Of all the postoperative complications in the older adults, delirium is the one that is the most challenging and requires the most input for all of the team members to prevent and manage. The prevalence o f postoperative delirium ranges from 9% to 44% depending on the patient population [72]. Thirty to forty percent of postoperative delirium episodes are thought to be preventable [73]. Patients who develop delirium after undergoing elective surgery have been found to have a significantly increased risk of an institutional discharge, prolonged hospitalization, readmission, and death [72].

Factors associated with delirium can be thought of as predisposing (i.e., patient risk factors) and precipitating. The predisposing factors should be determined in the preoperative assessment (see above), and a plan should be in place to mitigate the impact of these risk factors. Precipitating factors include those related to the physiologic insult of surgery, metabolic derangement, infection, inappropriate medications, use of tethers, unfamiliar environment, disturbance of bowel or bladder function, under or over treated pain, or a combination of these factors. When delirium occurs in the postoperative period, it is essential to make a careful search for the precipitating factors and promptly address them.

The initial treatment of delirium is based on removing precipitating factors where possible (i.e., stopping inappropriate medications) and instituting a multicomponent, multidisciplinary nonpharmacological strategy [58], which includes interventions such as:

Pharmacologic treatment with antipsychotic medication (i.e., Haldol) and the use of physical restraints should be reserved only for situations where other interventions have failed and the patient is in danger of harming themselves or others. When physical restraints are required, a plan must be in place to provide frequent reassessment of the need and to assist with nutrition, hydration, personal hygiene, and toileting [74].

As mentioned above, older adults are at increased risk of other serious complications including functional decline and deconditioning, poor nutrition and aspiration, falls, UTI, and pressure ulcers [37, 75]. In this context, input from all of the members of the team is required to provide safe high-quality care. Several models of interdisciplinary care have been developed, tested, and shown to improve care for older adults hospitalized for a variety of conditions, including surgery. For the most part, each model uses the same principles which include multidisciplinary participation, appropriate preoperative evaluation/screening, and standardized geriatric care with interventions based on baseline deficits or those developed during the perioperative period. Clear communication strategies among members of the multidisciplinary team have been identified as an essential component of these models of care [76]. As with any other intervention in healthcare, appropriate implementation of proven practices is critical to obtaining improved results. As such, multidimensional elder care “programs” have been shown to be more effective than any given isolated intervention [37, 76, 77].

The vast majority of data evaluating different acute care models for the geriatric surgical patient originate from studies of older adults undergoing orthopedic procedures, in particular hip fractures. As such the data is limited by both the specific population included (typically frail and vulnerable to other geriatric conditions) and the specific surgical procedure. Nevertheless, the different models provide frameworks through which geriatric surgical care can be improved and optimized in a given clinical surgical practice.

As previously discussed, geriatric patients more often require post-acute care prior to returning to their home environment. The transition of care from one phase to another can be a challenging and fragmented process for patients and families [89]. The incidence of readmission following surgery can be up to 20%; many of these represent failures in regaining independence and the ability to return to their baseline state [90]. Additionally, the burden of post-acute care in costs to the patients and the healthcare system is significant. It is among the fastest growing cost in Medicare expenses, representing close to $62 billion annually [4]. There are two well-described models to improve the transition of care, the patient-centered medical home and the transitional care models, both of which have been shown to improve outcomes for older adult patients with multiple comorbidities [91–95]. The patient-centered medical home model works to improve access and coordination of services through a team-based approach achieved through community engagement [93]. The transitional care model centers around an acute hospitalization, where an advanced practice nurse leads a multidisciplinary effort to coordinate the patient’s care from the hospital to the home and has been shown to decrease resource use in cognitively impaired older adults [93]. Patient navigation is a care model with many similarities to the transitional care model, which utilizes trained external coaches or support personnel in a similar fashion, assisting high-risk individuals through the healthcare process and improving their communication with providers and understanding of treatment decisions [96].

As opposed to the young healthy patient who recovers from an uneventful operation, the older adult patient often requires ongoing care even in the absence of complications or geriatric syndromes. The coordination of care during these transitions is essential to prevent readmissions and hasten recovery. The geriatric surgical team must facilitate this process by providing care for any new complications, providing a strategy to prevent functional and cognitive decline, reinitiating presurgical care processes, and communicating effectively with primary care providers. Key components of any given transitional care model include appropriate communication/coordination with the patient’s providers, engagement of family/caregivers, sharing of necessary medical information (medical record), post-discharge follow-up, medication management, education of warning signs specific to each individual patient/procedure, and clarification of ongoing care [6].

Using this framework, the ACS and the John A. Hartford Foundation have partnered to develop a formal geriatric surgery quality improvement program, similar to the other ACS quality verification programs. This project, the Coalition for Quality in Geriatric Surgery (CQGS ), brings together 59 national stakeholder organizations, representing surgical, medical and nursing specialists, allied health professionals, social workers, insurers, regulators, and most importantly patients and families to develop a formal program to improve the quality of care for geriatric surgical patients. The coalition will define the standards, processes, resources, and infrastructure necessary to provide high-quality, patient-focused care. Quality geriatric surgical care is built on an interdisciplinary perioperative team that can meet these standards, measure outcomes that matter to the patient, and use the data to continue the cycle of quality improvement. The standards will be based on peer-reviewed evidence and expert consensus opinion. They will include the patient goal-centered consent process, pertinent screening exams, perioperative management strategies, and the team leadership structure that will allow the system to flourish. Meeting the standards consistently requires a multidisciplinary team approach. The infrastructure in place must assure that the standards are met for every patient and are protected from system and human error.

As mentioned above, surgical outcomes usually focus on mortality and morbidity, but older adults are also at risk for functional decline and loss of independence. Factors contributing to these later outcomes, or identifying patients are risk for them, are not routinely measured. To address this gap, the Geriatric Surgery Task Force of the ACS began a Geriatric Surgery Pilot in 2014 to collect geriatric relevant variables in a subset of 23 ACS-NSQIP hospitals across the USA and Canada. Preoperative risk factors and outcomes data were and still are being collected on surgical patients over the age of 65, specifically addressing issues that are important to the geriatric patient (see Table 7.3) [52]. Analysis of this unique data set will allow for the implementation and subsequent measurement of interventions designed to reduce risk and improve outcomes for the geriatric patient population. To learn more about the CQGS program and the Geriatric Surgery Pilot, visit https://​www.​facs.​org/​quality-programs/​geriatric-coalition.