Perioperative Care of the Geriatric Patient

Preoperative Evaluation

• The American College of Anesthesiologists recommends a multidisciplinary preoperative evaluation for geriatric patients, including assessment of risk, optimization of modifiable factors, and consideration of ethical and legal issues regarding decision-making capacity and informed consent 1, 2
• Preoperative evaluation in geriatric patients allows for risk stratification, informing physicians, patients, and families about the risks and benefits of undergoing surgery, and proactive identification and optimization of modifiable risk factors 1
• The physiological reserve decreases by approximately 1% per year after age 40, making patients more vulnerable to stressful factors such as surgery 3

Specific Risk Factors

• The American Geriatrics Society notes that physiological deterioration related to age, multimorbidity, and frailty are independently associated with increased perioperative risk 1
• Adverse outcomes are more likely after emergency surgery than elective surgery in older adults 1
• Sarcopenia, or loss of muscle mass, strength, and function, represents a decline in musculoskeletal reserve that precedes frailty 3

Ethical Aspects in Decision-Making

Informed Consent

• The standard of information is "what a reasonable patient in the patient's circumstances might want to know" 4
• Specific information should be provided about how an intervention could affect the patient's remaining quantity or quality of life 4
• It is essential to communicate the short- and long-term risks and benefits of a specific procedure, an alternative procedure, or no procedure (conservative therapy) 4

Decision-Making Capacity

• All personnel involved in the care of older adults undergoing surgery should be aware of their duties under mental capacity laws 2
• Consultants should make decisions in relation to patients without capacity, taking into account the patient's known expectations and wishes, as well as those of their family and/or caregivers 2
• If a patient is critically ill, decisions about the degree and suitability of intervention will require the involvement of experienced surgeons, anesthetists, intensivists, geriatricians, and family members/caregivers 2

Preoperative Optimization

• Preoptimization should focus on reducing the risk of postoperative complications, including organ-specific morbidity, ischemia, postoperative cognitive disorders, and malnutrition 5, 2
• The American Heart Association recommends that guidelines be adapted to accommodate the older patient, considering the adverse effects of overinvestigation or polypharmacy 5

Legal Aspects

• High-risk surgery should not be performed without a preoperative commitment to adequate postoperative care 2
• Experienced personnel should be available at all times to anesthetize and operate on the patient, and to organize adequate postoperative care 2
• Managing expectations is important, and the provision and intensity of postoperative support and end-of-life care should be discussed before surgery 2

Intraoperative Management

• Older adults should expect the same level of dignity and anesthetic care as younger adult patients 6
• Additional time may be required to allow older adults to prepare for surgery 6
• Functional aids (glasses, hearing aids, dentures) should remain in place until just before induction of anesthesia 6
• Temperature control is crucial, as perioperative hypothermia is common and associated with adverse outcomes such as postoperative delirium, cardiac dysfunction, prolonged hospital stay, and poor wound healing 6

Multidisciplinary Communication

• Senior multidisciplinary communication about the nature of the surgical intervention is strongly recommended before and during surgery 7
• Anesthetists should ask their surgical colleagues exactly what procedure is proposed and whether it is appropriate for the patient's physiopathological state 7

Preoperative Evaluation of Geriatric Patients

Core Recommendations

• The British Journal of Anaesthesia recommends that all geriatric patients aged 65 years and older undergoing surgery must receive a validated, multidimensional frailty assessment during preoperative evaluation, followed by comprehensive geriatric assessment (CGA) for those who screen positive, with early multidisciplinary team involvement throughout the perioperative period 8, 9, 10
• The American College of Surgeons and British Journal of Anaesthesia suggest using validated multidimensional frailty instruments for assessment, as frailty assessment provides unique prognostic information beyond traditional risk stratification and is feasible in clinical practice 8, 9, 10, 11

Preoperative Assessment

• The British Journal of Anaesthesia recommends performing frailty screening on all patients ≥65 years as part of routine preoperative functional status evaluation, and using validated multidimensional frailty instruments for assessment 8, 9, 10
• The Anaesthesia journal suggests that CGA must evaluate specific domains, including cognitive function, functional status, nutritional status, polypharmacy, comorbidity burden, and social support 12, 13

Risk Stratification

• The Anaesthesia journal recommends not relying solely on ASA Physical Status classification for geriatric patients, as it does not predict 6-month mortality in older adults, and using CGA deficit scores which are strongly associated with postoperative mortality 12, 13

Preoperative Optimization

• The Anaesthesia journal suggests balancing optimization against surgical delay, and focusing on specific interventions such as ischemia prevention, medication management, nutritional optimization, functional optimization, and diabetes management 12, 13
• The British Journal of Anaesthesia recommends using START/STOPP criteria for medication optimization, and avoiding extending polypharmacy unnecessarily 8, 10

Multidisciplinary Team Involvement

• The British Journal of Anaesthesia recommends engaging multidisciplinary teams early in assessment and maintaining daily communication throughout perioperative care, and involving senior geriatrician and senior anesthetist with geriatric subspecialty training in higher-risk elderly patients 14, 15, 11, 12, 13

Intraoperative Management

• The British Journal of Anaesthesia recommends maintaining normothermia aggressively, ensuring mean arterial pressure (MAP) within 20% of preoperative baseline, and limiting urinary catheter use in patients with frailty 10

Perioperative Analgesia

• The British Journal of Anaesthesia suggests individualizing perioperative analgesia using validated pain assessment tools, and attempting to limit opioid and NSAID use 14, 15, 11

Postoperative Care

• The British Journal of Anaesthesia recommends adhering to Enhanced Recovery After Surgery (ERAS) protocols, maintaining hemoglobin levels above approximately 90 g/L in older surgical patients with frailty, and targeting blood glucose 7.8-10 mmol/L in diabetic patients with frailty 14, 11

Emergency Surgery Considerations

• The British Journal of Anaesthesia recommends obtaining collateral history from family/caregivers, being aware of atypical presentations in frail older adults, and assessing and managing hypothermia during ambulance transit 8, 10, 12, 13