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Learning Objectives

  • To understand what older patients undergoing surgery consider a successful outcome in contrast to the traditional surgical outcomes of length of stay, postoperative complications, and readmission.

  • To understand the long-term effects of surgery including associated complications and readmissions on the ability of patients to achieve functional recovery (physical, cognitive, psychological, emotional, social, and economic recovery) after surgery.

  • To review the effect of delirium and postoperative cognitive dysfunction on postoperative recovery.

Key Clinical Points

  1. Many older surgical patients value maintenance of functional independence and quality of life (QOL) as much as or even more than quantity of life and make decisions regarding their surgical care based on these values.

  2. Frailty is a stronger predictor of perioperative morbidity and mortality than chronological age alone. A comprehensive and efficient frailty assessment for patients in the preoperative period should be standardized.

  3. Hospitalized older adults undergoing surgery are at risk for geriatric events (delirium, dehydration, falls or fractures, failure to thrive, and pressure ulcers), which can contribute to worse outcomes.

  4. Geriatric co-management of patients has been associated with improved outcomes including shorter length of stay and lower rates of complications and mortality for older patients.


The US population is aging and increasing numbers of older adults are undergoing surgery. Adults 65 and older account for more than 40% of all inpatient operations and 33% of outpatient operations performed annually in the United States. With advances in care and surgical technique, it is not uncommon to have surgical patients in their 80s and 90s and beyond. However, operations in older adults are associated with a high risk of prolonged hospitalization, surgical complications, and functional decline. As we place increasing focus on improving these outcomes, we have found that chronological age is not sufficient for predicting surgical risk. Frailty has been shown to be a stronger predictor of perioperative morbidity and mortality than age alone, and we are now working to refine how we assess frailty in surgical patients so that we can have meaningful discussions with patients and their families about the impact and possible outcomes of surgery.

In contrast to younger patients, many older surgical patients value maintenance of functional independence and quality of life (QOL) as much as or even more than quantity of life. In this context, the long-standing traditional measures of surgical quality and a successful surgical outcome—short hospital stay, few postoperative complications, and avoidance of 30-day readmission must be reconsidered. Functional recovery following surgery is now perhaps the most important measure of surgical success in this older patient population and globally encompasses physical well-being as well as cognitive, psychological, emotional, social, and even economic recovery over a period of a year or more.

This chapter will review traditional surgical outcomes as well as patient-centered outcomes of functional and cognitive recovery and QOL for older patients undergoing surgery.

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