Even relatively modest stress before surgery may significantly affect how well older adults recover, according to new research from Duke University School of Medicine. The study suggests that psychological strain is not simply an emotional side effect of preparing for surgery, but a factor that can meaningfully influence physical recovery and post-operative wellbeing in later life.
The research found that older adults who entered the operating room carrying a greater number of worries faced higher risks of complications after surgery. These patients were more likely to experience delirium, report inadequately controlled pain, and remain in hospital for extended periods. Importantly, these outcomes were observed even among individuals who did not describe themselves as highly stressed, indicating that stress may exert its effects quietly and cumulatively rather than through overwhelming anxiety alone.
Senior author Leah C. Acker, an anaesthesiologist at Duke Health, said the findings point to a missed opportunity in pre-surgical care. Stress is rarely measured in a structured way before operations, yet it may be a modifiable risk factor. Identifying and addressing stress early, she noted, could help clinicians reduce complications and improve recovery trajectories for older patients.
The study focused on adults preparing for major surgery, excluding heart and brain procedures. More than 40 per cent of participants reported moderate to high distress in the lead-up to their operations — levels comparable to those seen in patients with advanced cancer. This finding highlights how demanding the pre-operative period can be for older adults, even when surgery is planned and medically routine.
One of the most striking results was that recovery outcomes were tied more closely to the number of stressors a patient faced rather than how intense those stressors felt. Each additional worry increased the odds of delirium by 19 per cent, while higher stress counts were also strongly associated with increased pain and more extended hospital stays. Acker described this pattern as an “overwhelmed phenotype”, in which multiple small pressures accumulate and interfere with the body’s ability to heal effectively.
To assess stress, researchers used a brief digital version of the NCCN Distress Thermometer with 132 patients between late 2022 and early 2024. Common concerns included sleep or appetite changes, communication with healthcare providers, and family responsibilities, alongside broader worries about finances, home maintenance, loss of independence, and maintaining meaningful activities. Because most adults over 65 will undergo surgery at least once, Acker emphasised the need for better tools to identify those at risk — particularly for delirium, a serious post-operative complication that increases hospital costs and long-term risk of dementia.
More information: Leah C. Acker et al, Mixed-methods Analysis of Preoperative Distress and Postoperative Outcomes in a Prospective, Observational Cohort of Older Adults, Anesthesiology. DOI: 10.1097/ALN.0000000000005780
Journal information: Anesthesiology Provided by Duke University
