental health professional or social worker. It is also important to have patient-facing materials available so they know about these resources, Bradford said. “Sometimes patients may not feel ready or comfortable answering those questions when they’re directly asked of them. It’s helpful to know that those support resources exist so that they can reach out and request an appointment with a counselor, a social worker, or someone who can connect them to a peer or a support group,” she added.

Whitlock reported having no financial conflicts of interest but does have National Institutes of Health funding and nonprofit funding for research. She was the handling editor for Anesthesiology who handled this paper. Acker, Bradford, Chen, and Hong reported having no disclosures.