The New Trend, Geriatric Surgery: Considerations in Geriatric Surgery

Abstract

Current demographic trends reveal we are experiencing an aging population. Life expectancy has extended, individuals are living longer, and electing to have surgery in their older age. Often older patients are more medically complex when compared to their younger counterparts, this places them at a higher risk for developing a complication after surgery. In addition, older patients may have a poor tolerance to anesthesia making their surgical care challenging. Complications after surgery can lead to longer hospital stays, readmissions back into the hospital, and can disrupt the patients’ quality of life. Presurgery screening and identification of any modifiable health concerns are the keys to prevention of bad outcomes after surgery. Surgeons, anesthesiologists, and the surgical team must be aware of the unique needs of the aging population to understand specific measures that can be taken to keep patients safe. Information that was presented in this chapter was obtained from clinical experience and an extensive literature search. A literature search was performed using search engines such as EBSCOhost, MEDLINE with Full Text, CINAHL Complete, Health Business Elite, Cochrane Database of Systematic Reviews, Cochrane Clinical Answers, E-journals, Google search engine, and Full-text Finder.

1. Introduction: What is geriatric surgery?

Current demographic trends reveal we are experiencing an aging population. Life expectancy has extended, individuals are living longer, and electing to have surgery in their older age. The United States (U.S.) census data reveals every day 10,000 Americans turn age 65 years [1, 2]. This is expected to continue for the next thirty years, which will double the U.S. population of older adults from now 46 million to 90 million in the year 2050 [2]. When it is all said and done, senior citizens will make up 75% of the surgical workload [2].

A senior is defined as a person who is age 65 years or older [3]. In medicine, the term senior citizen describes an individual who has reached the milestone of age 65 years [3]. Geriatrics rather is a term used to describe the health condition of an individual, specifically an older individual, who has begun to experience age-related changes that are making them more vulnerable to life stressors [3, 4].

As we age our bodies change, we begin to slow down, lose muscle mass, lose our senses, react differently to medications, and we may have chronic illnesses that start to take a toll on our bodies [3, 4]. The aging process, which tends to include an increased number of illnesses, malnutrition, difficulties in communication, difficulties in comprehension, and psychological and social alterations, can complicate the surgical process and serve as a precursor to poor outcomes after surgery [4]. Please refer to Table 1 for a summary of the Physiological Decline Seen in Older Adults. More than half of older adults who are 70 years of age or older, suffer from one chronic disease, and 30% of this same population suffer from two or more chronic diseases [4]. This can make the surgical care of older adults challenging and places them at a higher risk for developing a complication after surgery. In addition, older adults may have a poor tolerance to anesthesia making their surgery very risky.

Body system	Physiological decline in body function
Cognitive	Cognitive decline/impairment Memory loss Depression Increase risk of acute delirium Onset of dementia
Head, eyes, ears, nose, and throat (HEENT)	Decrease or loss of sensory functions (loss of taste and smell, hearing loss, vision loss such as cataracts, glaucoma, macular degeneration, and impairment in swallowing) Disruption of oral health (dry mouth, gum disease, and oral cancer) Impairment of mouth cavity/teeth (missing or broken teeth, poorly fitting dentures, and sore gums) Thinning hair, hair loss, and brittle nails Dysphagia
Cardiac	Atherosclerosis Increase in cardiac disease Decreased cardiac output
Pulmonary	Decline in pulmonary capacity Time of onset of chronic obstructive pulmonary disease (COPD)
Gastrointestinal	Decrease in gastric mobility Decrease in metabolism Decrease in absorption of medications Increase risk of malnutrition Constipation
Genitourinary/anorectal	Renal insufficiency, decrease in Glomar infiltration rate affecting elimination of wastes production Incontinence Increase in urinary tract infections (UTI)
Musculoskeletal	Demineralization of bones, bone loss Onset of osteoporosis, increase in pain Increase risk of injuries and falls
Integumentary	Skin atrophy Decrease in skin temperature Easy bruising
Psychiatric/behavioral	Onset of anxiety/depression Onset of chronic pain Decline in mental health Onset of dementia

Table 1.

Physiological decline seen in older adults [1, 2, 3, 4, 5, 6, 7].

Complications after surgery can lead to longer hospital stays, readmissions back into the hospital, and can disrupt the quality of life. Major complications seen after geriatric surgery include acute delirium, Small-Bowel Obstructions (SBO), Pulmonary Embolism (PE), and Urinary Retention (UR) leading to an Acute Kidney Injury (AKI). Delirium, an acute change in mental status, is the most common complication seen and occurs in 14–50% of older hospitalized adults with associated mortality ranging from 25% to 33% [4, 5]. Delirium is one of the main causes of hospital falls and has been linked to functional decline, increased hospital cost per day, longer hospital stays, restraint use, and increased mortality rates [5, 6, 7].

Just like there are doctors for our children (pediatricians) and doctors for our hearts (cardiologists), we have doctors for older age, known as geriatricians. A geriatrician is trained to recognize the unique needs of older adults and treat these conditions [3].

When you bring the two specialties together, geriatrics and surgery, you have a subspecialty of surgery that incorporates the unique needs of older adults into their surgical care [3]. No longer is the surgical care solely focused on the patient’s body part to be operated on (“knee surgery” or “abdominal surgery”). Geriatric surgery is looking at the patient as a whole person, everything that is going on simultaneously, not just the body part that is being operated on. Unfortunately, a surgeon may not have the time or expertise to investigate and treat the patient’s entire health history. That is one of the benefits of having a geriatric surgery program in place where a team of healthcare professionals can work together to meet the specific needs of the older surgical patient.

1.1 Story Time: (real patient encounter/true story experienced by author Ellen McHugh)

I will never forget one of my first patients. She was an 85-year-old female undergoing a hip replacement. She had lost her husband the previous year and was actively dealing with sadness and grief. She was having severe hip pain that was slowing her down. She elected to undergo a hip replacement to help decrease her pain and improve her quality of life. When she came into the surgery center, I can remember my first assessment of her, she is weak. She stepped on the scale and said, “I knew that was coming.” She had lost a significant amount of weight. She was not surprised. She explained that she was no longer cooking because it was too painful for her to stand. Prior, her husband was her motivation to push through the pain and cook. Now that he was gone, she lost all motivation and did not need to eat. My second assessment of her was that she was very weak and frail, I was afraid this surgery would harm her. Yet, surgery was essential to improving her quality of life. I remember saying, we need to make some changes and get you in shape before this surgery! That is when she looked up at me and said, “will you please help me get started.” I replied "Yes, absolutely!" Geriatric surgery is compassion! Having compassion and patience for the unique needs that the older adult brings to the table, including their chronic conditions, age-related conditions, and social needs while preparing them for surgery.

2. What is the comprehensive geriatric assessment (CGA)

We can expect to see more and more surgeries being performed in the elderly population, especially as older adults elect to have surgery to help improve and maintain a better quality of life. With geriatric surgery on the rise, every institution should have a surgical program in place that is designed to meet the needs of the older surgical patient. Having geriatric surgery program in place gives the surgical team an opportunity to meet the patient before surgery, perform comprehensive health screenings, and spend an adequate amount of time with the patient to really get to know them. This allows healthcare providers to identify any areas of health concern. In return they can put interventions in place to improve these areas of concern before surgery. With the end goal of getting the patient in their best health prior to their operation will lead to better outcomes and an improved quality of life.

Currently recommended for the older adult is a comprehensive health assessment, better known as, the comprehensive geriatric assessment (CGA). CGA can be described as a multidisciplinary diagnostic process that evaluates medical, functional, psychological, social capabilities, frailty status, and various geriatric syndromes [8, 9]. An easier way to sum up basis of the CGA is simply say, performing health screenings from head to toe. Performing a CGA can be useful in identifying patient health deficits that may not be assessed on a standard History and Physical (H&P) [9]. In addition, the CGA uses a multidisciplinary approach where healthcare providers work together to coordinate care and communicate for the patients. As a result, the surgical experience becomes less complicated and less confusing for the patient. Presurgery screening and identification of any modifiable health concerns are the key to prevention of bad outcomes after surgery. CGA can lead to early recognition of problems that can be modified presurgery to assist in preventing bad outcomes after surgery.

