Based on a literature review, each subcommittee developed a list of topics, and proposed specific recommendations with supporting evidence for each topic. Key issues were discussed at a meeting in January , after which a comprehensive document was circulated, and subjected to three rounds of revision. Subsequently, a draft report was prepared and sent to the Experts for modification and comment. Each author approved the final version prior to submission. We recommend cognitive assessment e.

We recommend a second-level specialist neurocognitive assessment for patients with pathological test scores. Every older patient should undergo a standardized pain history and physical examination. We recommend careful and prolonged assessment of blood glucose in older patients with or without diabetes. The preoperative assessment should evaluate the patient’s health status to assess the surgical risk, increase functional reserves, manage vulnerability, and anticipate, minimize, or prevent possible complications.

This requires a team-based approach throughout the entire care pathway [ 4 ]. The anesthetist should guide the team in the perioperative phase, and the geriatrician should take the lead thereafter.

Comprehensive Geriatric Assessment CGA is a multimodal, multidisciplinary, process aimed at identifying care needs, planning care, and improving clinical and functional outcomes for older people [ 5 ].

This process includes both clinical data and functional measures of cognitive, psychological, nutritional, and behavioral status, and evaluation of social or family support.

The aims are to improve diagnostic accuracy, optimize medical treatment, improve medical outcomes, optimize the home environment, minimize unnecessary service use, and arrange long-term management. CGA and frailty evaluation are extremely useful in surgical risk evaluation in older patients, and in making decisions about surgery [ 4 , 6 — 8 ]. However, evidence from randomized-controlled trials, large systematic reviews, and meta-analyses suggests that the effectiveness of CGA may vary according to the healthcare setting.

For example, home-based and in-hospital CGA programs have consistently been shown to improve health outcomes, whereas evidence is less conclusive for post-hospital discharge CGA programs, outpatient CGA consultation, and CGA-based inpatient geriatric consultation services [ 9 ].

The effectiveness of CGA may be reduced in patients with specific clinical conditions, such as frailty, cancer, or cognitive impairment [ 9 ]. However, because CGA is time-consuming and sometimes difficult to apply in clinical practice, involvement of hospital medical services to create specific management pathways is needed to implement this approach. Signs of frailty include unintentional weight loss, self-reported exhaustion, slow walking speed, weak grip strength, and low physical activity level [ 10 ].

It is not time-consuming, and can be easily used by non-geriatricians. Patients with functional impairment are at increased risk of postoperative complications [ 16 ]. Appropriate measures, where needed, should, therefore, be taken to increase functional reserves. Patients with functional deficits in activities of daily living, or difficulties with mobility, should be referred to an occupational or physical therapist.

Such patients may benefit from preoperative physical conditioning prehabilitation to enhance their capacity to withstand surgical stress and promote postoperative recovery [ 17 ]. Multimodal prehabilitation, including home exercise, nutrition assessment, and pain management, improves postoperative functional outcomes in older surgical patients [ 18 ].

Cardiopulmonary exercise testing objectively measures aerobic fitness or functional capacity. It provides an individualized estimate of patient risk that can be used to predict postoperative morbidity and mortality, inform decision-making, determine the most appropriate perioperative care environment, diagnose unexpected comorbidities, optimize medical comorbidities preoperatively, and direct individualized preoperative exercise programs [ 19 ].

Falls are the primary cause of unintentional injury, and a leading cause of death, in older adults. Limited mobility and falls lead to functional decline, hospitalization, institutionalization, and increased health care costs [ 20 ]. A history of falls within 6 months before surgery is associated with increased rates of postoperative complications, discharge to a rehabilitation facility, and hospital readmission [ 21 ].

Hence, it is recommended that the risk of falls be assessed preoperatively, and appropriate preventive measures taken, particularly in patients with reduced mobility, postural hypotension, or risk of syncope.

The risk of falls can be assessed with the TUG test [ 22 ]. Concomitant sensory and cognitive impairment is common in older individuals [ 23 ], and is an independent risk factor for postoperative death and complications [ 24 ]. Multimodal interventions including elements addressing visual or hearing impairment can significantly reduce the prevalence and duration of delirium in older hospitalized patients [ 25 ].

Routine screening for cognitive impairment should, therefore, be included in the preoperative evaluation, even in patients with no history of cognitive decline. Basic cognitive tests, such as the Clock drawing test, the Abbreviated Mental Test, or the Mini-Mental State Examination MMSE , can be used for screening; specialist investigation is required in patients with equivocal findings.

The combination of aging and comorbidities is the principal factor reducing tolerance to surgical stress in older patients [ 4 ]. Comorbidities increase markedly with age, largely due to increasing rates of chronic conditions [ 10 ]. Comorbidities are strongly associated with increased surgical and postoperative risks, and increased health care costs [ 35 ]. Age-related changes in the cardiovascular and autonomic nervous systems reduce cardiac responsiveness to stress [ 36 ].

Guidelines for the evaluation of cardiac risk published by the American College of Cardiology ACC and the American Heart Association AHA [ 37 ] recommend preoperative cardiac testing only if the results will change clinical management, and avoidance of testing before low-risk surgery.

