What are the guidelines for pre and perioperative evaluation of geriatric patients, including tools and medications to be used for assessment?

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Last updated: November 25, 2025 • View editorial policy

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Guidelines for Pre and Perioperative Evaluation of Geriatric Patients

Core Recommendation

All geriatric patients aged 65 years and older undergoing surgery must receive a validated, multidimensional frailty assessment during preoperative evaluation, followed by comprehensive geriatric assessment (CGA) for those who screen positive, with early multidisciplinary team involvement throughout the perioperative period. 1

Preoperative Assessment Framework

Mandatory Frailty Screening

  • Perform frailty screening on all patients ≥65 years as part of routine preoperative functional status evaluation 1
  • Use validated multidimensional frailty instruments (not single-domain tools) for assessment 1
  • Frailty assessment provides unique prognostic information beyond traditional risk stratification and is feasible in clinical practice 1

Comprehensive Geriatric Assessment (CGA)

Trigger CGA for any positive frailty screen 1

The CGA must evaluate these specific domains 1, 2:

  • Cognitive function: Screen for baseline impairment and delirium risk using validated tools (Montreal Cognitive Assessment recommended) 1, 3
  • Functional status: Assess activities of daily living (ADLs) and instrumental ADLs using standardized scales (Nottingham Extended Activities of Daily Living) 1, 3
  • Nutritional status: Evaluate for malnutrition, provide supplementation at least 28 days before elective surgery for nutritional deficiencies (iron, vitamin B12, folate) 1
  • Polypharmacy: Optimize medications using the START/STOPP tool 1
  • Comorbidity burden: Assess and optimize organ-specific conditions (diabetes, cardiorespiratory disease, anemia) 1
  • Sarcopenia: Evaluate muscle mass, strength, and function as precursor to frailty 2
  • Social support: Identify caregivers and establish decision-making capacity 1, 2

Risk Stratification Beyond ASA Classification

  • Do not rely solely on ASA Physical Status classification for geriatric patients, as it does not predict 6-month mortality in older adults 4
  • CGA deficit scores are strongly associated with postoperative mortality, while ASA classification is not 4
  • Emergency surgery carries significantly higher risk than elective procedures in older adults 1, 2

Specific Assessment Tools

Validated Instruments to Use

  • Frailty assessment: Multidimensional validated scales (specific tool selection based on institutional capacity) 1
  • Cognitive screening: Montreal Cognitive Assessment (MoCA) 3
  • Functional assessment: Nottingham Extended Activities of Daily Living scale 3
  • Frailty quantification: Edmonton Frail Scale 3
  • Hip fracture patients: Nottingham Hip Fracture Score 1
  • Medication optimization: START/STOPP criteria 1

Delirium Risk Assessment

Begin delirium risk stratification preoperatively 1

High-risk features include:

  • Advanced age (very old)
  • Frailty
  • Cognitive impairment
  • Cerebrovascular disease
  • Multimorbidity/polypharmacy 1

Communicate identified risk throughout the multidisciplinary team for multimodal preventive interventions 1

Preoperative Optimization

Critical Optimization Targets

Balance optimization against surgical delay - for hip fractures and emergency laparotomy, optimize simultaneously with surgery rather than consecutively 1

Focus on these specific interventions 1, 3:

  1. Ischemia prevention:

    • Reduce oxygen uptake: analgesia, thermoregulation, antibiotics
    • Improve oxygen delivery: supplemental oxygen, fluid optimization, medication review
    • Avoid hypotension and severe anemia 1

  2. Medication management:

    • Modify long-term condition medications (expected in 75% of patients) 3
    • Address polypharmacy using START/STOPP criteria 1
    • Avoid extending polypharmacy unnecessarily 1

  3. Nutritional optimization:

    • Provide oral supplementation for poor appetite
    • Correct subclinical nutritional anemia (iron, B12, folate) at least 28 days before elective orthopedic surgery 1
    • Avoid prolonged preoperative fasting 1

  4. Functional optimization:

    • Provide multimodal prehabilitation education (physical, lifestyle, psychological) 1
    • Deliver therapy interventions (expected in 23% of patients) 3

  5. Diabetes management:

    • Create individualized diabetic plan
    • Consider pre-admission support
    • Document plan on admission 1

Multidisciplinary Team Involvement

Engage multidisciplinary teams early in assessment and maintain daily communication throughout perioperative care 1