It is important to note that the CGA is an extremely timely process and is unrealistic to be completed by the surgeon alone. This CGA should include input from the surgeon, anesthesiologist, and geriatric nurse specialist. Other specialties that may be called into the assessment and treatment are nurses, dietitians, social work case managers, pharmacists, and or physical/occupational therapists. The American College of Surgeon’s (ACS) National Surgical Quality Improvement Program (NAQIP) and the American Geriatrics Society (AGS) published guidelines that identify the core domains to be assessed in the CGA, which include: cognitive function, depression screening, nutritional assessment, functional mobility and falls, frailty, polypharmacy, cardiac and pulmonary assessments, comorbidities, geriatric syndromes (urinary incontinence, dental needs, visual, and hearing impairment), and patient’s health goals [8, 9, 10, 11].

A review of the literature found a meta-analysis of 29 trials, which showed that hospitalized older adults who received the care of a CGA team were more likely to be alive and in their homes 12 months after surgery and hospitalization [12]. Kim et al. [10] identified supporting data concluding that older adult patients are more likely to survive surgery and return to their home if they receive a CGA during their surgical care. This is very appealing to older adults who are unsure about moving forward with surgery, due to their fear of the unknown or possible unfavorable outcomes after surgery. A geriatric surgery program can help alleviate anxiety and fear that older adults may have surrounding surgery in their older age. Thus, making the whole surgical experience better for them.

Xue et al. [9] reviewed a few studies that found the health information identified on the CGA directly predicts postoperative complications in patients.

A meta-analysis study in gastrointestinal cancer patients identified that the CGA is effective in identifying patients with multiple comorbidities, polypharmacy, and ADL dependency; all syndromes that are directly associated with development of major postoperative complications [9]. When healthcare providers can identify high risk patients, interventions can be put into place to help decrease the chance of these bad outcomes from occurring. Decreasing bad outcomes after surgery favorably affects length of stay and readmissions back into the hospital. Harari et al. [13] revealed that the use of presurgery proactive care bundles (PCB) in older patients undergoing surgery (compared to patients who received standard care) significantly lower rates of postoperative complications such as pneumonia (20% VS. 4%), delirium (19% VS. 6%), and pressure ulcers (19% VS. 4%). Cohen et al. [14] determined that health data collected in the presurgery assessment phase, such as a low Braden scale score (<18); was associated with a significantly higher risk of developing 30-day complications, longer length of stay (LOS) and were more likely discharged to a nursing home versus home.

If a CGA is unable to be completed, research implies at the least; comorbidity, polypharmacy, and functional status should routinely assess for all geriatric patients undergoing surgery due to the high predictability of postoperative complications [9]. Review of a meta-analysis conducted by Kim et al. [10] showed that patients who completed the CGA showed a benefit on short term mortality, reduced complications, reduced readmissions, improved cognitive function, and improve physical function after surgery. Available studies proved that the CGA reduces post-op delirium and improves surgery outcomes in patients with hip fractures, possibly due to the multicomponent interventions it uses [11].

There is so much evidence pointing to the benefits of utilizing the CGA. Performing a CGA also provides a time to discuss some of those uncomfortable topics that may have been rushed and/or overlooked at the initial decision to have surgery. Topics such as the patient’s expected life span, the benefits and risk associated with surgery, the patient’s overall health goals, and any unfavorable outcomes that may affect the patient’s quality of life after surgery [4]. See Appendix 1 for a visual diagram of the CGA workflow available at St. Luke’s Hospital in Bethlehem Pennsylvania. The next section of this chapter will review each of the categories of the assessments used in the CGA.

3. Preoperative geriatric assessment tools (POGAT)

3.1 POGAT: mini-cognitive assessment (MCA)

In the general adult surgical population, the incidence of postop delirium was found to be (2.5–4.5%), which increased to (12–23%) in patients who were 60 years and older [11]. Understanding acute delirium and being able to recognize symptoms postoperatively will help keep patients safe and prevent further complications from developing. Studies reported a higher incidence of postoperative delirium in patients undergoing cardiovascular surgery at (15.3–23.4%), and hip fracture surgery (16.9%) [11]. Noting that cardiac and major lower joint surgeries are two of the most common surgeries performed in the elderly.

Mental cognitive impairment (MCI) and/or mental decline has become a rather general term that is used to describe a variety of conditions that affects an individual’s mental state. Often it is used to describe any condition that interferes with brain function like; difficulty remembering things, difficulty learning new things, repeating the same stories over, asking the same questions over, the inability to make life decisions, etc. Most of the time, individuals with MCI can still function safely in everyday life. It may be seen that the term MCI is frequently miss used when trying to describe an acute delirium and/or chronic dementia. Knowing the differences between the three conditions, MCI, delirium, and dementia, will help healthcare providers understand their patients better and allow them to provide individualized care, specific to the patient’s needs. As we see more and more surgeries being performed in the elderly, which is the number one population that these conditions affect, it becomes essential to understand these terms.

Delirium is an acute condition, the onset is abrupt, and can last hours to days. During that time span, the patient’s mentation may wax and wean, showing improvements in mental cognition at times and then becoming worse again, especially, during the evening hours. Symptoms of delirium may be mild (impaired orientation and alertness) to severe (hallucinations and illusions). Delirium is reversible and most often resolves when the underlying cause is treated. Some causes of delirium may be electrolyte imbalance after surgery, infections, and the use of new medications. Patients with delirium cannot safely function alone [12].

There is a large amount of evidence that suggest postoperative delirium is directly associated with an increase mortality rate, and it is significantly linked to cognitive decline, and can lead to onset and/or development of dementia [11]. Specific to surgery, emergence delirium occurs during or immediately after emergence from general anesthesia and usually resolves within minutes or hours, and postoperative delirium mainly occurs 24–72 hours after surgery and resolves within hours to days [11].

Dementia is a long term, chronic, and disease process. Onset is gradual, and one’s mental cognition will continue to slowly decline over months to years. Dementia is irreversible, but one may be able to slow down the progression with sustained treatment. Some risk factors include advanced age, head injury, atrophy of brain cells. Patients cannot safely function alone (19).

All these conditions increase with older age, and impaired cognition may go unrecognized in up to 81% of affected patient’s [13]. The importance of presurgery cognitive screening is becoming more and more evident as (1) cognitive disorders are seen frequently in the elderly population and (2) research shows patients with MCI are at the highest risk for poor outcomes after surgery, such as longer hospital stays, higher hospital cost, increase chance of admission to an institution for rehab, and altered quality of life [4]. Recognition of any these cognitive concerns before surgery is essential as cognitive decline and/or postop delirium can persist for months or years and have a detrimental impact on the patient’s quality of life, long-term survival, and increases the risk of developing dementia [11].

The use of at least one of the several cognitive assessment tools available should be considered during the perioperative stage when caring for an elderly patient. This can help alert healthcare providers to patients who are at a higher risk for developing a delirium after surgery. More importantly, this will provide the surgery team a clear baseline picture of the patient’s mental status, which can be used for comparison after surgery if changes in cognition have been suspected.

Let us look at some of the tools that can be used in the cognitive assessment. Cognitive function can be assessed by direct interaction, and observation of the patient, concerns raised by family and friends, and self-reported by patient [13]. Cognitive assessment should be performed during the history taking both before and after surgery. Obtaining a baseline mental status is key in assisting suspected postoperative changes.

A more detailed assessment, like the mini-cognitive assessment (MCA) is a three-word recall and clock drawing activity that improves detection of MCI or dementia from 59% to 83% [13]. This assessment does not diagnose dementia, but alerts healthcare providers to those patients who may be at a higher risk for developing a delirium after surgery. Most favored due to its easy to use and time efficiency.

Other cognitive screening tools: such as, the Mini-mental state examination (MMSE), Confusion Assessment Method (CAM), digital span test (DST), and the Montreal Cognitive Assessment (MoCA) have all been validated assessments and easily incorporated into the perioperative environment [11, 13, 14, 15]. Please refer to Table 2 for a summary of the cognitive assessments screening tools available to healthcare providers. Concerns identified on any of the screens should lead to a more detailed comprehensive evaluation that can be done by primary care doctor or a geriatric specialist.