The type of surgery is an important determinant of the risk of cardiac complications and mortality. In patients undergoing noncardiac surgery, functional status, generally defined in terms of metabolic equivalents METs , is a reliable predictor of both perioperative and long-term risk [ 38 ].

The Lee index [ 39 ] is widely used for assessment of cardiac risk, because it is simple and has been extensively validated. However, more recent measures, such as that of Alrezk et al. The ACS-NSQIP Surgical Risk Calculator [ 41 ] has been specifically validated in geriatric patients, and is an accurate tool for preoperative assessment in this population, especially if combined with cardiac biomarkers [ 42 ].

The risk of postoperative venous thromboembolism is increased in patients over 70 years of age, and in geriatric patients with comorbidities such as cardiovascular disorders, malignancy or renal insufficiency. Therefore, risk stratification, correction of modifiable risks, and sustained perioperative thromboprophylaxis are essential in these populations. The timing and dosing of thromboprophylaxis in older patients should be the same as in younger patients [ 43 ].

Postoperative pulmonary complications PPCs are common in geriatric patients, and contribute to the risks of perioperative and postoperative morbidity and mortality. The surgical site is the most important predictor of pulmonary complications; others include COPD, recent smoking, poor general health status, and functional dependency [ 44 ].

Age is a minor risk factor after adjustment for comorbidities, conferring an approximately twofold increase in risk [ 45 ]. Thus, older patients who are otherwise acceptable surgical candidates should not be denied surgery solely on the basis of concern about potential PPCs [ 46 ]. Routine preoperative spirometry is not recommended before high-risk surgery, because it is no more accurate in predicting risk than clinical evaluation.

Patients who might benefit from preoperative spirometry include those with unexplained dyspnea or exercise intolerance, and those with COPD or asthma in whom the extent of airflow obstruction is unknown.

Strategies for reducing the risk of PPCs in older surgical patients include risk factor minimization or avoidance including preoperative smoking cessation , optimization of COPD or asthma treatment, deep breathing exercises, and epidural local anesthesia [ 46 , 49 ]. In a general population of patients scheduled for elective upper abdominal surgery, a min preoperative physiotherapy session provided as part of an existing multidisciplinary preadmission evaluation was shown to halve the incidence of PPCs, particularly hospital-acquired pneumonia [ 50 ].

Anemia is common in surgical patients, and is associated with increased perioperative mortality [ 51 ]. Preoperative anemia should, therefore, be considered a significant medical condition, rather than as simply an abnormal laboratory finding [ 52 ].

Investigation should begin with an assessment of iron status: when ferritin or iron saturation levels indicate an absolute iron deficiency, referral to a gastroenterologist may be indicated to exclude gastrointestinal malignancy as a source of chronic blood loss. In the absence of an absolute iron deficiency, measurement of serum creatinine and glomerular filtration rate GFR may indicate chronic kidney disease CKD and the need for referral to a nephrologist.

When ferritin or iron saturation values are inconclusive, further evaluation is necessary to exclude inflammation or chronic disease. A therapeutic trial of iron would confirm absolute iron deficiency, whereas a lack of response would indicate anemia of chronic disease, suggesting that treatment with an erythropoietin-stimulating agent should be initiated [ 54 ]. Iron-deficiency anemia should be treated with iron supplementation [ 55 ]. Oral iron replacement should be targeted to patients with iron deficiency with or without anemia whose surgery is scheduled 6—8 weeks after diagnosis [ 53 ].

Anemia and transfusion are associated with increased morbidity and mortality in surgical patients [ 56 ]. PBM should be started before surgery, and continued throughout the perioperative period. Systematic preoperative PBM has consistently been shown to improve postoperative clinical outcomes [ 56 , 59 ]. Maintenance of a preoperative hemoglobin level above Intraoperative PBM includes monitoring anemia and related physiological changes, conserving autologous blood, and using surgical and anesthetic strategies to contain and minimize blood loss.

During the postoperative period, monitoring of anemia, organ perfusion, blood loss, and hemostasis is an important part of clinical management [ 58 ]. The age-related decline of renal function varies markedly, due to nephrotoxic effects of comorbidities such as hypertension or diabetes, and drug treatment, particularly with non-steroidal anti-inflammatory drugs NSAIDs and angiotensin -converting enzyme ACE inhibitors.

Renal impairment can affect anesthetic pharmacokinetics and pharmacodynamics, and hence, renal function should be assessed before any surgery in older patients [ 36 ]. Increasing age is often associated with an unhealthy nutritional status [ 61 ], which is a risk factor for postoperative complications [ 36 , 62 ].

However, poor nutritional status is often insidious and, hence, often goes unrecognized. Assessment of nutritional status is, therefore, essential in older surgical patients [ 63 , 64 ].

European Society for Clinical Nutrition and Metabolism ESPEN guidelines emphasize the importance of screening for malnutrition on admission or first contact, observation and documentation of food intake, regular assessment of weight and body mass index BMI , and nutritional counseling [ 65 ].

Patients at high nutritional risk before elective surgery should be managed with a multimodal approach including evidence-based interventions to optimize nutritional status, and surgery should be postponed if possible [ 68 ]. In one study, A comprehensive medication review, including over-the-counter medications, vitamins, and herbal supplements, is essential to identify medications that should be continued during the perioperative period, and potentially harmful, ineffective, or contraindicated medications [ 16 ].

