Eric Cohen, MD, still remembers his hesitation the first time an 83-year-old asked to go home the same day she underwent joint replacement surgery.
“At first, it was kind of like a pause,” said Dr. Cohen, program director of the Total Joint Center at Miriam Hospital and co-director of Brown University’s Adult Reconstruction Fellowship, both in Providence, R.I. “You’re 80, you’re 83, you’re 84. Should you be going home the same day? Is that safe?”
He now runs a total joint program that performs about 1,700 procedures a year at the Miriam center alone. His answer to that question has changed.
“The short answer is yes, it is,” he said. “Age is just a number. It’s more about your health and your physiology and your motivation.”
What drove the shift
Before 2020, Hip and knee replacement patients typically spent two to three days in the hospital. Dr. Cohen pointed to two reasons for same-day discharge becoming more common: The COVID-19 pandemic strained hospital capacity and pushed more procedures toward faster discharge, and CMS removed hip and knee replacement from its inpatient-only list, allowing Medicare to pay for the procedures on an outpatient basis for the first time.
At first, same-day discharge was assumed to be for younger, motivated patients. Then Dr. Cohen’s practice started seeing healthy patients in their 80s asking for the same option. The program initially set a hard cutoff for anyone over 80, though that did not last.
“We started to say, ‘Hey, this 82-year-old is healthier than some of my 65-year-olds. Why are we not letting this person go home same day?'” Dr. Cohen said.
Once the cutoff was lifted, he said those patients “all did extremely well. In fact, I think they are better in some ways than their younger counterparts.”
What the evidence shows
Dr. Cohen and his colleagues published a retrospective case series in June in Gerontology evaluating same-day discharge outcomes specifically in octogenarians undergoing elective primary hip or knee arthroplasty at a single institution. Fifteen patients met inclusion criteria, with a mean age of 81.6 years. Most were relatively low risk by standard surgical scoring.
The procedures consisted of eight total knee arthroplasties, six total hip arthroplasties and one unicompartmental knee arthroplasty. Average blood loss was low and average operative time was 72 minutes. Each of the 15 patients was discharged the same day, with a mean discharge time of about four hours after surgery. There were no intraoperative complications and no readmissions at 30 or 90 days, according to the study.
Dr. Cohen’s team also reviewed the broader literature on perioperative optimization for older surgical patients, highlighting geriatric comanagement, individualized anesthesia planning, early mobilization and standardized discharge protocols as key factors in avoiding complications such as delirium, infection or prolonged hospitalization.
“This case series reinforces growing evidence that age alone should not preclude surgical intervention,” the authors concluded in the study.
Dr. Cohen said he saw these results in real time in his own patients.
“We watched how they did, and they all did extremely well,” he said
Not about the birthday
Dr. Cohen said the predictors he looks for have little to do with a patient’s age. He evaluates mobility directly in the office using a “get up and go” test — watching how quickly and steadily a patient rises from a chair and walks. He also wants to see a patient’s blood sugar and blood pressure well controlled, no major cardiac or lung issues, a support system at home, and a level of motivation he said surgery itself demands.
“Having surgery is like running a marathon,” he said. “You want to have all of those different factors: physical, medical and then even mentally.”
Support at home matters regardless of age, he said, but it carries more weight for older patients.
“You gotta have someone at home to help you,” he said. “Even if you’re 50, but if you’re 80, especially, you gotta have someone at home to help you.”
What’s next
Dr. Cohen expects the number of older patients discharged the same day to keep climbing as anesthesia techniques, surgical approaches and patient education continue to improve.
“People are living longer and staying healthier and active longer, and there’s no reason to think that’s going to stop,” he said.
He also pointed to preventive, whole-health approaches such as nutrition, bone health and weight management as increasingly central to preparing older patients for surgery and for life afterward. He said that as a surgeon at Brown, he has seen the program building a more comprehensive care model rather than treating joint replacement as an isolated, one-time procedure.
That shift matters, he said, because patients today are more likely to need a second joint replacement decades after their first.
Now, healthier and more active patients are returning for additional procedures later in life, reinforcing, in his view, why age alone should never be the deciding factor.
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