Cognitive screens	Details	Summary of results
Mini-Cognitive Assessment (MCA)	Clock drawing activity and 3-word recall. Patient is given three words to remember and then instructed to draw a clock. Patient is instructed to draw a time on the clock and then word recall is done.	Assessments are made to determine if patient can place the numbers correctly on the face of a clock (attention to position of 12, 3, 6, 9) and identify the specific time announced. After clock drawing patients are asked to recall three words. Points are accumulated for a score (1–5).; 0–2 suspect cognitive impairment 3–5 no concerns
Mini-Mental State Examination (MMSE)	Provider administers questionnaire. Includes questions and activities in the domains of orientation, registration, attention and calculation, recall, language, and copying.	Questions are used to assess cognitive function. Points are accumulated for a score (0–30).; 0–17 severe cognitive impairment 18–23 mild cognitive impairment 24–30 no cognitive impairment
Confusion Assessment Method (CAM)	Provider completes 2-part assessment form after interviewing patient. Domains assessed are acute onset of confusion, inattention, disorganized thinking, and altered level of consciousness.	If all items in part one is YES and one item in part two: diagnosis of delirium expected
Digital Span Test (DST)	Verbal test to exam short term memory. Provider has patient repeat back a series of numbers, up to a group of five.	Repeating sequence of numbers (two trails each series). Scoring is pass or fail.
Montreal Cognitive Assessment (MoCA)	Provider administered questionnaire. Includes questions in activities in the domains of short-term memory, visual abilities, command functions, attention span, language, reasoning, and orientation.	Points are accumulating for score (1–26); 0–16 impairment 16–25 mild to moderate impairment 26–30 no impairment

Table 2.

Cognitive assessment screening tools [11, 13, 14, 15].

Patients who are identified as being high risk of developing delirium after surgery should have both nonpharmacological and pharmacological recommendations in place. During surgery preparation in the perioperative stage, patients should be encouraged to remain on a healthy diet and continue oral hydration, (until diet restrictions for surgery start, NPO), encourage daily exercise, avoid toxins (drugs and alcohol), and stay socially active. Emphasis should include ways to stay mentally active through reading, playing games, and doing puzzles. A meta-analysis of 11 studies, showed that an exercise program, when routinely completed, greatly improved global cognition (believed to be related the aerobic component) and is something that can be incorporated into a patient at home surgery preparation plan [13]. A thorough medication review should be done assessing for any medication that may flag immediate geriatric concerns. Assessment for polypharmacy, medication redundancy, and medication safety are essential. Identification of any medications that can increase the risk of delirium, such as benzodiazepines and anticholinergics, should be noted, and consideration should be taken to decide if these medications should be stopped and/or decreased prior to surgery [11]. Recommendations such as the use of a geriatric pain protocol (the use of pain medications at a lower dose and slowly titrating up while monitoring for any changes in the patient’s mental status) after surgery should be made. During the intraoperative phase interventions such those noted on the Table 7 Geriatric ERAS should be put into place. Lastly, an inpatient consult to the facilities inpatient geriatrics team should be placed so the patient could be seen after surgery, at the bedside, to ensure standards of geriatric care being delivered. This team of experts makes sure that patients are participating in activities of daily life (ADL). For example, if the surgeon has cleared the patient to get up, that they are getting Out Of Bed (OOB) and moving, if the patient is cleared to eat that they are getting adequate nutrition. The geriatric team is also specialized in recognizing signs that point to changes in mental status.

3.2 POGAT: depression screening

Depression can be defined as feelings of sadness, hopelessness, and or despair that are occurring every day, for two or more weeks. Research reveals that depression has been directly linked to longer recovery times after surgery, which can lead to a longer hospital stay [9, 13]. Longer hospital stays may lead to deconditioning, weakening, and an increased risk of developing a postsurgical complication. Development of postoperative complications creates overall higher hospital costs for the patient and the institution. All these things are not safe for the patient and not ideal for the institution, thus making presurgery depression screening more and more important.

This is a topic that is rarely discussed, if at all. After most surgeries, there may be a period of physical limitations and restrictions. One may need help with basic activities of life (ADL) like going to the bathroom, bathing, and getting dressed. There may be restrictions set in place after surgery like not driving a car for a few weeks. Patients will need to rely on family and friends for help. This can create a lot of stress.

Patients have described feelings of anxiety, depression, and fear. There is a fear of the unknown. They fear things like; will I wake up from anesthesia, will I fully recover, who will take care of me after surgery? Even down to who will take care of my dog while I am hospitalized? These are all-natural human responses to stress and are preoperative psychological burdens that patients endure and may complicate the surgical experience [9]. This can be referred to as a situational depression, having these feelings related to the situation at hand. Often the patient will have surgery, start recovery, and day-by-day these feelings will begin to fade and eventually subside.

The real concern is patients who have an underlining chronic depression. These are the patients that may find it difficult to process the feelings surrounding surgery. Depression has been linked to longer recovery times, which then leads to longer hospital stays [9]. In the elderly specifically, depression was directly associated with pain and frailty, giving them a 3-fold risk of developing a delirium after surgery [9, 13]. Patients with MCI alone, are at a higher risk for being depressed due to the loss of independence [9]. Depression can lead to significant weight loss, decline in functional status, increase risk of suicide, overall increase in mortality, and increased use of healthcare services, all of which can complicate the surgical process [13].

Depression may present itself in different forms such as lethargy, weight loss, cognitive impairment, functional decline, and failure to thrive [13]. The standard history and physical conducted prior to surgery may miss the identification of depression. Specific prescreening for depression will allow healthcare providers to obtain a baseline picture of the patient’s mental health, which will give a better understanding of any specific needs they may have throughout the entire surgical process. Interventions can be put into place to help monitor and prevent bad outcomes.

Screening for depression can be done with a brief 2-item screen, known as the patient health questionnaire-2. A positive result score of two on this simple screen should be followed by the patient health questionnaire-9, which is a more detailed assessment and has been validated as a reliable measure of depression severity and older adults [13]. Geriatric Depression Scale (GDS) is another screening tool that can be used for screening. Please see Table 3 for a summary of depression tools. A retrospective study of patients greater than 75 years of age with colorectal cancer revealed that the GDS was an independent factor of postoperative delirium [9]. Another study that evaluated patients who were 75 years and older, diagnosed with thoracic cancer, showed that the use of GDS was able to predict the incidence of major complications [9].

Depression screens	Details	Summary of results
Patient health questionnaire -2 (PHQ-2)	Two-item questionnaires; self-reported or administered by provider, if fails patient advances to the PHQ-9	Score 0–1, stop Score two or more, advanced to further screening via PHQ-9
Patient health questionnaire – 9 (PHQ-9)	Nine-item questionnaire; self-reported or administered by provider	Score; 1–4 minimal depression 5–9 mild depression 10–14 moderate depression 20–27 severe depression
Geriatric Depression Scale (GDS)	30-item questionnaire; Self or assisted; Yes or no format	Scores; 0–9 normal 10–19 mild depressive 20–30 severe depressive

Table 3.

Depression screening tools [9, 13].

Interventions in the presurgery phase may be as simple as having the patient speak with someone about their fears and concerns related to surgery. Offering support groups or access to online communities of patients who suffer from the same diagnosis process have shown to be very helpful. Specifically, in patients who are undergoing abdominal surgery that results in creation of a colostomy bag. These patients benefit tremendously from meeting with a community of patients who have undergone the same procedure. Example: living life after colostomy. Online communities and blogs are terrific options as they can be attended from the comfort of patient’s own home. Patients have expressed feelings of fear and thoughts that their life is over now having to have a colostomy bag attached to them. Not to mention feelings of isolation and embarrassment. Patients who have attended these support groups have come back expressing much relief and calmness after speaking with other patients who went through the same procedure and now are living a normal life.

When concerns arise about the depression screening, healthcare providers always want to identify if this is a new depression or chronic depression. Any new depression should be assessed in further detail and a referral placed to the appropriate provider and/or resources the patient may need. If it is a chronic depression, make sure the family physician is aware and patient is on appropriate treatment. Evaluation of all the medications they are taking to make sure the dose is appropriate and/or assessment of any medication changes they may need throughout the surgical phases. Some patients may benefit from starting a selective serotonin reuptake inhibitors (SSRI) during their surgical phase.

After surgery, it is important to continue to monitor the patient’s mental status and mood. This will allow for quick interventions if needed. This will also allow for assessment of potential development of postoperative delirium. A thorough medication review should be conducted and determine if patient would need further readjustments of any medications. Last, an inpatient consult with the institution’s psychology team may want to be considered.