This may be particularly important in patients experiencing, or at increased risk of, delirium, because any medication change could trigger delirium [ 70 ].

Treatment with anticholinergics and poly-medication are considered predisposing risk factors for POD; because anticholinergic compounds are present in a number of medications frequently prescribed to older patients for different purposes, the total anticholinergic burden should be considered in patients at risk of POD [ 71 ].

Delirium is an acute fluctuating alteration of mental state, reduced awareness, and disturbance of attention, that may be triggered by acute medical illness, surgery, trauma, or drugs [ 75 , 76 ]; multiple factors may be present in an individual patient [ 77 , 78 ]. Delirium is independently linked with poor postoperative outcomes, including medical complications, falls, prolonged hospitalization, permanent cognitive dysfunction, need for institutionalization, and death, and can cause significant patient and care giver distress.

It is frequently missed in routine clinical care [ 79 , 80 ]. European Society of Anaesthesiology ESA guidelines recommend that the preoperative evaluation should include identification of potential risk factors for postoperative delirium, to identify patients at high risk [ 70 , 81 ].

If a specialist geriatrician is not available, preoperative screening for delirium risk should be performed by anesthetists, and the best strategic approach determined by the multidisciplinary team [ 82 ].

The Confusion Assessment Method CAM may be useful in screening for delirium [ 79 ], but sensitivity and specificity vary markedly, possibly due to the need for users to have training and knowledge of delirium.

The Arousal, Attention, Abbreviated Mental Test 4, and Acute change Test 4AT is brief and easy to use without specific training, and has wide applicability in various clinical settings [ 83 ]. It offers good sensitivity and patient completion rates [ 84 ], and can also be used to assess older patients presenting in emergency departments [ 83 ].

In patients over 60 years of age, avoiding episodes of deep anesthesia during surgery lasting more than 1 h can significantly reduce the risk of postoperative delirium. To avoid excessively deep anesthesia, guidelines from the UK recommend that depth of anesthesia should be monitored in all patients in this age group [ 77 , 78 ].

Several classes of medication can increase the risk of delirium, and hence, medication review can decrease rates of delirium [ 77 , 78 ]. Opioids can cause delirium, but remain vital for treating pain, which, in itself, can precipitate delirium. The perioperative analgesia plan must consider multimodal strategies and reducing the use of opioids: older patients have increased sensitivity to opioids, and need individual dose titration [ 85 ].

Older patients should undergo a standardized pain history and physical examination, to determine an appropriate analgesic plan [ 72 ]. Because cognitive impairment alters the experience of pain, the ability to communicate that experience, and the medical management of pain [ 86 ], specific behavioral scales have been developed to assess pain in cognitively impaired older adults [ 87 ].

Depressive symptoms are associated with poor functional recovery and increased likelihood of institutionalization after discharge [ 90 ]. Similarly, patients with preoperative anxiety and depressive symptoms have worse patient-reported outcomes than those without [ 91 ]. Patients with preoperative depressive symptoms are also more likely to develop POD [ 92 ]. Social support predicts day postoperative morbidity when included in a geriatric preoperative assessment [ 94 ].

If there is concern about insufficient family or social support, preoperative referral to a social worker should be considered [ 13 ]. In older adults, the risk of peripheral nerve damage and pressure injuries resulting from malposition is increased by skin atrophy and decreased skin integrity [ 72 ]. Measures should, therefore, be taken to ensure proper positioning, taking into account musculoskeletal conditions such as kyphoscoliosis, and padding of bony prominences [ 36 , 72 ].

Care should be taken when transferring the patient between their bed and the operating table, and when removing adherent items such as surgical dressings [ 36 ]. There is insufficient evidence to recommend a single anesthetic plan for all older adults. The use of regional anesthesia as the primary modality may be beneficial in reducing perioperative mortality or major complications in patients undergoing surgery with intermediate or high cardiac risks [ 95 ].

In accordance with Enhanced Recovery After Surgery ERAS principles, combining neuraxial or regional techniques with general anesthesia results in less intra- and postoperative metabolic derangement and better control of postoperative pain.

Age-related alterations in anesthetic pharmacokinetics and pharmacodynamics render older patients prone to unintentional overdosing [ 96 ], and appropriate dose adjustment is therefore essential. Particular care should be taken with hypnotic agents, because the dose required to induce anesthesia in older patients is lower, and the onset time longer, than in younger patients [ 97 ]. Propofol is suitable for older patients because of the rapid recovery time, and favorable adverse event profile.

In patients older than 80 years, propofol is associated with less post-anesthetic cognitive impairment than other hypnotic agents [ 98 ]. However, the brain becomes more sensitive to the effects of propofol with age, and the elimination rate decreases linearly in patients older than 60 years; furthermore, geriatric patients are more sensitive to adverse effects of propofol, such as hypotension, compared with the general population [ 99 , ]. Therefore, the dose should be reduced in older patients, particularly when administered with other induction agents [ 98 , 99 ].

