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

Figures & data

Table 1 Geriatric-specific preoperative evaluation tests

	ML	KM
Metabolic equivalent task score (METS)	4.2	1.3
Mobility (MAT-sf)	48.05	36.9
Nutrition (MNA-sf)	14	9
Frailty score	1 (Not frail)	3 (Intermediately frail)
Pain score	0	0
Estimated weekly energy expenditure	996 kcal	409 kcal
BMI	26 kg/m^2	35 kg/m^2
C-reactive protein (hs-CRP)	0.53 mg/L	57 mg/L
Vitamin D	25.2 ng/mL	7.1 ng/mL

Abbreviations: MNA, mini-nutritional survey scored 0–14 (increasing score = better nutritional status); MAT-sf, mobility assessment tool-short form, scored 30–69 (increasing score = better mobility); Frailty scored 0–5 (increased score = increased frailty vulnerability); Pain, scored numerically 0–10 (increasing score = increased pain); BMI, body mass index; hs-CRP, high-sensitivity C-reactive protein (>1 mg/L = increased inflammation); Vitamin D, serum 25-hydroxyvitamin D [25(OH)D] (≤20 ng/mL = deficiency; 21–29 insufficiency, and ≥30 ng/mL sufficient).

Table 2 Eleven items of the modified Frailty Index

History of diabetes mellitus

History of congestive heart failure

History of hypertension requiring medication

History of either transient ischemic attack or cerebrovascular accident

Functional status 2 (not independent)

History of myocardial infarction

History of either peripheral vascular disease or rest pain

History of cerebrovascular accident with neurological deficit

History of either COPD or pneumonia

History of either prior PCI, PCS, or angina

History of impaired sensorium

Notes: Functional status measured in the 30 days prior to surgery. The presence of each variable was scored as 1 point. The score ranges 0–11, with a score 0 representing absence of frailty, while a score of 11 represents highest degree of frailty.

Abbreviations: COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; PCS, prior cardiac surgery.

Table 3 Nutritional risk scoring models

SGA

A standard form including food intake and complaints such as vomiting, diarrhea, and loss of weight

A: Well nourished

B: Moderately malnourished

C: Severely malnourished

NRI = [1.489× serum albumin, (g/L)] + [41.7× present weight/usual weight]

>100: not malnourished

97.5–100: mild malnourishment

83.5–97.5: moderate malnourishment

<83.5: severe malnourishment

Maastricht Index =20.68 − [0.24× albumin (g/L)] − [19.21× prealbumin (g/L)] − [1.86× lymphocytes, (10^6/L)] − [0.04× ideal body weight]

>0: malnourished

MNA-sf

Composed of six questions, including anthropometric measurements (body mass index and weight loss), global assessment (mobility), dietary question, and health assessment (acute disease/psychological stress and neuropsychological problems)

12–14: normal nutritional status

8–11: at risk of malnutrition

0–7: malnutrition

Abbreviations: SGA, subjective global assessment; NRI, Nutritional Risk Index; MNA-sf, Mini Nutritional Assessment-short form.

