Preoperative Assessment in Older Adults: A Comprehensive Approach

 

Am Fam Physician. 2018 Aug 15;98(4):214-220.

Author disclosure: No relevant financial affiliations.

Surgical outcomes are significantly influenced by patients' overall health, function, and life expectancy. A comprehensive geriatric preoperative assessment of older adults requires expanding beyond an organ-based or disease-based assessment. At a preoperative visit, it is important to establish the patient's goals and preferences, and to determine whether the risks and benefits of surgery match these goals and preferences. These discussions should cover the possibility of resuscitation and ventilator support, prolonged rehabilitation, and loss of independence. The assessment should include evaluation of medical comorbidities, cognitive function, decision-making capacity, functional status, fall risk, frailty, nutritional status, and potentially inappropriate medication use. Problems identified in any of these key areas are associated with an increased risk of postoperative complications, institutionalization, functional decline, and, in some cases, mortality. If a patient elects to proceed with surgery, the risks should be communicated to surgical teams to allow for inpatient interventions that lower the risk of postoperative complications and functional decline, such as early mobilization and limiting medications that can cause delirium. Alcohol abuse and smoking are associated with increased rates of postoperative complications, and physicians should discuss cessation with patients before surgery. Physicians should also assess patients' social support systems because they are a critical component of discharge planning in this population and have been shown to predict 30-day postoperative morbidity.

Nearly 5 million major operations are performed annually in the United States in patients 65 years and older, and older adults undergo operating room procedures at two to three times the rate of younger age groups.1 The demand for surgical services is projected to increase as the population ages.2 Although advances in care have decreased surgical risks, older adults experience disproportionate levels of postoperative morbidity and mortality. Conducting a geriatric preoperative assessment involves eliciting patients' goals and priorities in the context of their overall health and likely surgical outcomes, and considering whether the risks and benefits of surgery match these goals.3 If the benefits appear to outweigh the risks, then the physician should evaluate the patient's decision-making capacity, cognition, comorbidities, presence of depression and frailty, functional status, fall risk, nutrition, and use of potentially inappropriate medications. These factors can help predict possible postoperative complications and inform recommendations on preoperative optimization and risk reduction. This article summarizes the key components of a comprehensive geriatric preoperative assessment for primary care physicians based on 2012 guidelines.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Older adults planning to undergo surgery should be assessed for impaired sensorium (delirium, cognitive impairment, or depression).

C

30, 33, 35

Older adults planning to undergo surgery should be evaluated for functional impairment by asking about activities of daily living and instrumental activities of daily living.

C

4, 20, 33

Older adults should be screened for fall risk by asking about falls within the past 12 months and difficulty with walking.

B

43, 44

Patients should be counseled to quit smoking and provided behavioral support to aid in smoking cessation before surgery.

B

54

Physicians should use a validated tool, such as the updated Beers criteria, to screen for potentially inappropriate medications in older adults during a medication review.

C

28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Older adults planning to undergo surgery should be assessed for impaired sensorium (delirium, cognitive impairment, or depression).

C

30, 33, 35

Older adults planning to undergo surgery should be evaluated for functional impairment by asking about activities of daily living and instrumental activities of daily living.

C

4, 20, 33

Older adults should be screened for fall risk by asking about falls within the past 12 months and difficulty with walking.

B

43, 44

Patients should be counseled to quit smoking and provided behavioral support to aid in smoking cessation before surgery.

B

54

Physicians should use a validated tool, such as the updated Beers criteria, to screen for potentially inappropriate medications in older adults during a medication review.

C

28


A = consistent, good-quality patie

The Authors

show all author info

CHANDRIKA KUMAR, MD, is an assistant professor of medicine in the Section of Geriatrics at Yale University School of Medicine, New Haven, Conn. She is also associate fellowship director of the Clinical Fellowship in Geriatric Medicine and the director of resident geriatric education....

BROOKE SALZMAN, MD, is an associate professor in the Department of Family and Community Medicine at Thomas Jefferson University, Philadelphia, Pa. She is also program director of the geriatric fellowship and medical director of the Division of Geriatric Medicine and Palliative Care.

JESSICA L. COLBURN, MD, is an assistant professor of medicine in the Division of Geriatric Medicine and Gerontology at Johns Hopkins University School of Medicine, Baltimore, Md.

Address correspondence to Chandrika Kumar, MD, Yale University School of Medicine, 20 York St., New Haven, CT 06519 (e-mail: Chandrika.kumar@yale.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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