Opioids have useful analgesic properties, but can cause delirium. Older patients have increased sensitivity to opioids, necessitating individual dose titration [ 85 ]. Depth of anesthesia monitors are recommended for patients at higher risk of adverse outcomes, irrespective of the anesthetic used [ ]. If depth of anesthesia monitoring is unavailable, iso-MAC charts should be used to calculate the dose according to age-adjusted MAC values [ 36 , ].

Depth of anesthesia monitoring to avoid episodes of deep anesthesia can significantly reduce POD in patients aged over 60 years under general anesthesia for surgery lasting more than 1 h [ , ]. Therefore, guidelines from the UK recommend that depth of anesthesia should be monitored in all patients aged over 60 years [ 77 , 78 ].

It is not possible to titrate anesthetics on the basis of on-line electroencephalography EEG [ ]. By contrast, brain monitoring using processed EEG, such as the bispectral index BIS , facilitates anesthetic titration and reduces episodes of deep levels of anesthesia [ , ]. BIS monitoring may also prevent awareness phenomena related to light anesthesia levels, although these are rare events in older patients [ , ]. Brain monitoring should also be extended to procedures performed under sedation.

In a subgroup analysis of a randomized study, limiting sedation levels resulted in a reduction in POD in patients with low comorbid state [ ]. However, the benefits of lighter sedation levels may be confounded by baseline comorbidities that increase the risk of delirium. Aging significantly affects the pharmacokinetics of neuromuscular blocking agents NMBAs , particularly with drugs eliminated by hepatic or renal metabolism [ ], and older patients are more sensitive to NMBAs than younger patients [ ].

The intermediate-acting relaxants, vecuronium and rocuronium, which depend on end-organ elimination, may have a significantly prolonged duration of action in older patients, and appropriate dose adjustment is necessary [ ]. Mivacurium action is also prolonged, due to age-related decreases in plasma acetylcholinesterase activity. Atracurium and cisatracurium, which are eliminated primarily by temperature-dependent, spontaneous Hoffman degradation, do not require dose adjustments in older patients, because the recovery time is almost identical to that in younger patients, although onset time may be delayed.

Monitoring the depth of neuromuscular blockade is essential in older patients to ensure appropriate dosing of NMBD during anesthesia and to avoid incomplete recovery from neuromuscular blockade after surgery. Complications related to postoperative residual curarization PORC are more frequent in older patients than in younger patients [ ].

Furthermore, pharyngeal function, which is often impaired in geriatric patients, may be worsened by PORC, possibly resulting in postoperative aspiration-induced pneumonia [ ]. PORC is strongly linked to inadequate reversal of neuromuscular blockade, and hence, accurate dosing of NMBAs, vigilant monitoring of neuromuscular blockage, and appropriate administration of reversal agents, are essential.

The duration of action of the cholinesterase inhibitors neostigmine and pyridostigmine is prolonged in aged patients [ , ], whereas this is not true for edrophonium [ ]. Hence, neostigmine and pyridostigmine are preferable to edrophonium for reversal of neuromuscular blockade in older patients, because their prolonged duration of action can counteract age-related increases in the duration of action of NMBAs.

Sugammadex binds to aminosteroidal NMBAs rocuronium and vecuronium , forming a complex that is primarily excreted by the kidneys. Decreases in kidney function reduce sugammadex clearance, and prolong its half-life and duration of action [ ]. Sugammadex is significantly faster than neostigmine in reversing neuromuscular blockade, and is more likely to be associated with higher TOF values and a lower risk of PORC [ ].

Reversal of NMB with sugammadex is rapid, although slightly slower than in younger adults [ ], especially with low-dose sugammadex [ ]. Older patients are particularly predisposed to hypothermia due to altered thermoregulation resulting from decreases in muscle mass, metabolic rate, and vascular reactivity [ 72 ]. Active warming procedures are, therefore, necessary to maintain normothermia. These may include covering the patient’s head and body, increasing the ambient room temperature, warming intravenous and irrigating solutions, and applying external warming devices.

Core temperature should be monitored in operations lasting more than 30 min, and warming should be used in older patients [ 72 ]. Appropriate use of intravenous fluids is important to prevent hypovolemia or dehydration in geriatric surgical patients. Multiple international guidelines allow unrestricted intake of clear fluids up to 2 h before elective surgery [ ].

Concerns remain about impaired organ perfusion with this restrictive approach. In one study, patients managed with a restrictive fluid approach had a significantly higher risk of acute kidney injury AKI than those receiving liberal fluid administration [ ]. In ERAS guidelines, the preoperative goal is to prepare a hydrated, euvolaemic patient by avoiding routine mechanical bowel preparation and encouraging patients to drink clear liquids up to 2 h before induction of anesthesia.

The postoperative goal is early transition from intravenous to oral fluid therapy [ ]: GDT reduces postoperative mortality, compared with standard hemodynamic therapy, even in high-risk patients [ ]. Recent Italian guidelines [ ] recommend perioperative GDT to reduce morbidity, and possibly mortality in high-risk patients.

Intraoperative PBM includes: meticulous hemostasis and surgical technique; cell salvage; appropriate use of drugs and hemostatic agents; point-of-care tests for bleeding; and restrictive transfusion thresholds [ 58 ].

