Perioperative Care of Elderly Patients

Equipment needed: Timer and chair

Directions: Patients wear their regular footwear and can use a walking aid if needed

Begin by having the patient sit back in a standard armchair and identify a line 10 feet away on the floor

Instructions to the patient: When I say “go,” I want you to:

1. Stand up from the chair

2. Walk to the line on the floor at your normal pace

3. Turn

4. Walk back to the chair at your normal pace

5. Sit down again

On the word “go” begin timing

Stop timing after patient has sat back down and record the time: ______ seconds

Interpretation: ≤10 s, fast

11–14 s, intermediate

≥15 s, slow (associated with increased postoperative complications and increased 1-year mortality)

Adapted with permission by [4]

Table 40.2

Tools to measure frailty

Method of measuring frailty	Impact of frailty on surgical outcome	Surgical population studied	Authors
Grip strength	Increased postoperative complications and increased LOS	All ages Elective major abdominal surgery	Klidjian et al. [15]
Timed Up and Go	Increased postoperative complications and 1-year mortality	Elective colorectal and cardiac ≥65 years old	Robinson et al. [4]
7 frailty traits Timed get Up and Go ≥ 15 s Katz score ≤ 5 Mini-Cog ≤ 3 Charlson index ≥ 3 Hct < 35 % Albumin < 3.4 Falls score > 1	Increased postoperative complications, increased LOS, higher 30-day readmission rates	Elective colorectal or cardiac surgery	Robinson et al. [6]
Edmonton Frail Scale Cognition General health Functional independence Social support Medication use Nutrition Mood Continence Functional performance	Increased postoperative complications, prolonged LOS, increased institutionalization rate	≥70 years old Lower limb orthopedic surgery Spinal surgery Abdominal surgery Vascular surgery	Dasgupta et al. [16]
Fried criteria Weight loss Decreased grip strength (weakness) Exhaustion Low physical activity Slowed walking speed	Increased postoperative complications, prolonged LOS, new institutionalization at discharge	≥65 years old Elective surgery (major and minor)	Makary et al. [5]

Adapted with permission from Oxford University Press on behalf of the British Geriatrics Society [2]

Preoperative History and Physical Examination

In addition to the standard preoperative evaluation, attention should be given to the following issues:

History of surgical or anesthetic complications
Identifying patients with likely diastolic dysfunction from echocardiography or a history of “heart failure” after surgery
Nutritional status—calculate body mass index (BMI) and document unintended weight loss > 10–15 % within 6 months (see Chap. 41)
Functional capacity and performance status: consider quantification via the TUG if patient is mobile; document deficits in vision, hearing, or swallowing; document history of falls (“Have you fallen in the past year?”) [7]
Cognitive function: if suspicious of poor baseline cognitive function, perform Mini-Cog screen (Table 40.2) [7]
Frailty: among patients with multiple chronic diseases, consider additional quantification of functional impairment using a frailty assessment tool such as the Fried criteria (Table 40.3)
Identifying alcohol and substance use: among patients 65 years or older, the prevalence of binge drinking is as high as 14.5 % among men and 3.3 % among women [8].
Use of multiple psychoactive medications.

Table 40.3

Mini-Cog screen: 3-item recall and clock draw

1. Get the patient’s attention and then say:

“I am going to say three words that I want you to remember now and later. The words are:

Banana Sunrise Chair

Please say them for me now.”

Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item

2. Say all the following phrases in this order:

“Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in the circle and set the hands to show 11:10 (10 past 11).”

If the subject has not finished clock drawing in 3 min, discontinue and ask for recall items

3. Say: “What were those three words I asked you to remember?”

Scoring:

3-item recall (0–3 points): 1 point for each correct word

Clock draw (0 or 2 points): 0 points for abnormal clock^a

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