Team Composition and Roles

  • Senior geriatrician and senior anesthetist with geriatric subspecialty training should assess higher-risk elderly patients 1
  • Include physical therapists, occupational therapists, nurses, speech-language pathologists, dietitians, pharmacists as needed 5
  • Involve family members/caregivers, especially for cognitive or mood concerns 5

Shared Decision-Making

Initiate shared decision-making upon contemplation of surgery 1

Discuss:

  • Short- and long-term risks and benefits of the specific procedure
  • Alternative procedures
  • Conservative therapy (no surgery)
  • Impact on remaining quantity and quality of life 2
  • Postoperative support intensity and end-of-life care preferences 2

Establish early who will be involved in medical decision-making and provide support 1

Decision-Making Capacity and Legal Considerations

Capacity Assessment

  • All personnel must be aware of duties under mental capacity laws 2
  • Use the standard: "what a reasonable patient in the patient's circumstances might want to know" 2
  • For patients without capacity, make decisions considering patient's known expectations, wishes, and family/caregiver input 2

Critical Illness Decisions

For critically ill patients, involve experienced surgeons, anesthetists, intensivists, geriatricians, and family members/caregivers in decisions about intervention degree and suitability 2

Mandatory Commitments

  • Do not perform high-risk surgery without preoperative commitment to adequate postoperative care 2
  • Ensure experienced personnel available at all times for anesthesia, surgery, and postoperative care organization 2

Intraoperative Management

Temperature Control

Maintain normothermia aggressively - perioperative hypothermia is common in older adults and associated with delirium, cardiac dysfunction, prolonged hospital stay, and poor wound healing 1, 2

Ensure mean arterial pressure (MAP) within 20% of preoperative baseline 1

Urinary Catheter Management

Limit urinary catheter use in patients with frailty (strong evidence) 1

Patient Dignity and Preparation

  • Allow additional time for older adults to prepare for surgery 2
  • Keep functional aids (glasses, hearing aids, dentures) in place until just before anesthesia induction 2
  • Use strategies when moving/positioning to protect musculoskeletal and integumentary systems 1

Surgical Communication

Senior multidisciplinary communication about the surgical intervention is mandatory before and during surgery 2

Anesthetists should confirm:

  • Exact proposed procedure
  • Appropriateness for patient's pathophysiological state 2

Perioperative Analgesia

Individualize perioperative analgesia using validated pain assessment tools 1

  • Involve multidisciplinary team in pain management
  • Attempt to limit opioid and NSAID use 1

Postoperative Care

Enhanced Recovery Programs

Adhere to Enhanced Recovery After Surgery (ERAS) protocols 1

Specific Monitoring Targets

  • Hemoglobin levels: Maintain above approximately 90 g/L in older surgical patients with frailty 1
  • Blood glucose: Target 7.8-10 mmol/L in diabetic patients with frailty, monitor associated complications 1

Sensory and Cognitive Support

Ensure appropriate aids and strategies throughout all perioperative phases for patients with physical, sensory, or cognitive impairments 1

Admission and Discharge Planning

Begin admission and discharge planning in the preoperative period through collaboration with various services involved in patient care 1

Emergency Surgery Considerations

Specific Actions

  • Obtain collateral history from family/caregivers 1
  • Be aware of atypical presentations in frail older adults 1
  • Assess and manage hypothermia during ambulance transit 1
  • Recognize that optimization and surgery must occur simultaneously, not consecutively 1

Common Pitfalls to Avoid

  1. Do not delay emergency surgery for optimization - this worsens outcomes in hip fractures and emergency laparotomy 1
  2. Do not rely on ASA classification alone - it fails to predict mortality in geriatric patients 4
  3. Do not over-investigate or extend polypharmacy unnecessarily when managing comorbidities 1
  4. Do not proceed with high-risk surgery without secured postoperative care commitment 2
  5. Do not use single-domain frailty tools - multidimensional validated instruments are required 1

Expected Intervention Burden

Based on CGA implementation data, expect 3:

  • Median of 9 interventions per patient (range 0-28)
  • Long-term medication changes in 75% of patients
  • Lifestyle advice in 54% of patients
  • Therapy interventions in 23% of patients
  • Shared decision-making documentation in 99% of patients
  • Individualized admission plans in 96% of patients
  • 15% of patients may not proceed to surgery after CGA

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Perioperative Care of the Geriatric Patient

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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