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INTRODUCTION

As the population ages, increasing numbers of older adults are undergoing major surgery. People over 65 years of age are more likely to have medical comorbidities, functional and cognitive impairment, and other geriatric syndromes, rendering them higher risk for postoperative complications and poor outcomes. Increased rates of delirium, cardiac, pulmonary and infectious complications, mortality, and prolonged cognitive and functional decline have all been described following surgery in this population. Based on available literature, experts in geriatrics, anesthesia, and surgery have delineated best practices for the optimization of older adults before surgery and for their perioperative care.1–3

PREOPERATIVE EVALUATION AND RISK REDUCTION

Older adults must undergo the standard medical preoperative assessment with several important additions. Heightened focus on domains of function, cognition, socioenvironmental surroundings, goals of care, and nutrition are key, as well as screening for common geriatric conditions.1,3 The older adult also merits an extended discussion of overall health goals, expectations/hopes for the surgery, and education on specific risks for geriatric patients. This is intended to shape expectations to match likely outcomes. Exploring the role of surgery in satisfying a patient’s goals and priorities can help ensure that risks incurred do not outweigh anticipated benefits and improvement in quality of life.2

Geriatric syndromes commonly encountered in patients over 65 years old can negatively impact surgical outcomes. It is important to identify and modify risks well in advance of major surgery. At the preoperative visit, a collection of screens should be employed as time and resources allow. While data does not clearly support which evaluations to prioritize, it is reasonable to start with screening for cognitive impairment, functional dependence, delirium risk, polypharmacy, BEERS “potentially inappropriate medications,” and malnutrition prior to surgery.1,2 Additional areas of evaluation might include mental health, alcohol use, urinary retention, constipation, hearing and vision impairment, and adequacy of social supports. A comprehensive geriatric assessment (CGA) is the gold standard for evaluation of geriatric syndromes but requires multiple disciplines and extended visits to complete. Shortened screening instruments in the preoperative period are a more realistic approach to identifying vulnerable patients who may benefit from in-depth geriatric evaluations or even consideration of delay or cancellation of surgery. Recommended screening tools can be found in Table 31-1.

TABLE 31-1Suggested Screens and Interventions for Geriatric Syndromes

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