How to assess and risk stratify elderly surgical patients for operative management?

Assessment and Risk Stratification of Elderly Surgical Patients

All elderly surgical patients aged 65 years and older must undergo comprehensive geriatric assessment (CGA) combined with traditional surgical risk scoring to optimize perioperative outcomes and reduce mortality. 1, 2

Initial Risk Stratification Framework

Perioperative risk in elderly patients represents the combined effect of two distinct components: surgical procedure risk and patient-specific risk factors. 1

Surgical Procedure Risk Assessment

• Emergency surgery carries 2-5 times higher mortality risk than elective procedures in elderly patients. 1 Postoperative mortality increases from 1% in patients <60 years to 10% in those >80 years, with emergency procedures showing the steepest gradient. 1

• Classify surgical invasiveness as low-risk (<1% major adverse cardiac events), intermediate-risk, or high-risk based on hemodynamic stress and tissue trauma. 3

• Procedural risk can be modified by selecting less invasive initial operations to permit patient stabilization before definitive surgery, particularly in emergency settings. 1

Patient-Specific Risk Factors

Three independent patient factors drive perioperative risk: age-related physiological decline, multi-morbidity burden, and frailty status. 1, 2

• Physiological reserve decreases approximately 1% per year after age 40, making elderly patients vulnerable to surgical stress. 2

• Do not rely solely on ASA Physical Status classification for elderly patients, as it fails to predict 6-month mortality in this population. 2 The ASA score must be supplemented with geriatric-specific assessments.

• Age alone significantly predicts poor outcomes, but biological age differs from chronological age—a 75-year-old with minimal comorbidities may tolerate surgery better than a frail 68-year-old. 1

Comprehensive Geriatric Assessment Protocol

CGA must evaluate six mandatory domains: cognitive function, functional status, nutritional status, polypharmacy, comorbidity burden, and social support. 2

Cognitive Assessment

• Perform Mini-Mental State Examination (MMSE) preoperatively on all patients ≥65 years. 4 Impaired cognitive function independently predicts postoperative mortality (OR 1.33,95% CI 1.15-4.22). 5

• All patients with low MMSE scores develop postoperative delirium (p=0.0003), making this the strongest predictor of this complication. 4

• Screen for delirium risk using age, ASA physical status >2, and Charlson Comorbidity Index ≥2 as key predictors. 3

Functional Status Assessment

• Measure activities of daily living (ADLs) using the Barthel index. 4 Functional dependency independently predicts postoperative complications (p=0.041) and is the second strongest predictor after cognitive impairment. 6, 5, 4

• Assess functional capacity using the Duke Activity Status Index (DASI), with inability to achieve 4 metabolic equivalents (METs) indicating increased cardiovascular risk. 3

• The cumulative number of CGA domain impairments shows dose-dependent association with adverse outcomes, in-hospital events, and prolonged hospital stays. 6

Frailty Screening

All patients ≥65 years must undergo validated multidimensional frailty screening as part of routine preoperative evaluation. 1, 2, 3

• Frailty provides unique prognostic information beyond traditional risk scores and shows dose-dependent effects on failure-to-rescue rates, postoperative complications, reoperation, and mortality. 1

• Patients over 65 years with positive frailty screens require full CGA by a geriatrician. 1

• Sarcopenia (loss of muscle mass, strength, and function) precedes frailty and represents declining musculoskeletal reserve. 2

Nutritional Assessment

• Evaluate body mass index, arm-muscle circumference, albumin, transferrin, lymphocyte count, and cholinesterase levels. 4

• Poor nutritional status independently predicts adverse outcomes including in-hospital death and post-discharge institutionalization. 6

• Malnutrition increases prolonged air leak risk seven-fold (p=0.045), while obesity increases postoperative infectious disease risk 24-fold (p=0.0013). 4

Comorbidity Assessment

• Higher comorbidity burden independently predicts postoperative morbidity (OR 2.12,95% CI 1.06-4.22). 5