Compensatory mechanisms for anemia are severely impaired in older patients, and this may result in greater vulnerability to anemia-related ischemic events and perioperative complications [ 54 ].

In the absence of specific clinical conditions reducing tolerance of anemia, restrictive rather than liberal, transfusion strategies are recommended [ ]. Conversely, transfusion was associated with increased mortality in patients with preoperative hematocrits between 30 and Avoiding exaggerated or prolonged Trendelenburg or anti-Trendelenburg positions.

Administering deep neuromuscular blockade, to allow the use of low working pressures. Where feasible, laparoscopic surgery is becoming standard treatment for many common pathologies that disproportionately affect older patients. Benefits of laparoscopy include decreased postoperative pain, shorter hospitalizations, improved cosmesis, and a quicker return to normal activity. However, laparoscopy may be technically challenging, and imposes specific physiologic demands on older patients [ ].

A recent systematic review found that short-term outcomes after laparoscopic surgery for colorectal cancer were generally similar in older and younger patients, although the overall complication rate was slightly but significantly higher in older patients [ ]. Recent years have seen the introduction of robot-assisted surgical techniques. These techniques appear to be safe in older patients, with no increased risk of death or morbidity compared with younger patients [ ].

Nevertheless, their use should depend on the specific history and comorbidities of the individual patient [ ]. ERAS protocols aimed at reducing postoperative morbidity cover the whole perioperative period [ ]. This multidisciplinary approach decreases length of stay and healthcare costs by better postoperative pain and nausea control, integration of preoperative, intraoperative, and postoperative care, and education to enable patients and families to participate in care. In a systematic review of 24 studies, the ERAS items that most strongly predicted shorter hospitalization and lower morbidity were: absence of a nasogastric tube; early mobilization, oral nutrition, and removal of the urinary catheter; and use of nonopioid analgesia [ ].

Importantly, reduction in surgical stress through ERAS appears to be particularly effective in reducing complications and supporting recovery in older and frail patients [ , ]. POD assessment should be performed, while the patient is still in the recovery room, and repeated over 5 days. We, therefore, recommend using POD screening tools in the postoperative period [ ].

However, CAM requires specific training to ensure reliability of diagnosis, whereas the 4AT can be used in various care settings without specific training [ ]. It also allows evaluation of patients who are unable to complete more detailed cognitive tests because of drowsiness or agitation.

We, therefore, recommend that the 4AT is included in the preadmission assessment of older surgical patients, and if possible incorporated into nursing routines [ ]. An Italian intersociety consensus has highlighted recommendations for the prevention, diagnosis, and treatment of delirium in older hospitalized patients [ ]. All patients with delirium should receive an individualized treatment plan, including identification of underlying acute diseases and other clinical conditions that may lead to delirium.

Medication reconciliation, early mobilization, promotion of physiologic sleep—wake rhythm, maintenance of adequate nutrition and hydration, and the provision of visual and auditory aids, should be implemented [ 78 ].

This requires a multidisciplinary, coordinated, approach, coordinated where possible by the geriatrician. It is also important to recognize the potential role of family and caregivers in supporting the patient.

Cognitive changes after anesthesia also include postoperative neurocognitive disorders. Specific risk factors for such disorders should be evaluated in susceptible patients [ , ]. Postoperative nausea and vomiting can cause fear and anxiety before surgery, and can result in poor patient satisfaction, prolonged time in the postanesthesia care unit, and unplanned hospital admission in surgical outpatients.

Risk factors for PONV should be assessed in all older surgical patients. Patients at moderate or high risks should receive appropriate prophylactic interventions and risk mitigation strategies, according to guidelines and local practice [ 72 ]. Inadequate analgesia for older surgical patients contributes to postoperative morbidity, including delirium, cardiorespiratory complications, and failure to mobilize.

However, postoperative pain is poorly assessed and treated in older patients, particularly those with cognitive impairment [ 36 ]. Pain can be assessed using the numerical rating scale, visual analogic scale, or verbal rating scale in patients with mild-to-moderate cognitive impairment; we recommend the use of specific scales PAINAD, NOPPAIN, and Doloplus-2 for those with severe cognitive disorders [ ]. Analgesic plans for older adults should be multimodal to avoid adverse effects of opioid analgesics and anxiolytics [ ].

Non-pharmacological methods e. Benefits of this approach include better pain scores, reduced sedation frequency, and reduced usage of opioid medications, compared with systemic opioids alone [ 72 ]. If paracetamol is ineffective, NSAIDs should be used at the lowest possible dose and for the shortest possible duration, with concomitant proton pump inhibitor therapy and monitoring for gastric and renal damage. Older patients are more sensitive to adverse effects of opioids and NSAIDs, and more prone to postoperative morbidity.

The combination of opioid-free general anesthesia with neuraxial or regional local anesthesia, according to ERAS principles, is indicated in this situation [ ]. Morphine is an effective analgesic for moderate or severe pain, but should be administered cautiously, particularly in patients with poor renal or respiratory function, cognitive impairment, or both [ 36 ].