Table 4 Studies of comprehensive geriatric assessment

Author (year)	Subjects’ age (years)	Surgery (sample size)	Study design	Risk assessment	Findings
Robinson et al^Citation92	≥65	Major elective operations requiring ICU admission (233)	Prospective cohort	Frailty a. Burden of comorbidity 1) Charlson Index 2) ASA Score 3) Number of outpatient medications (polypharmacy) 4) Hematocrit (35%) b. Function 1) Katz ADL Score 2) Timed Up and Go Test c. Nutrition 1) Albumin level 2) BMI 3) ≥ 10 lbs of weight loss in the past 6 months d. Cognition/mental function 1) Mini-Cog Test 2) Two-Question Depression Screen e. Geriatric syndrome f. Extrinsic frailty (social vulnerability)	Predictors of postoperative institutionalization • Timed Up and Go Test ≥ 15 sec • Any functional dependence • Charlson Index ≥3 • Hematocrit ≤35%
Brouquet et al^Citation93	≥75, MMSE > 10/30	Major elective abdominal surgery (118)	Prospective cohort	a. IADL Score (0–4) b. Timed Up and Go Test c. MMSE d.GDS (short form)	Risk factors for PD • ASA Score ≥3 • Impaired mobility • Postoperative tramadol Outcomes in patients with and without PD • Mortality 14% vs 3% • LOS was 19±11 days vs 14±8 days • Discharge to rehabilitation 63% vs 32%
Lawrence et al^Citation94	≥60	Major abdominal surgery (372)	Prospective cohort	a. Self-reported measures 1) Hand grip strength 2) Timed Up and Go Test 3) Functional reach b. Self-reported measures 1) ADL – Modified Katz Scale 2) IADL – Modified Lawton and Brody Scale c. Additional measures 1)MMSE 2)GDS 3) Health-related quality of life (PCS, MCS) 4) Social support with the Medical Outcomes Study Social Support Survey	Mean recovery times • MMSE: 3 wk • Timed walk: 6 wk • ADL, SF-36, PCS, and functional reach: 3 mo • IADL: 6 mo • Mean grip strength: no return by 6 mo Incidence of persistent disability at 6 mo • ADL: 9% • PCS: 16% • MCS: 17% • Timed walk: 39% • Functional reach: 58% • Grip strength: 52%
Robinson et al^Citation95	≥65	Major Operation requiring postoperative ICU admission (110)	Prospective cohort	a. Age b. Cognitive function using the Mini-Cog Test c. Chronic undernutrition 1) Weight loss of 10 lbs in the past 6 mo 2) BMI 3) Albumin d. Fall e. Depression f. Anemia	Risk factors of 6 mo mortality and institutionalization • Impaired cognition • Recent falls • Lower albumin • Greater anemia • Functional dependence • Increased comorbidities Any functional dependence (OR 13.9) was the strongest predictor of 6-mo mortality
Robinson et al^Citation96	≥65	Elective or cardiac surgery (201)	Prospective cohort	7 frailty characteristics a. Timed Up and Go Test b. Katz ADL Score c. Mini-Cog Test d. Charlson Index e. Anemia of chronic disease (HCT <35%) f. Poor nutrition: albumin <3.4 g/dL g. Geriatric syndrome of falls: within 6 mo	Postoperative complications in non-frail, pre-frail, and frail groups • 21% vs 40% vs 58% after colorectal surgery • 17% vs 28% vs 56% after cardiac surgery Frail individuals had longer hospital stays and higher 30-day readmission rates
Fukuse et al^Citation97	≥60	Thoracic surgery (120)	Prospective cohort	a. Performance Status 1) ECOG Performance Status 2) Barthel Index of ADL b. Comorbidity c. Nutrition 1) BMI 2) Arm muscle circumference 3) Albumin 4) Transferrin 5) Lymphocyte count 6) Cholinesterase level d. Cognitive Status l)MMSE e. Negative emotions for operation	Risk factors for postoperative complications • Dependence for ADL • Dementia Malnutrition increases the incidence of prolonged air leak by 7 fold Obesity increases the incidence of postoperative infection by 24 fold Low MMSE score can predict postoperative delirium
Kim et al^Citation98	≥69	Elective surgery (197)	Prospective cohort	a. Nutritional status using MNA-sf b. Mobility disability using MAT-sf c. ASA Score d. Hopkins Frailty Score e. Pain score f. Serum markers 1)CRP 2) Albumin 3) Ferritin 4) Vitamin D	Risk factors for prolonged LOS • ASA Score ≥3 • Longer anesthesia time • Low mobility • BMI >25 kg/m^2 was associated with short LOS

Abbreviations: ADL, activities of daily living; ASA, American Society of Anesthesiologists; BMI, body mass index; CRP, C-reactive protein; ECOG, Eastern Cooperative Oncology Group; GDS, Geriatric Depression Scale; HCT, hematocrit; IADL, instrumental activities of daily living; ICU, intensive care unit; LOS, length of stay; MAT-sf, Mobility Assessment Tool-short form; MCS, quality of life mental component score; MMSE, Mini Mental State Examination; MNA-sf, Mini Nutritional Assessment-short form; OR, odds ratio; PCS, quality of life physical component score; PD, postoperative delirium.

RobinsonTNWallaceJIWuDSAccumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patientJ Am Coll Surg201121313742 discussion 42–4421435921

 PubMed Web of Science ®Google Scholar

BrouquetACudennecTBenoistSImpaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgeryAnn Surg2010251475976520224380

 PubMed Web of Science ®Google Scholar

LawrenceVAHazudaHPCornellJEFunctional independence after major abdominal surgery in the elderlyJ Am Coll Surg2004199576277215501119

 PubMed Web of Science ®Google Scholar

RobinsonTNEisemanBWallaceJIRedefining geriatric preoperative assessment using frailty, disability and co-morbidityAnn Surg2009250344945519730176

 PubMed Web of Science ®Google Scholar

RobinsonTNWuDSPointerLDunnCLClevelandJCMossMSimple frailty score predicts postoperative complications across surgical specialtiesAm J Surg2013206454455023880071

 PubMed Web of Science ®Google Scholar

FukuseTSatodaNHijiyaKFujinagaTImportance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patientsChest2005127388689115764772

 PubMed Web of Science ®Google Scholar

KimSEdwardsARustowiczLDo sex differences in preoperative mobility, nutrition and frailty status predict length of hospital stay among older noncardiac surgical patients?J Am Geriatr Soc201361s1B155

 Google Scholar