3.3 POGAT: nutritional assessment

The World Health Organization (WHO) defines malnutrition as having deficiencies, either a lack of, an excess of, or an imbalance in patient’s intake of energy, vitamins, minerals, and other nutrients [16]. Malnutrition can be used to describe two conditions, both undernutrition and/or overnutrition “overweight” [16]. Undernutrition is a state of deficit where there is lack of nourishment from poor diet intake and/or poor access to healthy foods. Overnutrition is too much, as in overweight, and excess of caloric- energy intake. Overnutrition can lead to an overweight state, increasing a patient’s weight and Body Mass Index (BMI), which contributes to poor health and an increased the risk of diabetes, heart disease, stroke, and cancer [16]. Elderly patients are at risk for overnutrition and becoming overweight due to their sedentary lifestyle as they get older. Patients who are overweight should be considered for weight management programs to help improve their health and quality of life. Especially patients who are electing to have a major lower joint replacement as the extra weight can place stress on the new replacement and lead to higher rates of dislocation.

Unexpected weight loss and undernutrition are also very common in older age, especially the geriatric cancer population. A review of a study conducted by Tatum et al. [13], revealed among older adults receiving home care after surgery, 12% were malnourished and 51% were at risk for malnourishment [13]. Significantly increasing their chance of poor wound healing and surgical site infections (SSI). Malnutrition can be caused by physical, psychological, or social changes associated with aging, leading to decreased resistance to infection, immune function, and quality of life [17]. As we age, our bodies change and we begin to lose our senses, which causes a decrease or loss in appetite. Other conditions that can cause malnutrition in the elderly are medication use, decrease in exercise, difficulty swallowing, poor dentition, poorly fitting dentures, and difficulty digesting certain types of food [18]. Studies also show that malnutrition was directly related to an increase in the length of stay, an increase in the risk of readmission back into the hospital, and an increase in the over mortality of patients [18]. Preoperative nutrition screening is recommended and can help improve care of surgical patients, unfortunately, it is commonly overlooked.

Knowing the nutritional status of our patients is key to providing better care. More and more research showS just how important understanding nutrition is, however, it is still often underlooked at. Serum albumin less than 3.5 have been shown to be predictor of mortality and postoperative pulmonary complications (PPC) [4]. Malnutrition has been related to poor wound healing, increased risks of surgical site infection, and precursor to frailty. Nutritional screening should be done prior to the operation. If deficits are identified, patient-specific plans should be put in place to optimize the patient, for example, implementation of protein supplements should be considered prior to surgery, and education on the appropriate diet should be provided to patient.

Nutritional screening should be conducted prior to surgery. A simple question: such as, have you had any unintentional weight loss? A yes to this question should trigger a more thorough nutritional exam to be completed. Assessment of the patient’s BMI and any BMI result of less than (<18), should trigger a more detailed nutritional assessment. In addition, there are several different patient health questionnaires that can be used to screen for malnutrition.

The Mini-Nutritional Assessment (MNA) form looks at different domains such as has the patient had any unintentional weight loss, whether there has been a decrease in food intake and why, have they had any psychological stress in the last year, and assessment of the patient’s BMI. Answers to these questions are linked to points, points are accumulated and used to determine the risk of malnutrition.

Some more nutrition screening tools that can be incorporated into the presurgery screening process include the Geriatric Nutritional Risk Index (GNRI), Subjective Global Assessment, and the Malnutrition Screening Tool. See Table 4 for a breakdown summary of nutritional screening tools available. The GNRI evaluates the patient’s albumin level, in comparison to their present body weight, and ideal body weight. The GNRI has been used to help predict the risk of nutrition-related morbidity and mortality in elderly patients [17]. The GNRI was defined as a crucial independent prognosis for both overall survival and disease-specific survival [17].

Nutrition screens	Details	Summary of results
Mini Nutritional Assessment (MNA)	Six-item questionnaire; helps determine if patients are well-nourished, at risk for malnutrition, or malnourished	Points are assigned to each answer; 0–7 pts. malnourished 8–11 at risk for malnutrition 12–14 normal nutritional status
Malnutrition Screening Tool (MST)	3-step questionnaire used more in acute care and inpatient setting	Points are assigned to each answer; 0–1 pts. not at risk 2 - < at risk
Geriatric Nutritional Risk Index (GNRI)	Predicts the risk of complications and mortality linked to malnutrition.	Very severe GNRI <73 Severe GNRI 73–82 Moderate GNRI 82–92 Mild GNRI 92–98 Norm >98
Subjective Global Assessment (SGA)	Gold standard; Used often in long-term care.	Clinical assessment: Assessment includes history of recent intake, weight changes, GI symptoms, and clinical evaluation.

Table 4.

Nutrition screening tools [9, 17].

One prospective study reviewed by Xue et al. [9] found that patients who were identified as malnourished via SGA were at a higher risk for postoperative morbidity [9].

Patients who are identified as at risk for malnutrition or malnourished, should follow the institutions’ nutrition protocol or be enrolled in the nutrition program. If there are none in place, providers can refer patients to their family doctor for a complete nutritional assessment and any possible blood work they may need (prealbumin, albumin). The presurgery assessment phase is a great time to complete a thorough nutritional assessment. After the assessment, time should be set aside with the patient to review the findings. During this time, the provider can review the best diet type for the patient. Labs, prealbumin, and albumin levels can be obtained. Patients should be educated on how many grams of protein a day they should be consuming. A simple calculation can be done. It is recommended that healthy adults should consume 0.4 grams of protein for every pound of weight [16, 18]. Grams of protein a day should be increased from the patient’s baseline during all phases of surgery to help build strength and promote tissue repair. Examples of different ways in which a patient can achieve their goal should be explored and taught to patient. Several weeks before surgery is an ideal time to begin protein supplements for ampule time to make improvements. Placing a consult to the institution’s nutrition team to see the patient after surgery, at the bedside. For maximal benefits Protein supplements should begin 30 days before the operation to significantly decrease the chance of poor wound healing and surgical site infections. A medication review should be conducted. The American Geriatrics Society (AGS) recommends providers review the medication list and discontinue any medications that contribute to weight loss and diminished appetite [13]. Lastly, providing a list of appealing peeling foods, ensuring social support, and offering feeding assistance when patients are identified as at risk for malnutrition [13].

Nutritional assessments often get overlooked as they are not considered urgent matters like those of the heart and lungs. Not mandatory, but highly recommended in all presurgery assessments, at the least, nutritional screening should be a must in major abdominal surgeries. This is extremely important as weight loss can be expected with many abdominal surgeries, especially, when there is a bowel prep involved, surgery, inpatient hospital stay, and diet restrictions. Nutrition is key, the better your nutrition is before surgery the better your body will heal after surgery, which could mean shorter recovery times.

3.4 Storytime (Real patient encounter/true story experienced by author Ellen McHugh)

My mother had a very difficult time healing after her foot surgery. Not only was it painful, but the surgical wound was positioned right where the inner edge of her shoe lay, hence, impairing her walking. The wound was not healing and within weeks the wound grew bigger and was infected. This required multiple trips to the wound care center, which had taken time from both of our days and disrupted her quality of life. Not to mention, it required multiple resources from the hospital supplies and increased cost for all involved. I often question to this day, if she would have benefited from a nutritional evaluation prior to her surgery. (Later, a low albumin and protein level revealed itself on random blood work she had done). I often think about if we could have worked on improving her nutrition prior to her operation, could we have possibly prevented this outcome? Ultimately adding to a better quality of life (less pain, less anxiety, less burden of wound care, and no extra trips to the hospital). In addition, saving extra costs for everyone involved. Improving your nutrition may be one of the easier tasks to achieve in your health, something so simple that was overlooked. The better your nutrition is before surgery, the better your body will recover after surgery!