Meperidine has consistently been associated with an increased risk of POD in older surgical patients, but the incidence of POD and cognitive decline with this agent appear to be similar to those seen with more frequently used postoperative opioids such as morphine, fentanyl, or hydromorphone [ ]. Regional or neuraxial techniques, such as transversus abdominus plane TAP block, can decrease the need for intraoperative or postoperative systemic narcotics [ ].

Patient-controlled analgesia can be considered in appropriate patients. Postoperative pulmonary complications PPCs increase postoperative mortality, and health care costs [ 72 , ]. Older age may be an independent predictor of PPCs [ ]. Hence, periodic evaluation of oxygen saturation, arterial blood gases, and respiratory rate is recommended in older patients.

In addition to optimization of pulmonary status during the preoperative and intraoperative periods, several postoperative strategies can be used to prevent PPCs in older patients, including screening for signs and symptoms of dysphagia [ ], incentive spirometry, chest physical therapy, and deep breathing exercises [ 44 , 49 ].

Monitoring of vital signs in the post-anesthetic setting is essential to identify patients at potential risk of postoperative respiratory failure [ ].

Incentive spirometry is widely used to prevent PPCs, although clinical effectiveness data are limited, and standardized protocols are lacking [ , ]. Age has not consistently been found to be an independent predictor of perioperative cardiac risk, although perioperative mortality following acute myocardial infarction is higher in older than in young patients [ ]. Strategies to reduce cardiac risk in older patients include the use of beta blockers and statins, perioperative blood pressure control, and preoperative ECG [ ].

Thromboprophylaxis is usually based on low-molecular-weight heparins. Graduated compression stockings or intermittent pneumatic compression are a valuable alternative in selected situations, such as neurosurgery, and a useful complement in others, including some orthopedic procedures. Use of such measures in older surgical patients is endorsed in current ESA guidelines [ 43 ]. The optimal approach to preventing AKI in older surgical patients is unknown, but perioperative close monitoring of fluid balance, avoidance of nephrotoxic drugs, appropriate adjustment of renally excreted drugs, careful use of contrast media, and prompt treatment of sepsis are appropriate in all older patients.

Because relatively small changes in serum creatinine can predict or define AKI [ ], estimation of GFR should be available prior to surgery to facilitate the early detection of AKI.

Older adults are at particular risk for urinary tract infection UTI , particularly if immobilized [ 72 ]. Guidelines for the prevention and management of UTI recommend limited use of urinary catheters, aseptic insertion of catheters, and maintenance of a closed drainage system [ ].

Clinical evidence suggests that early removal of urinary catheters, whenever possible, is related to a lower risk of urinary infection and faster hospital discharge [ 72 , ]. Thus, nutritional support should be continued from the preoperative period, or instituted early after surgery, to improve wound healing and recovery [ 36 ]. Enteral nutrition is associated with better outcomes shorter hospitalization, reductions in incidence or severity of complications, and decreased healthcare costs , compared with parenteral nutrition [ ].

Oral feeding ability and aspiration risk should be assessed daily in older patients. A dietary consultation should be initiated, and a formal swallowing assessment performed if indicated [ 72 ].

During oral feeding, the head of the bed should be elevated at all times, and the patient should be sitting upright while eating and for 1 h after each meal, to prevent aspiration [ 72 ]. Older persons undergoing hip fracture surgery are generally at risk of malnutrition due to the acute trauma and surgery-related anorexia and immobility. Voluntary oral intake in the postoperative phase is often inadequate in such patients, and hence, rapid deterioration of nutritional status and impaired recovery are common [ ].

Thus, the ESPEN guidelines for geriatric patients recommend that older patients with hip fracture should be offered oral nutritional supplements postoperatively, to reduce the risk of complications [ ]. Such nutritional support should be part of an individually tailored, multimodal, and multidisciplinary intervention to ensure adequate dietary intake, improve clinical outcomes, and maintain quality of life [ ].

Hospitalized older patients, particularly frail patients with hip fractures [ ], are at high risk of pressure ulcers. Health care teams should, therefore, assess the risk of pressure ulcers in all older postoperative patients, and should implement multimodal interventions to prevent and treat pressure ulcers, especially in at-risk patients [ 72 ]. Surgical site infections SSIs are associated with delayed wound healing, prolonged hospital stays, increased use of antibiotics, unnecessary pain, and rarely death.

Antibiotic prophylaxis is a principal strategy for preventing SSIs, but reductions in SSIs can also be achieved by implementing multidisciplinary, hospital-wide, measures such as bowel preparation, skin preparation, disinfection and hygiene, maintenance of normothermia during surgery, and glycemic control [ ].

In older patients, it is important to choose the antimicrobial agent according to the susceptibility profile of colonizing bacteria. Particular attention should also be paid to the dosing regimen, because the relationship between appropriately dosed preoperative antibiotics and reduced risk of SSIs is well established.

However, older patients may have renal impairment necessitating dose adjustment [ 60 , ]. In older patients, postoperative hyperglycemia is associated with poor wound healing, SSI, acute complications fluid and electrolyte disorders, acute renal failure , longer hospitalization, and death [ ]. The question of where the patient can receive the best possible support after discharge should be considered throughout the perioperative period.

The lack of an appropriate discharge and transition plan makes early readmission more likely, and may impair functional status and quality of life [ ]. Changes to medication frequently occur during hospitalization of older adults, and prompt review within primary care is essential following discharge [ , ].

