Preoperative assessment of the older surgical patient: honing in on geriatric syndromes

Abstract

Nearly 50% of Americans will have an operation after the age of 65 years. Traditional preoperative anesthesia consultations capture only some of the information needed to identify older patients (defined as ≥65 years of age) undergoing elective surgery who are at increased risk for postoperative complications, prolonged hospital stays, and delayed or hampered functional recovery. As a catalyst to this review, we compared traditional risk scores (eg, cardiac-focused) to geriatric-specific risk measures from two older female patients seen in our preoperative clinic who were scheduled for elective, robotic-assisted hysterectomies. Despite having a lower cardiac risk index and Charlson comorbidity score, the younger of the two patients presented with more subtle negative geriatric-specific risk predictors – including intermediate or pre-frail status, borderline malnutrition, and reduced functional/mobility – which may have contributed to her 1-day-longer length of stay and need for readmission. Adequate screening of physiologic and cognitive reserves in older patients scheduled for surgery could identify at-risk, vulnerable elders and enable proactive perioperative management strategies (eg, strength, balance, and mobility prehabilitation) to reduce adverse postoperative outcomes and readmissions. Here, we describe our initial two cases and review the stress response to surgery and the impact of advanced age on this response as well as preoperative geriatric assessments, including frailty, nutrition, physical function, cognition, and mood state tests that may better predict postoperative outcomes in older adults. A brief overview of the literature on anesthetic techniques that may influence geriatric-related syndromes is also presented.

Keywords:

• frailty
• mobility-disability
• postoperative delirium
• preoperative evaluation
• stress response

Acknowledgments

This was funded in part by a grant from the Anesthesia Patient Safety Foundation (LG), National Institutes of Health/National Institutes on Aging grants AG-042758, AG-033727 (LG), and pilot funds from the Wake Forest Translational Science Center and Center of Integrative Medicine (LG) at Wake Forest School of Medicine, Winston Salem, NC.

We also acknowledge our patient volunteers who participated in our institutional review board-approved geriatric preoperative assessment study (IRB number 00019392).

Disclosure

The authors report not conflicts of interest in this work.