Is there a specific risk score tool for preoperative risk assessment in geriatric patients?

Preoperative Risk Assessment Tools for Geriatric Patients

The Association of Anaesthetists of Great Britain and Ireland recommends a structured multifactorial approach for preoperative risk assessment in geriatric patients, with frailty assessment using validated tools being particularly important for patients over 70 years of age. 1

Recommended Risk Assessment Tools for Geriatric Patients

Primary Tools for Geriatric-Specific Assessment:

1. Frailty Assessment:

   • Mandatory for all patients >70 years using validated tools 1
   • Options include:
     • Clinical Frailty Scale
     • Edmonton Frail Scale
     • Fried Frailty Phenotype

2. Functional Status Evaluation:

   • Two-flight of stairs test or Duke Activity Status Index (DASI) 1
   • Katz Score for functional dependence 2

3. Cognitive Assessment:

   • Mini-Cog Test 2
   • Assessment for delirium risk factors

4. Comprehensive Geriatric Assessment (CGA):

   • Shown to reduce postoperative complications in elderly patients 3
   • Should be performed by senior geriatrician and anesthetist with geriatric training 1

Enhanced Risk Calculators:

1. ACS NSQIP Surgical Risk Calculator with Geriatric Modifications:

   • Standard calculator enhanced with geriatric-specific variables 4
   • Additional geriatric risk factors that improve prediction:
     • Living situation
     • Fall history (within past 6 months)
     • Mobility aid use
     • Cognitive impairment
     • Surrogate-signed consent
     • Palliative care status

2. Robinson's Preoperative Assessment:

   • Includes 6 geriatric-specific markers 2:
     • Cognitive impairment
     • Recent falls
     • Albumin level
     • Hematocrit (anemia)
     • Functional dependence
     • Comorbidity burden (Charlson Index)
   • ≥4 markers predicts 6-month mortality with 81% sensitivity and 86% specificity

Essential Laboratory and Diagnostic Components

• Basic Assessment:

  • Vital signs and cardiac physical examination (within 2 hours preoperatively) 1
  • ECG for all intermediate and high-risk geriatric patients 1

• Laboratory Tests:

  • Full blood count and renal function 1
  • Coagulation profile (prothrombin time, platelet count) 1
  • Albumin level (predictor of poor outcomes) 2
  • Cardiac biomarkers (troponin) for high-risk cases 1, 5

• Advanced Testing:

  • Echocardiography for high-risk patients undergoing high-risk surgery 1
  • Consider biomarker panel (hsCRP, H-FABP) to enhance risk prediction 5

Implementation Considerations

• The presence of ≥4 geriatric risk markers significantly increases 6-month mortality risk 2
• Functional dependence is the strongest predictor of 6-month mortality (odds ratio 13.9) 2
• Standard risk calculators (like ACS NSQIP) may underestimate complications in geriatric patients without geriatric-specific modifications 6
• Combining risk calculators with cardiac biomarkers can improve prediction accuracy 5

Pitfalls to Avoid

• Relying solely on traditional risk assessment tools without geriatric-specific components
• Overlooking frailty assessment in patients >70 years
• Delaying urgent surgeries for excessive optimization 1
• Conducting routine laboratory tests without clinical indication 7
• Using the standard ACS NSQIP calculator without geriatric modifications for elderly patients 4, 6

By implementing these geriatric-specific risk assessment tools, clinicians can better predict postoperative complications, mortality, and quality of life outcomes in elderly surgical patients, allowing for more informed decision-making and targeted perioperative care.