3.5 POGAT: cardiac and pulmonary assessments

Aside from postoperative delirium, cardiac and respiratory complications are the most common adverse events in elderly patients when recovering from surgery [19]. These events are seen more frequently in the advanced age, >80 years of age population [19]. Cardiac and respiratory complications can lead to an admission to the Intensive Care Unit (ICU), and admissions to ICU can lead to increased risk of death, all of which are not safe for the patient and not ideal for the institution [19]. The standard cardiac and pulmonary assessments are recommended to be included in the CGA. The patient’s heart health should be evaluated prior to surgery to make sure their heart is strong enough to undergo anesthesia and have the operation. During completion of the H&P, any past and present heart conditions can be identified. The surgery team should be aware of any cardiac history and if the patient follows up with a cardiologist. Information should be collected on when the patient saw their cardiologist last and what were the recommendations at the end of the visit. Were those recommendations followed? Simple yes or no questions, such as, does the patient have chest pain (CP) or a new shortness of breath (SOB) in the last few months should be included in the assessment. Screening through a more detailed questionnaire such as a risk and triage, patient questionnaire to obtain a metabolic equivalent of task (METS) score is recommended. Any METS score less than four should be further investigated. Last, has the patient had any recent cardiac testing done like an electrocardiogram (ECG) or echocardiogram (ECHO). A complete review of those tests should be done and determine if any further cardiac testing is needed before moving forward. This is a time in which the healthcare team can discuss the patient’s cardiac risk of having surgery.

Aging reduces the capacity of all pulmonary functions due to a decline in thoracic elasticity and weakening of respiratory muscles [4]. All underlying pulmonary diseases should be optimized prior to surgery. Again, the H&P is a good time to collect this information. Chronic obstructive pulmonary disease (COPD) is a frequent condition seen in the elderly and is a recognized risk factor for postop complications [4]. If the patient has a diagnosis of COPD, the patient should be assessed to ensure their breathing is stable and COPD is optimized. Questions to ask: are you compliant with your daily inhalers? when is the last time you used your rescue inhaler? and does your COPD affect your everyday life? If the patient is following up with a pulmonologist, information should be collected on when was their last visit and what were the recommendations made at that visit.

Active smokers who are interested in quitting smoking before the operation should be offered tobacco therapy. Tobacco therapy, the use of nicotine replacement therapy should be started as soon as possible. Ideal timing is 30 days prior to surgery, minimum is 2 weeks prior to surgery. Arrangements should be made to continue tobacco therapy treatment on admission for surgery.

The aging process reduces the capacity of lung functions from weakened respiratory muscles over time, and you may see a decrease in the protective reflexes such as coughing and swallowing leading to an increased chance of postoperative aspiration pneumonia [4]. During the CGA visit, lung exercises can be taught. Incentive spirometer can be taught. Deep breathing and cough exercises can be taught so the patient can begin their lung exercises immediately to help reduce risk of postoperative pneumonia.

3.6 POGAT: functional mobility

As our bodies age, our functional status (FS) and mobility begin to decline. Functional mobility can be described as a person’s ability to move independently and safety in their environment [4]. FS can be defined as the number of behaviors that are needed to maintain daily activities, including social and cognitive function, it determines the patient’s ability to actively mobilize and attend to basic activities of daily life (BADL) and instrumental activities of daily life (IDAL) by themselves [4]. Without good mobility, a person is at risk for further deconditioning, weakening of their body, and FS decline. Older age goes hand and hand with FS decline and can be seen in almost every frail patient. There is more and more evidence suggesting that impaired FS status is associated with poor postoperative outcomes [4, 9, 20] and unfortunately, most anesthesiologists and surgeons do not measure physical needs in the preop phase [4]. It is recommended that patients undergo presurgery screening and assessment of functional mobility and their ability to perform BADLs and IADLs. Information about the patient’s ability to form BADLs/IADLs should be documented prior to surgery. This should include the patient’s ability to bathe, dress, ambulate, budget the checkbook, their nutritional status, and their social needs [4, 9]. ADL dependency and deficiencies in performing ADLs are shown to be a direct predictor of 30-day postoperative complications [4, 9, 11, 20]. In addition, patients with an ADLs deficiency may not have enough physiological reserve to endure and rehabilitate from major surgery and this should be discussed with the patient and their family before the decision is made [9]. During FS screening, assessment of home safety and fall risk should also be included. Knowing the patient’s fall risk is huge as it is detrimental to the geriatric population. Falls have also been related to 30-day mortality in patients who are 85 years of age and older [20, 21]. Falls can lead to further complications and impair the quality of life in the older adult population. More and more research shows that when we can accurately identify older patients who are at risk for falling, we can then implement interventions that reduce the rates of injurious falls, and/or detrimental outcomes [21]. Identification of any physical needs presurgery can give the team time to implement presurgery treatment with the goals of improving physical limitations prior to surgery.

There are different screenings and assessment tools that can be used to evaluate one’s functional status. Please refer to Table 5, for a summary of FS assessment tools. The easiest way to assess one functional mobility is by direct observation. This can be done by the provider by watching the patient walk throughout the office visit and paying attention to their ability to get up and down from chair to chair and move. Assessments should be made on how fast or slow their gait is. How steady or unsteady their gait is. Reduced gait speed has been associated with increased falls and reduced survival rates [13]. One activity that can be used to test the patient’s functional mobility is the Time Up to Go (TUG). This activity requires a nurse to observe a patient getting up from a chair, walking straight for 10 ft, then turning around, walking back, and sitting back down [4, 13]. The activity should be timed. Studies suggest that patients who take longer to do the TUG (>15 seconds) are at a higher risk for falls [10]. A standardized assessment tool, such as the Barthel scale for ADLs, which gathers information on the patient’s ability to perform everyday activities may be used. Fall risk can be assessed with a single screening question; have you fallen in the past 6 months? [13]. A positive answer to falling is associated with a 2.8 times higher likelihood of falling again within the next year, which is extremely important to note in elderly’s having major lower joint surgeries [13].

Functional status screens	Details	Summary of results
Direct provider observation	Provider observes patient ambulate	Assessments made: Steady or unsteady Fast or slow
Fall screening	Simple yes or no question. Have you fallen in the last 6 months?	Answer of yes indicates high risk of falling again
Time Up to Go (TUG)	Timed physical activity test. Provider observes patient stand from chair, ambulate 10 feet, turn around, walk back, and sit down.	More than 15 seconds to complete this activity indicates high risk of falls
Barthel scale: Basic Activities of Daily Life (B-ADL)	Ambulating, transferring, dressing, eating, drinking, personal hygiene, and taking medication	Each activity is a point: Abilities maintain for each group; 5–6 independence 3–4 intermediate dependence 1–2 total dependence
Barthel scale: Instrumental activities of daily life (IDAL)	Driving, preparing meals, doing housework, shopping, managing finances, managing medication, and using telephone	Each activity is a point: Abilities maintain for each group; 5–6 independence 3–4 intermediate dependence 1–2 total dependence

Table 5.

Functional status screening tools [4, 10, 13].

Identifying FS decline and high fall risk can allow healthcare providers to implement interventions that can maximize independence and safety [13]. Patients who are identified as having an impaired FS and/or high fall risk should be taught bilateral upper extremity and bilateral lower extremity exercises for muscle strengthening and balance coordination. Generic exercises can be taught at the time of the presurgery assessment. An exercise routine should be developed for the patient that fits into their life and accommodates their physical needs. For example, if the patient is currently walking 1000 steps a day, set a goal to increase to 2000 steps a day. Wieland and Ferrucci [21] investigated the effectiveness of patient’s using a wearable activity tracker device to monitor and improve patient’s functional status prior to surgery [21]. They completed a systematic review of 26 studies with a total of 2767 participants that showed those who wore the device had increased their physical activity by almost 27% over their baseline [21].

Patients who are at high risk for falling should be taught exercises that can be done sitting or lying down. For severe FS decline, it may be beneficial for the patient to see a physical therapist or occupational therapist prior to the operation to address impairments [9]. Education on fall prevention should be provided to the patient. Home safety should be included. Emphasis on ways to prevent falls after your operation should be discussed. Including an FS evaluation in the anesthesia consult provides useful information about the surgical risk and can help develop a patient’s specific plan for postoperative care [4].

This is also a good time to document any functional sensory impairments the patient may have. Other assessments that are rarely taken into consideration are assessing the patient’s vision and hearing. Evaluation of the patient’s vision, hearing, smell, and tactile abilities should all be documented in the presurgical phase. This can help determine a patient’s baseline which can be used as a comparison if there are any changes suspected after surgery. Hearing loss is often unrecognized by patients and affects more than 80% of adults older than 80 years of age [13]. Moderate to severe hearing loss is associated with a 3–4-fold higher incidence of dementia [13]. Hearing loss can also be mistaken for depression. Urinary incontinence can impair in patient’s quality of life and should also be documented [13].