• Evaluate cardiovascular risk factors including unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease, cerebrovascular disease, diabetes mellitus, and renal insufficiency. 3

• Preexisting comorbidities strongly influence resection type (elective versus emergency) and consequently long-term outcomes. 1

Medication Review

• Use START/STOPP criteria for medication optimization and avoid extending polypharmacy unnecessarily. 2

• Document all medications including over-the-counter drugs, as polypharmacy contributes to perioperative risk. 2

Multidisciplinary Team Assessment

Higher-risk elderly patients require preoperative assessment by both a senior geriatrician and a senior anesthetist with geriatric subspecialty training. 1, 2

• Rapid access to geriatricians, anesthetists, intensivists, and surgeons is essential within the emergency department to develop early intervention plans and manage comorbidities. 1

• Early senior decision-making is mandatory to provide appropriate care or palliative management for patients who would not benefit from invasive intervention. 1

• Engage multidisciplinary teams early in assessment and maintain daily communication throughout perioperative care. 2

Risk Prediction Models

Combine traditional surgical risk scores with CGA findings for optimal risk stratification. 5

• Use the Revised Cardiac Risk Index (RCRI) for cardiac risk, assigning 1 point for each of 6 predictors. 3 However, the American College of Surgeons NSQIP perioperative MI and cardiac arrest (MICA) calculator provides superior discrimination. 3

• The best predictive model combines MMSE scores (p=0.031) and Barthel index (p=0.04), with operation time >300 minutes adding strongest effect (p=0.016). 4

• CGA deficit scores show stronger association with postoperative mortality than ASA classification in elderly patients. 2

Preoperative Optimization Strategy

Balance optimization interventions against surgical delay risks, as delays before hip fracture surgery and emergency laparotomy worsen outcomes. 1, 2

Specific Optimization Targets

• Smoking cessation at least 4 weeks before surgery and alcohol abstinence for 4 weeks prior. 3

• Screen and treat undiagnosed hypertension, optimize diabetes management targeting blood glucose 7.8-10 mmol/L in diabetic patients with frailty. 2, 3

• Maintain hemoglobin levels above approximately 90 g/L in older surgical patients with frailty. 2

• Consider perioperative statin therapy for pleiotropic anti-inflammatory effects. 3

• Optimization and surgery should occur simultaneously rather than consecutively in emergency settings. 1

Emergency Surgery Considerations

Emergency elderly surgical patients require modified assessment protocols due to time constraints. 1, 2

• Obtain collateral history from family/caregivers during ambulance transport, documenting pre-morbid physical and cognitive status, medications, and next-of-kin. 1, 2

• Assess and manage hypothermia during ambulance transit, measuring core temperature and actively warming to ~37°C. 1, 2

• Be aware of atypical presentations in frail older adults, as standard clinical presentations may be masked. 2

• Establish intravenous access for fluid resuscitation, balancing hypovolemia correction against fluid overload risks. 1

Evidence-Based Outcomes

CGA reduces mortality in older hip fracture patients (RR 0.85,95% CI 0.68-1.05) and decreases discharge to increased care levels (RR 0.71,95% CI 0.55-0.92). 7

• CGA probably leads to slightly reduced length of stay and slightly reduced total costs. 7

• In elective surgery, carefully selected elderly patients—even those in their 90s—benefit from surgery, with large proportions surviving ≥2 years regardless of age. 1

• For elective surgery, long-term cancer-related and short-term morbidity/mortality outcomes for elderly patients equal those of younger patients when properly selected. 1

Critical Pitfalls to Avoid

• Never ration surgical or critical care based solely on age—biological age and frailty status matter more than chronological age. 1, 2

• Do not delay emergency surgery for optimization—concurrent optimization during surgical preparation is the correct approach. 1

• Avoid underestimating risk in vascular surgery patients, as risk scores show poorer discrimination in this population. 3

• Do not assume mental incapacity—elderly patients should be presumed to have decision-making capacity unless clearly demonstrated otherwise. 1, 2