CGA of frail geriatric patients can reduce the risk of readmission when performed immediately before hospital discharge or on arrival in community settings. This should include targeting criteria to identify vulnerable patients, a multidimensional assessment program, comprehensive discharge planning, and home follow-up. Some frail patients may develop a transient period of health vulnerability following hospitalization, known as the post-hospital syndrome PHS [ ]. PHS is characterized by the risk of early re-hospitalization due to physiologic stressors resulting from the initial admission, including disruption in sleep—wake cycles, inadequate pain control, deconditioning, and changes in nutritional status.

Patients hospitalized within 90 days of elective surgery are at increased risk of PHS [ ]. Geriatric patients, especially if frail, often need prolonged hospitalization, or care in intermediate care facilities, before returning home. For some patients, worsening health and functional status make it impossible to return home.

Discharge to residential care, and inability to maintain independence after surgery, may be unacceptable to many older patients [ ]. Anticipating which adults will require discharge to care facilities is important for preoperative counseling and care planning for both patients and caregivers.

Before surgery, patients and surgeons should discuss clearly what they hope to achieve with the intervention, and what secondary strategy should be adopted if these objectives are not achieved or complications occur. These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of surgeons, anesthetists, geriatricians, and other specialists and health care professionals.

A number of general statements can be made about the perioperative care of geriatric surgical patients. First, prehabilitation and ERAS protocols are recommended in all older candidates for elective surgery. Second, continuity of care is the hallmark of optimal care, and this requires early planning of the expected needs, final location of care and transition strategies for problematic cases. Finally, for medium- to high-risk patients, implementation of CGA and associated care should be considered in terms of the relative costs and benefits, rather than cost alone.

The authors would like to thank Dr. Luigia Scudeller for assistance with methodology. Medical writing and editorial assistance in the preparation of this paper were provided by Michael Shaw Ph.

This work, including travel and meeting expenses, was supported by an unrestricted grant from MSD Italia Srl. The sponsor had no role in selecting the participants, reviewing the literature, defining consensus statements, drafting or reviewing the paper, or in the decision to submit the manuscript.

All views expressed are solely those of the authors. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Aging Clinical and Experimental Research. Aging Clin Exp Res.

Published online Jul Author information Article notes Copyright and License information Disclaimer. Stefano Volpato, Email: ti. Corresponding author. Received Mar 3; Accepted Jun 3. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material.

If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. This article has been corrected. See Aging Clin Exp Res. Abstract Background Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment.

Aims To develop evidence-based recommendations for the integrated care of geriatric surgical patients. Results A total of 81 recommendations were proposed, covering preoperative evaluation and care 30 items , intraoperative management 19 items , and postoperative care and discharge 32 items.

Conclusions These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals where available as needed. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial Offer or provide this service C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences.

These is at least moderate certainty that the net benefit is small Offer or provide this service for selected patients depending on individual circumstances D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits Discourage the use of this service I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service.

Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined Read the clinical considerations section of USPSTF Recommendation Statement.

If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. Open in a separate window. Quality of evidence Description High A The available evidence usually includes consistent results from a multitude of well-designed, well-conducted, studies in representative care populations.

These studies assess the effects of the service on the desired health outcomes. Because of the precision of findings, this conclusion is, therefore, unlikely to be strongly affected by the results of future studies. These recommendations are often based on direct evidence from clinical trials of screening, treatment or behavioral interventions.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion Low C The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The very limited number or size of studies Inconsistency of direction or magnitude of findings across the body of evidence Critical gaps in the chain of evidence Findings are not generalizable to routine care practice A lack of information on prespecified health outcomes Lack of coherence across the linkages in the chain of evidence.

More information may allow an estimation of effects on health outcomes. Table 3 Summary of recommendations. We recommend a multimodal approach or, when possible, locoregional or plane blocks e. Frailty Statement Quality of evidence Strength of recommendation We suggest using multiparametric frailty scales e. Prehabilitation strategy Statement Quality of evidence Strength of recommendation We recommend a systematic prehabilitation strategy to improve functional status and increase the organic functional reserve Low A We recommend a cardiopulmonary exercise test before major surgery e.

Prehabilitation Patients with functional deficits in activities of daily living, or difficulties with mobility, should be referred to an occupational or physical therapist. Cardiopulmonary exercise testing Cardiopulmonary exercise testing objectively measures aerobic fitness or functional capacity.

Falls Falls are the primary cause of unintentional injury, and a leading cause of death, in older adults. Sensory deficits and use of functional aids Concomitant sensory and cognitive impairment is common in older individuals [ 23 ], and is an independent risk factor for postoperative death and complications [ 24 ].

Cognitive function Statement Quality of evidence Strength of recommendation We recommend cognitive assessment e. Comorbidities Statement Quality of evidence Strength of recommendation We recommend that the relative implications of comorbidities, and chronic or degenerative pathologies, for the response to surgery be recognized Low A. Respiratory Statement Quality of evidence Strength of recommendation We recommend that risk factors for respiratory complications be assessed and reduced where possible e.