3.7 POGAT: frailty

Understanding a patient’s physical needs and frailty status is key in providing best care and can make a huge impact on recovery after surgery and improve surgical outcomes. Identifying if your patient is frail, pre-frail, or at risk for frailty is important because there is so much evidence to show that frail patients typically do not do well after surgery. Frailty is directly associated with major complications in the 30-day postoperative phase [4, 8, 9]. In fact, frail patients have a 4-times higher risk of developing 30-day postoperative major complications [9]. Patients who are frail are at a higher risk for developing complications after surgery leading to longer recovery times, physical deconditioning, discharge to nursing facilities, and even death. Frail patients are at a higher risk for developing cardiac and pulmonary complications that can lead to ICU stays, in addition, frailty is a direct risk factor for postoperative delirium [4]. Regarding surgery, frailty has been shown to be an independent risk factor for length of stay, postop complications, morbidity, and mortality [8]. All these complications will create chaos in the surgical experience and can disrupt the patient’s quality of life.

Let us start by defining frailty. Frailty can be defined as a medical syndrome with numerous causes and contributing factors that are characterized by diminished strength, decreased endurance, and reduced physiological function that increases an individual’s vulnerability to developing increased dependency and/or death [22, 23, 24]. Other studies defined frailty as a distinct clinical syndrome meeting three or more or five criteria, including weakness, slowness, low-level physical activity, self-reported exhaustion, and unintentional weight loss [8, 22]. Several factors that contribute to frailty are advanced chronological age, poor mechanical performance, decrease in level of energy, decreased metabolism, weakness, slowness, exhaustion, low activity, and weight loss [22]. Frailty is common health problem recognized among the older adult and has been shown to increase the risk of moderate to severe adverse outcomes, including longer recovery times, falls, delirium, higher readmission rates, and even death [20, 22]. Assessing for frailty in the older patient is crucial, as it has been a direct indicator of those patients who may do well versus those patients who may not do well after surgery [21]. Screening patients in the presurgery phase can help identify high-risk patients. Once patients are identified, the surgical team can put individualized care plans in place to help optimize them before their surgery and prevent these bad outcomes.

Refer to Table 6 for a summary of frailty screening tools. The gold standard of measuring frailty is using the CGA, frailty can easily be defined by confirmative deficits identified in the comprehensive geriatric assessment [20, 21]. Concerns for frailty can be identified on almost all the assessments that are performed during the CGA (through a single assessment and/or combination). There are multiple other tools that have been used to identify states of frailty. The use of a hand-held device, known as a hand dynamometer, measures a patient’s grip strength (in lbs. or kg) and has been used to identify patients who are prefrail, or frail. Patient has three trials of squeezing the hand dynamometer. Scores are average. Assessments in the form of patient questionaries include the Clinical Frailty Scale (CFS), freed criteria, frailty index, and the frail scale. The questionnaires that are available look into different domains such as comorbidities, social factors, psychological conditions, functional decline, and cognitive decline answers are incorporated into an index with a higher number of conditions indicating a higher level of frailty [22]. The TUGT, summarized in Table 5, is a physical assessment that is used for functional screening, and can also be an indicator of frailty and a predictor of falls.

Frailty screens	Details	Summary of results
Comprehensive Geriatric Assessment (CGA)	Gold standard: Assessment domains: cognitive, depression, nutrition, functional status, frailty, polypharmacy, and patient’s health goals	Can be a positive score on one of domain or a combination of domains
Hand dynamometer	Three trial physical assessment. Patient squeezes a handheld device three times. Strength of grip measured in pounds or kilograms	Number is calculated from average of three scores. Scores are compared on the B&L engineering grip strength norm chart: designed for ages 6–19 and adults 20 to 75+. Patient will fall in out of range for their age group.
Clinical Frail Scale (CFS)	Clinical judgment. Physician assigned scores to categories	Score; 1- very fit 2- well 3- well with treated comorbid diseases 4- vulnerable 5- mildly frail 6- moderately frail 7- severely frail
Frailty index	Evaluates the presence of health deficits: Morbidity, symptoms, disabilities, and diseases.	Provider assessment
Frail scale	Self-reported. five domains: Fatigue, resistance, ambulation, illness, or weight loss.	Score (# deficits present); 0-no frailty 1–2-pre-frail 3 or more frail
Frailty phenotype	Checklist of five criteria: weight loss, weakness, self-reported exhaustion, slowness, and low activity questionnaire.	Score (# criteria present); 0- not frail 1–2- pre-frail >3 - frail

Table 6.

Frailty screening tools [4, 8, 9, 20, 21].

Frailty is a common problem among older adults. Frailty increases the risk of adverse outcomes, falls, hospitalization, and death [22]. Identifying patients who are frail is key, however, emphasis needs to be placed on treatment and management to make a real difference [8]. Patients who are pre-frail, frail, or at risk for frailty should be evaluated and considered for prehabilitation (prehab) prior to their surgery. Most are familiar with the term rehabilitation (rehab), which is therapy after surgery, prehab refers to therapy before surgery to improve the patient’s state of health. The goal is to increase their stamina and endurance. Prehab may consist of a variety of interventions, but most commonly include physical therapy (PT) and nutrition supplementation. PT for muscle strengthening and balance coordination and nutrition supplements to get the patient stronger and help tissue repair after surgery. Additional types of interventions included in prehab are vitamin D therapy, reduction of polypharmacy, multicomponent-focused interventions, and individually tailored geriatric care models [8, 22]. Vitamin D has been shown to help reduce falls, hip fractures, and overall mortality [8]. For best results, these interventions should be put into place at least 3–6 months prior to their operation [22].

Understanding frailty is important, when assessed correctly it can help us alert the patients who will not do well after surgery. The important takeaway is to identify frail syndromes and implement individual tailored geriatric interventions that can lead to continuous care and emphasize interventions that focus on improving clinical outcomes of the older adult [10]. With the goal of restoring a patient’s preexisting reserves to bring them to a better state of health, one that can withstand surgical stress and maintain baseline functions postoperatively [23]. This is especially important as frailty has been directly related to adverse health outcomes, unplanned repeated hospitalizations, extended hospital stays, and high patient mortality [10], all things that are not safe for our patients and not ideal for the institution.

3.8 POGAT: polypharmacy

Changes in the pharmacodynamics and pharmacokinetics induced by aging make this population very sensitive to medications, especially those medications administered in the pre and intraoperative phases of surgery [4]. In the geriatric population, there is an increased incidence of unexpected reactions to medications, anesthesia, and surgery, making it extremely important to understand your patient’s full medication history [4]. A thorough medication review should be done at the time of the CGA. This is critical as many elderly patients describe some confusion around their medication use, specifically, on what the medications are used for and how to take them correctly. It is very common to see misuse, underuse, and abuse of medications in this population [4]. Most older patients are on several medications and it may be hard for them to keep track. It was reported that geriatric patients are great consumers of medications (four drugs a day for ages 65–80 years, 4.5 drugs a day for ages >80 years) [9]. Providers should conduct a thorough medication review looking for polypharmacy, medication redundancy, and medication safety. Polypharmacy is a term used to describe the use of multiple medications; polypharmacy is defined as the use of >5 drugs a day [9]. Polypharmacy was found to be a direct predictive factor of 30-day postoperative major complications [9].

During the review, the provider should be assessing effectiveness of each medication with the goal of discontinuing or substituting medications that could potentially cause unsuitable side effects in the geriatric patient [9, 13]. Some medications may need to be reduced and/or placed on hold during the different surgery phases. Medications that are sensitive to the geriatric population and should be used cautiously are anticholinergic drugs such as (antiemetics, bronchodilators, antiarrhythmias, antihypertensive, antiParkinson’s), which have been shown to disrupt cognitive function [4, 11]. Inappropriate drugs that act on the central nervous system such as benzodiazepines have been shown to increase the risk of falls, confusion, and cognitive deterioration [4, 9, 11].

The Beers, STOPP (screening tool for older person prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources to utilize during the medication review. The Beers, STOPP, and START criteria lists potentially inappropriate medications, medications to avoid, medication combinations that may lead to harmful interactions in older adults, and dose adjustments for patients with chronic kidney disease (CKD) [13].

