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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #4, #14, #16, #18, #21, #43, #44, #55

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LEARNING OBJECTIVES

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Learning Objectives

  • Describe the effect of surgery on postoperative functional and cognitive status.

  • Understand surgical outcomes in specific surgical population.

  • Recognize the future directions in preoperative optimization.

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Key Clinical Points

  1. Identifying frailty preoperatively is important for the prediction of postoperative adverse events and mortality.

  2. Age alone does not predict functional decline after surgery.

  3. Prehospital rehabilitation is emerging as a strategy to improve postoperative outcomes for frail older adults.

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INTRODUCTION

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As the population over the age of 65 grows, so will the proportion of older adults undergoing surgical procedures. Estimates of general surgery workload predict a 32% increase between 2000 and 2020 with a population increase of only 18%, reflecting the larger proportion of older patients. With advances in care and surgical technique, older patients with treatable conditions continue to be referred for surgery; however, operations in frail older adults are associated with a high risk of complications, prolonged hospitalization, and functional decline.

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Recently, frailty as a distinct clinical syndrome has been recognized as a surgical risk factor that contributes to adverse surgical outcomes independent of age. Surgical decision making in frail older patients is complex. The balance between high operative risk and the potential benefits of surgery is not always clear. How to effectively prepare frail patients for surgery and identify which patients will benefit most from operative intervention is still a subject of investigation. In this chapter, we will review the risk factors for adverse events and predictors of long-term outcomes of surgery in older patients.

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FRAILTY AS A RISK FACTOR

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Frailty, or a decreased physiologic reserve with vulnerability to stressors, is an increasingly common focus of surgical research, and is integral to any discussion of surgical outcomes in older adults. The prevalence of frailty in the surgical population is estimated between 40% and 50%. Frailty is independently associated with complications such as postoperative delirium, with an odds ratio (OR) of 1.84. A modified frailty index with points given for comorbidities and functional dependence was found to be associated with mortality in emergency general surgery operations with an OR of 11.7. In multivariate analysis, the association between frailty and mortality was stronger than that observed for increasing age or American Society of Anesthesiologists (ASA) class. Whether to use a particular score or combination of variables (and which variable to use) to define frailty in the surgical population is a subject of debate.

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OUTCOMES

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Functional Status

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For older surgical patients, even transient loss of independence is a major concern; therefore, it is essential to understand the effects of surgery on functional status in the short and long term. In a seminal 2004 study, ...

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