Preoperative stress may matter more than surgeons once thought.
A new US study shows that even passing worries can increase the risk of delirium, pain and longer hospital stays.
The Duke University School of Medicine study found that even modest stress can affect how older adults recover from surgery.
The study, published in Anesthesiology, showed that those who carried more worries into the operating room faced higher risks of delirium, experienced more uncontrolled pain, and spent extra days in the hospital afterwards, even when they didn’t think of themselves as highly stressed.
The findings point to a simple but overlooked opportunity: identify and address patient stress before surgery to improve surgical outcomes, said senior study author Leah C Acker, an anaesthesiologist and cognitive neuroscientist at Duke Health.
More than 4 in 10 older adults scheduled for major surgeries, not including heart or brain operations, said they experienced moderate to high distress, a level comparable to patients with advanced cancer.
Stress among cancer patients is often tracked, but the Duke study is one of the most in-depth looks at pre-surgery stress in the general geriatric surgical population.
Surprisingly, it wasn’t how intense the worry felt, but the number of stressors a patient faced before surgery that predicted worse outcomes. Stress count was strongly correlated with pain levels and hospital stays. The odds of experiencing delirium grew with each additional stressor.
Acker described an ’overwhelmed phenotype’, in which minor stressors pile up to the point of hindering recovery.
Among patients who experienced delirium, the median distress intensity was 3.5 (measured on a scale of 0 to 10) compared with 2 for those who did not.
Although the study focused on adults aged 65, the results may apply to surgical patients of all ages.
To measure stress, researchers used a three-minute, tablet-based version of the National Comprehensive Cancer Network Distress Thermometer with 132 patients between November 2022 and December 2024.
Patients rated their distress before surgery, selected concerns from a 39-item checklist and shared open-ended thoughts.
Common pre-surgery worries included:
• Sleep and appetite changes
• Communication with the health care team
• Caregiving responsibilities
• Loss of independence
• Family-related stress.
Others revealed concerns about break-ins, identity theft, home repairs and bills. Some expressed concerns about the ’general direction of the country’ and holding on to activities that bring them joy and meaning, such as travelling, concerts and golf.
Although most of the group were retired, many expected to continue meeting the daily demands of caring for pets, spouses, and grandchildren.
"Overall, these free-text responses highlight the complex and often unspoken concerns that weigh on geriatric patients as they await surgery,’ the authors wrote.
Because most adults over age 65 will undergo surgery at least once, Acker says doctors need better ways to spot who may be at risk for problems after surgery.
One of the most serious post-operative risks is delirium – particularly devastating for older adults.
Acker says a larger study could pinpoint which stressors matter most, offering clearer insight into how patients can achieve the best possible recovery.