Education should be provided to the patient on each medication, including the use, dose, frequency, side effects, and interactions. Providers should assess the patient’s ability to understand this information by having the patient recite the medication instructions by to them. If cognitive impairment is expected, information should be given to the patient’s main caregiver. Providers should ensure that patients are able to adhere to the daily medication routine. Any medications that can be taken as a single daily dose should be prescribed that way to reduce the need for frequent dosing. Strategies to improve medication adherence include identifying a main caregiver to assist patient, recommending the use of pill boxes and daily organized medication blister packs, once-a-day medication instead of more frequent administration, and offering direct patient education with the pharmacist [13].

3.9 POGAT: substance abuse

If there are any concerns for substance abuse, substance abuse screening can be conducted at the time of the CGA. Standard tools such as the CAGE questionnaire (cutting down, annoyance, guilty, eye-opener) and alcohol screening are most used. Any abnormal finding on the screenings should alert healthcare providers to push for further investigation and treatment. Patients can be offered outpatient therapy and inpatient rehab depending on severity of their needs. Consideration of starting preop vitamins such as folic acid and thiamine may be beneficial. All findings should be documented and communicated with the surgical team. Assessments of potential withdrawal concerns should be made and implementation of Ethanol (ETOH) withdrawal monitoring protocols should be set in place as needed.

3.10 POGAT: caregiver needs

During the CGA, a main caregiver for the patient should be identified. Complete documentation in the health records on caregiver name and contact information. If the patient is without a caregiver, time should be spent with the patient to help determine who could help them. For example, discussing with the patient if they have family, friends, or neighbors that would be willing to help throughout the surgery process.

3.11 POGAT: patient health goals

When performing the CGA, time should be set aside to review the patient’s overall health goals. Healthcare providers should present questions to the patient such as: What is important to you? What are your goals for after surgery? What is one thing that you cannot live without? Healthcare providers should explore these topics with the patient and review all options available to them, including surgical and nonsurgical treatment plans. Once identified, the patient’s health goals should be documented in their health record and incorporated into their surgery plan of care. Evaluation of goals can be made throughout all phases of surgery and even used to remind the patient of the intended outcome after surgery.

Discussions should include what the patient’s quality of life looks like with and without surgery. Although almost all surgical procedures enhance the quality of life, the balance between the expected benefits and the risk of adverse events (such as cognitive disorders, infections, or other medical complications) should be explored [4, 24]. In the advanced age adult, surgery should be considered when the disease process produces continued discomfort, unmanageable pain, disability, economical loss, and interference with a normal routine of life [25]. However, evaluating the surgical risks must be balanced against the expected beneficial results, the current enjoyment of life, and life expectancy with and without surgery, as unfavorable outcomes are a key issue [4, 25].

4. Enhanced Recovery After Surgery (ERAS)

Enhanced Recovery After Surgery (ERAS) protocols are one-way healthcare institutions can ensure that a thorough surgical plan has been developed, implemented, and carried out. ERAS protocols are designed to assign specific care measures to be delivered to patients at each phase of their surgical experience to help reduce and/or eliminate stressors on the body caused by surgery. ERAS protocols aim to produce better outcomes for patients after surgery. ERAS refers to condition-specific care pathways that use a multidisciplinary team approach, which begins in the preoperative phase, to effectively reduce the perioperative stress response, which then reduces the incidence of infectious complications, and chronic complications after surgery and achieves the goal of rapid rehabilitation [26]. ERAS protocols are available for many surgical conditions (colorectal, orthopedics, vascular, etc.) and universal guidelines recommend that a total of 20 elements of care, be divided into the perioperative, intraoperative, and postoperative phases of surgery [27]. The way in which an institution plans to deliver the different phases of the ERAS protocol may vary from place to place. Most intuitions assign each phase of care to be delivered (pre, intra, and post) to the appropriate units, which the patient will visit throughout the surgical experience.

Paduraru et al. [27] found that elderly patients who followed an ERAS protocol had fewer postoperative complications and a shorter hospital stay when compared to patients who received conventional care [27]. After the review of 18 independent studies, Paduraru et al. [27] concluded that ERAS can safely be applied to the elderly patients, both in emergency and elective surgery, to reduce post-op complications, shorten duration of hospital stay, and reduce readmissions [27]. Yu et al. [19] reviewed a study that utilized “care bundles” to closely follow patient’s medical conditions and provide recovery care. Results showed patients who received care bundles, compared to patients who received conventional care, had a shorter duration of intubation, shorter length in PACU stay, and less adverse events such as respiratory tract, cardiovascular complications, and postoperative pain agitation were discovered during recovery [19].

ERAS protocols can serve as a great guide for pharmacological considerations in the geriatric population. Reference should be made to consider 2019 AGS BEERS Criteria Update Expert Panel [28, 29]. Special attention should be placed on minimizing and/or avoiding the use of the medication class benzodiazepines. Some medications to avoid include: diphenhydramine, meperidine, metoclopramide, and pancuronium. Induction dosing of propofol should be decreased between 20% and 60% in the geriatric population (consider an initial dosing of 1 mg/kg) [28, 29]. If a provider chooses to use inhalation agents consider with MAC levels decrease with age decade over 40) [28, 29]. Drug distribution is altered with normal aging due to a decrease in total body water and increase in adipose tissue resulting in a smaller volume of distribution and increased plasma concentration of water-soluble medications. There is an increased volume of distribution with possible delay in the onset of action and accumulation of more lipid-soluble drugs such as fentanyl. Phase I metabolism through the liver is also impacted by normal aging secondary to decreased enzymatic activity and number of hepatocytes resulting in an increased half-life for several medications. Creatinine clearance may decrease up to 40% by age 80 and analgesic doses should be adjusted accordingly [28, 29]. Regional anesthesia should be prioritized in the orthopedic trauma patient, with strict consideration of avoiding hypotension.

With the aging population and growing number of geriatric surgeries seen, encouraging the use of a geriatric ERAS pathway is essential and has been shown to improve the surgical outcomes of older adults. Please refer to Table 7, for an example of a geriatric enhanced recovery after surgery protocol.

Preadmission testing phase (PAT):	Discuss personal goals and treatment preferences Provide realistic expectations of postoperative functional decline, loss of independence, and skilled care burden Identify advance directive and a designated health care proxy Discuss resuscitation wishes One-on-one teaching (surgery type, smoking cessation, ETOH cessation) Provide references to preoperative education and counseling Chlorhexidine skin cleansing twice in 24 hrs prior to surgery Consider performing a comprehensive geriatric Assessment or minimal cognitive and physical assessment NPO guidelines: No solids after midnight except medication, with clear liquids, if ordered use of carbohydrate drink prior to surgery
Preoperative management:	Chlorhexidine skin cleansing repeated inhouse Fingerstick blood glucose check Evaluation for VTE prophylaxis: both mechanical and pharmacological Preoperative warming device (Bair Hugger) to keep temperature > 35C. Consider regional anesthetic or neuraxial use for case type, perform in preoperative setting Consider oral premedication: Acetaminophen, Gabapentin, Celebrex Scopolamine transdermal patch for motion sickness, PONV prophylaxis Perform a cognitive assessment test to document a baseline (if not already performed in PAT process)
Intra-operative management:	Maintain MAP >70 mmHg, heart rate within 20% of baseline Minimize or avoid narcotics; consider total IV anesthesia (TIVA) Hyperglycemia control, goal for blood glucose level: < 180 mg/dL IV antibiotics within 1 hour before skin incision, redose as per pharmacy guidelines Maintain normothermia (>96.5 degrees Fahrenheit) Goal hemoglobin levels: > 10 Hb? Maintain euvolemia Identify glomerular filtration rate (GFR) to determine risk for AKI, if high risk Lung protective ventilation PONV prophylaxis > 2 antiemetics (dexamethasone, ondansetron) Consider nonopioid pain management regimen Full reversal of neuromuscular blockade is required Consider postoperative ventilation if neuromuscular blockade is questionable
Postoperative management:	Blood glucose check Analgesia as needed, minimize narcotics Initiate epidural infusion if appropriate Initiate clear liquids if cleared by surgery Consider postoperative delirium screening tool prior to discharge from PACU Diet: advance as tolerated IV fluids: discontinue as soon as tolerating oral hydration Continue hyperglycemia screening as protocol dictates Consider bowel regimen if appropriate Continue antibiotics at surgeon’s direction Continue VTE prophylaxis Continue multimodal postoperative pain regimen Begin ambulation as soon as possible with surgeries direction after evaluation of her fall risk Discontinue Foley catheter as soon as possible Begin postoperative education Aggressive pulmonary rehab (incentives spirometry) Begin postoperative physical/occupational/speech therapy as needed. Daily evaluation Delirium/cognitive impairment Postoperative acute pain Pulmonary complications Fall risk Nutrition UTI prevention Functional decline Pressure ulcers Daily family communication

Table 7.