Nutritional Statement Quality of evidence Strength of recommendation We recommend evaluation of nutritional status and correction of any deficiency, especially before major surgery Moderate A We recommend that albuminemia be assessed in all older surgical patients, especially those with hepatic comorbidity, multiple comorbidities, recent major pathology or suspected malnutrition, or candidates for major surgery Moderate A In candidates for major surgery with organ failure, we recommend an estimation of hydration and volume status with an instrumental method e.

Medication Statement Quality of evidence Strength of recommendation It is recommended that the pharmacological history must be extended to include all drugs used by the patient, including over-the-counter and herbal medicines Low A If the patient is taking inappropriate medications e.

Emotional status Statement Quality of evidence Strength of recommendation We suggest screening for depression using validated scales e. Social support Statement Quality of evidence Strength of recommendation It is recommended that the availability of family and social support be investigated during the preoperative assessment to allow planning of substitutive support measures Low A. Intraoperative management Positioning Statement Quality of evidence Strength of recommendation When positioning an older patient on the operating table, we suggest that attention be paid to conditions of the skin e.

Depth of anesthesia monitoring Statement Quality of evidence Strength of recommendation During general anesthesia, we recommend EEG-based monitoring to avoid excessive anesthesia depth, which is associated with increased risk of postoperative delirium High A It is recommended that EEG-based monitoring is extended to procedures performed under sedation High A.

Neuromuscular blocking agents Aging significantly affects the pharmacokinetics of neuromuscular blocking agents NMBAs , particularly with drugs eliminated by hepatic or renal metabolism [ ], and older patients are more sensitive to NMBAs than younger patients [ ].

Neuromuscular blockade reversal in older patients Complications related to postoperative residual curarization PORC are more frequent in older patients than in younger patients [ ]. Temperature control Statement Quality of evidence Strength of recommendation We recommend body-temperature monitoring and active warming of the patient, preferably with a forced-air system, during the pre-, intra-, and postoperative periods High A If forced-air heating is only partially efficacious e.

Postoperative delirium Statement Quality of evidence Strength of recommendation It is recommended that prevention, recognition and treatment of postoperative delirium must be an objective of the multidisciplinary team Moderate A We recommend that patients at risk for POD be monitored with validated diagnostic tools such as the CAM or 4AT, starting when they wake from anesthesia and continuing for 5 days thereafter Moderate A.

Postoperative nausea and vomiting Statement Quality of evidence Strength of recommendation Because of the high risk e. Postoperative pain Statement Quality of evidence Strength of recommendation Personalized prevention and treatment of postoperative pain are mandatory. Postoperative pulmonary complications Statement Quality of evidence Strength of recommendation We recommend periodic evaluation of oxygen saturation and respiratory rate in the postoperative period Moderate A We recommend that arterial blood gas analysis be used when conditions interfere with percutaneous oximetry e.

Postoperative cardiovascular complications Statement Quality of evidence Strength of recommendation To prevent postoperative cardiac complications, we recommend monitoring continuously in selected cases and maintenance of cardiovascular measures e. Urinary tract infection Statement Quality of evidence Strength of recommendation We recommend that urinary catheters be used only when essential, and be removed as soon as possible High A We recommend to adopt strategies to prevent urinary tract infections before, during, and after insertion of a urinary catheter High A We do not recommend complementary strategies such as the use of alpha-blockers in men to promote spontaneous urinary function after catheter removal High D.

Nutrition and liquid balance Statement Quality of evidence Strength of recommendation It is recommended that older patients undergo daily assessment of caloric intake and water balance Moderate A We recommended that swallowing should be evaluated, and the presence of oral lesions excluded in patients with signs and symptoms of dysphagia or a history of aspiration pneumonia Moderate A We suggest that all older patients are seated during meals and for an hour after eating Moderate B It is recommended that nutritional supplementation be given in patients with malnutrition or inadequate nutrition Moderate A It is recommended that dental prostheses, if used, are readily available and easily accessible Moderate A.

Pressure ulcers Statement Quality of evidence Strength of recommendation Strategies to prevent and treat pressure injuries are recommended in patients at risk Moderate A. Surgical site infections Statement Quality of evidence Strength of recommendation We recommend guideline-consistent antimicrobial prophylaxis in older patients, considering antibiotic pharmacodynamics and pharmacokinetics to avoid overdoses and drug-related adverse events Moderate A.

Conclusions These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of surgeons, anesthetists, geriatricians, and other specialists and health care professionals. Acknowledgements The authors would like to thank Dr. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest.

Footnotes Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Demographic Indicators Estimates for the year Accessed 26 Feb Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice. Int Orthop.

Grade definitions. Bettelli G. Preoperative evaluation of the elderly surgical patient and anesthesia challenges in the XXI century. Rubenstein LZ. Joseph T. Freeman award lecture: comprehensive geriatric assessment: from miracle to reality. Geriatric assessment in surgical oncology: a systematic review. J Surg Res. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review.

Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. Three decades of comprehensive geriatric assessment: evidence coming from different healthcare settings and specific clinical conditions. J Am Med Dir Assoc. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.

The place of frailty and vulnerability in the surgical risk assessment: should we move from complexity to simplicity? Peri-operative optimisation of elderly and frail patients: a narrative review. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.

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