Geriatric enhanced recovery after surgery (ERAS) protocol [1, 2, 3, 4, 5, 6, 7, 19, 25, 26, 27, 30, 31, 32].

5. Anesthesia in the older adult

Surgical procedures have numerous benefits, including saving and prolonging life, providing continuous physical comfort, relieving pain, and can serve for functional and social usefulness [25]. These are all attractive benefits to the older adult, especially those who are looking to improve and maintain a good quality of life. That is why more and more adults are electing to have surgery in their older age and geriatric surgery is becoming the new trend. Unfortunately, we cannot ignore that surgical procedures and the anesthesia required can cause stress on all organs in the body and can disrupt hemostasis. Older adults with reduced physical reserve may not be able to tolerate the stress of surgery and/or the use of the anesthetics that are required. Changes in pharmacodynamics and pharmacokinetics induced by the aging process can make elderly patients very sensitive to medications, especially those administered in the pre and intraoperative phases of surgery [4]. Studies show that older adults are at an increased risk of adverse events even after induction of anesthesia alone, and a presedation assessment should be conducted to ensure that the patient is indeed a candidate for moderate sedation and analgesia (MSA) [30, 31]. The preoperative phase is the best time to conduct a presedation assessment. The sooner a patient’s needs are identified the more time healthcare providers will have to intervene. Older adults undergoing surgery should have the standard history and physical (H&P) completed, in addition, an assessment for frailty, functional status, and cognitive impairment should now be included [30]. This is supported by the Association of Peri-Operative Registered Nurses (AORN) and the American Society of Anesthesiologists (ASA) and has made perioperative anesthesia management a challenge [30].

Perioperative anesthesia management is a challenge in the geriatric population; hence, the anesthetic plan should always be individualized to each patient’s needs and then cautiously administered [31]. One way to accomplish this is to extend the anesthesia consult to incorporate additional assessments that are specific to the geriatric population. Two known risk factors seen in older patients that directly increase the patient’s surgery risk include functional decline and multiple comorbidities [4]. Elderly patients with comorbid diseases like diabetes, and/or hypertension have been shown to lead to higher complication rates after surgery and significantly increase the length of stay and hospital costs [4]. These patients have an increased incidence of unexpected reactions to medications and anesthesia, particularly developing an acute delirium [4]. Geriatric screening tools used to assess cognition, frailty, and functional status should be incorporated into the assessment and the findings should be used to develop a plan of care that will choose the safest anesthetic regimen, keep patients safe, and produce the best outcomes after surgery. For example, patients who are identified with cognitive decline should be evaluated to see if they would be a good candidate for an epidural or nerve block with their surgery to reduce the number of sedatives they would need. In all geriatric patients, especially those with cognitive decline, the use of a geriatric pain protocol should be implemented. A consult with the institution’s inpatient geriatric team can be ordered so the patient can be evaluated after surgery, at the bedside, and ensure best geriatric care is being delivered. Patients who are identified as prefrail, frail, and/or who have impaired functional status should be considered for prehabilitation (prehab) prior to their surgery.

Once the patient assessment is completed, providers should educate patients on the different types of anesthetics available to them and allow them to participate in the decision-making process. Studies revealed that when anesthesiologists provided preoperative education and followed plans of care specific to a patient’s individual needs, patients reported less anxiety and showed better cooperation in the postoperative period [26].

The discussion should always start with the surgeon when the surgery is determined beneficial and then be reinforced by the anesthesiologist and other members of the surgical team. Once the patient assessment is obtained, information gathered should be used to determine if they are a good candidate for the use of a nerve block or an epidural with their surgery. Consideration of the risks and benefits of the use of nerve blocks, epidurals, and/or IV sedation with and/or without general anesthesia should all be reviewed with the patient in the presurgery phase. Research shows extreme benefits of using nerve blocks in the elderly population, as they have been beneficial in providing postoperative analgesia, and lessened the amount of reported postoperative nausea, vomiting, and sedation [32]. The use of nerve blocks and/or epidurals with surgery has been shown to offer better postop pain control [32]. This is beneficial as increased amounts of pain after surgery are associated with the development of postop complications such as pneumonia and deep vein thrombosis [32]. Numerous studies have shown that when measures are taken to minimize the side effects of anesthesia, opioids patients have reported improved satisfaction and acceleration in their recovery [32]. A study conducted by Li et al. [32], demonstrated a significant decrease in delayed postoperative mobility, improved surgical results, and faster rehabilitation in patients who had received nerve block anesthesia [32]. During their presurgery screening, they should be evaluated to see if they are a good candidate for a nerve block or epidural with their surgery to help manage postop pain and decrease opioid use. Choices should be based on avoiding deep anesthesia, cerebral oxygen desaturation, and avoiding intraoperative hypothermia, all measures that can directly cause postoperative delirium [11].

For the most part, presedation assessment is standardized and only captures a small portion of the necessary information, especially, about functional status and frailty [4]. The unique needs of the older adult should be taken into consideration. Please refer to Table 8 for a breakdown of anesthetic considerations in the geriatric patient. Surgical procedures and anesthetic drugs disrupt the hemostasis of the human body, so it is important that both surgeon and the anesthesiologist consider the preexisting physical conditions and comorbidities of this fragile population to ensure the safest outcomes after surgery [4].

Presurgery	Identification of health needs through CGA Cardiac and pulmonary assessments Assessment of chronic diseases and any organ reserve decline Development of surgery care plans to improve surgery outcomes Planning for choice of anesthesia Discussion of utility of surgery Identification of patient’s wishes for resuscitation Identification of health goals
Intraoperative	Anesthesia mode-least invasive Pharmacology-geriatric dosing Continuous monitoring—avoiding ischemic complications Volume management: blood pressure fluctuations Transfusion management Lung ventilation and protection Prevention of hypothermia Prevention of skin breakdown
Postoperative	Assess for cognitive impairment Assess for deconditioning and body system Analgesia management-geriatric dosing Respiratory distress–postop pneumonia Urinary retention, acute kidney injury Functional decline, physical deconditioning Higher morbidity or mortality rates Loss of independence failure to thrive

Table 8.

Anesthetic considerations in the geriatric patient [1, 2, 3, 4, 5, 6, 7, 24, 25, 30, 31, 32].

6. Conclusions

The number of older patients who are medically complex with significant past medical histories, and who are electing to undergo surgery, will continue to grow over the years. Comprehensive health screening can be a lengthy job, but it is worth it and proves to be very meaningful. Presurgery identification of any of these issues is key to the prevention of bad outcomes. Through this extensive screening, we have the potential to improve our patient’s overall health, which will lead to a safer surgical experience and better postoperative outcomes. With better surgery outcomes we can reduce length of stay, and overall morbidity and mortality. Presurgery preparation just makes sense. Ideally, the presurgical assessment team should include, at the least, a geriatric specialist, the surgeon, and anesthesia. Mid-level providers such as advanced practice nurses are most appropriate to accommodate leading this team and serving as a patient advocate.

If you prepare for anything in life, most likely you will do better. If a student studies and prepares for the examination, most likely they will do better. If an athlete trains and practices before the big game, most likely they will do better. When you prepare for surgery you can only hope to do better. Research supports that presurgery identification of medically complex patients or functionally debilitated patients can assist in reducing preventable adverse outcomes [4]. Many studies revealed that using a comprehensive geriatric assessment conducted by interdisciplinary team has shown large improvements in the outcomes of elderly surgical patients, including an increased survival rate, improved physical function, and decreased nursing home place placement [21].

Conflict of interest

The authors declare no conflict of interest.

Appendix

Appendix 1.

Compressive geriatric assessment (CGA) workflow diagram.

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