Geriatricians are originally trained in family medicine or internal medicine and are able to evaluate chronic medical conditions that are prevalent in older adults such as heart failure, diabetes, or chronic kidney disease. Geriatricians will also routinely assess patients in terms of functional status and identify geriatric syndromes (see below) that may impede maximal functional abilities. Studies have shown an association between functional dependence and mortality after surgery [4–6]. Functional status is one of the most important predictors of outcomes after anesthesia. In general, low levels of function and functional dependence were associated with postoperative complications and operative mortality.

The geriatric assessment extends beyond the traditional medical evaluation and management of medial illnesses . It involves an evaluation of issues including physical, cognitive, affective, social, environmental, and spiritual aspects that may have a great impact on older adult’s life. The goal of such an assessment is to delay the onset of functional impairment while maintaining the highest level of independence, autonomy, and quality of life possible over a patient’s life course.

The comprehensive geriatric assessment (CGA ) is a tool that is familiar to all geriatricians. It is an evaluation and diagnostic framework that aims to maximize function by identifying common conditions such as geriatric syndromes and issues that reduce quality of life. Table 8.2 captures the core aspects of almost all CGAs. CGAs may vary by having additional components in the assessment.

The use of CGAs in community-dwelling older adults guides management that in turn results in a decrease in mortality and a reduction in functional decline [7, 8]. However, there is significant variability in the implementation of CGAs in the outpatient environment. Positive results come from programs where a greater number of recommendations are implemented compared to those where there is limited or no implementation of recommendations [9]. In hospitalized older adults, care that is based on CGAs provided more consistent benefits in comparison to standard medical care. A Cochrane Review shows subjects who received CGA were more likely to be alive and in their own homes throughout the surveillance period (median 12 months). Hospitalized subjects who received CGAs were also less likely to be institutionalized, were less likely to suffer death or deterioration, and were more likely to experience improved cognition compared to the usual care group. These effects are consistently demonstrated from trials of geriatric wards (patients admitted directly to the specialist geriatric team) but not replicated in trials of geriatric consultation teams where the geriatric team passes on their recommendations to the primary team and may or may not be involved in delivering direct care [10]. Again, trials showing the most clinically and statistically significant improvement in mortality and functional decline are where recommendations are implemented.

Figure 8.1 illustrates the concept of maximizing function and using aspects of the CGA to achieve that goal. Over time older adults will experience a decline in function due to physiologic changes and conditions that are prevalent among older adults. Many of these changes and conditions are chronic, and cure is not possible. However, mitigating the impact of each condition may be enough to maintain one’s level of function above the threshold of losing independence .

Geriatric syndromes are multifactorial health conditions that occur when the accumulated effect of impairments in multiple different systems renders an older adult vulnerable to situational challenges [11]. These situational challenges can be a change in an environment such as a hospitalization or an acute exacerbation of a chronic medical condition.

A key aspect of geriatric syndromes is that underlying risk factors often overlap with other fields of medicine (e.g., physical therapy or occupational therapy ) because the syndrome is impacted by different physiologic systems. An example of a geriatric syndrome is falls. It is easy to imagine how the decline illustrated in Fig. 8.1 could contribute to falls. Assessment of physical deconditioning, cognition, the physical home environment, medications, and social support all involves different systems and assessment from different specialties. Intrinsic and extrinsic risk factors are identified with the goal of mitigating each risk factor’s impact on the geriatric syndrome. Risk factors are often not reduced to zero, but its impact on overall function can be lessened where the cumulative effects have a significant positive impact similar to what is illustrated in Fig. 8.1, Panel b.

Delirium can be used to exemplify this above concept. Delirium occurs not uncommonly in hospitalized older adults and often has multifactorial causality. The Hospital Elder Life Program (HELP ) is a multifaceted nonpharmacologic intervention that addresses some of the risk factors that contribute to developing delirium. Table 8.3 outlines HELP’s interventions. The HELP interventions have been shown to reduce delirium [12]. More importantly, HELP has been shown to be dose dependent [13]. The more the risk factors mitigated, the better the results.

In 2012, the American College of Surgeons (ACS) NSQIP and the American Geriatrics Society (AGS) published “Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practice Guidelines.” The preoperative domains addressed were those most likely to affect the elderly, including cognition, frailty, polypharmacy, nutrition, and social support [14]. In the following sections, we will be addressing these areas from a geriatrician’s perspective.

Many aspects of the geriatric functional assessment require multidisciplinary input. The CGA as outlined above is an inherently multidisciplinary diagnostic and treatment process. The geriatrician identifies the need for mitigating the risk factor’s impact on functional decline but then recruits the necessary discipline to evaluate and recommend a treatment course that is integrated into a patient-centered care plan.

Another central task of geriatricians is to coordinate care among several subspecialists and to define, sustain, and communicate clear goals of treatment to all providers involved. In addition to coordinating subspecialist providers, geriatricians must generally work in multidisciplinary teams. Their training and clinical practice often includes long-term care, rehabilitation, and hospice facilities where there is daily side-by-side collaborative care in furthering the patients’ goals. Geriatricians’ collaborative care coordination among family members, nurses, nurse practitioners, therapists, aides, social workers, and others is a particular skill that is not usually taught in physician training. When a patient depends on others, the patient’s physician should have a working knowledge of who is providing that help. In fact, most older adults depend on many individuals to maintain function and independence. The decisions as to whether an older adult should live at home alone, drive independently, or proceed with surgery with anticipated postoperative rehabilitation all can be improved by multidisciplinary input.

It is important to ensure that the patient’s goals for care and expectations are in line with anticipated outcomes prior to both elective and nonelective surgical procedures in older adults. The surgical intervention is only the beginning of a longer course to recovery for many older adults. Approximately 65% of Medicare patients who had a lower-extremity joint replacement surgery required stays in either a skilled nursing facility or inpatient rehab after surgery [15]. Incorporating discussions about the typical clinical course after surgery should be an important part of informed consent for surgery. A priority should be placed on understanding the patient’s goals and expectations for surgery.

The concept of lag time to benefit is helpful when thinking about goals of care for older adults [16]. Lag time to benefit refers to the time between the intervention (in this case surgery) and when positive health outcomes are received (e.g., improvement in mobility, cure from cancer, prevention of repeated bouts of cholecystitis). In other words, lag time to benefit addresses the question “when will it help my patient?” The model was originally intended for decisions of outpatient preventive interventions, such as cancer screening, but can be adopted for decisions regarding surgical interventions. One would expect that most surgical interventions have an immediate benefit. However, when extensive rehabilitation is required before the primary goal is achieved (e.g., improved function), surgery may not be the ideal solution.

Figure 8.2 illustrates a stepwise approach in helping to determine the benefits of offering interventions in older adults. This model incorporates life expectancy, the lag time to benefit, and patient preferences. It is important to elicit your patient’s preferences whenever you are delivering care and is most essential when the risks and benefits for a particular intervention are not straightforward.

It can be difficult to estimate life expectancy . Although age is an important factor in life expectancy, it is not the only predictor. At any given age, an older adult’s life expectancy may be shortened by comorbidities or decreased functional status (i.e., dependence for activities of daily living) [17]. Life expectancy is also shortened by the presence of frailty. Although most clinicians will have a general clinical gestalt about any given individual’s life expectancy, incorporating different mortality models based on demographic variables can provide for a more standardized discussion based on evidence. Many models exist that attempt to prognosticate mortality and life expectancy. These models differ in the cohorts that generate the data for their modeling and range from community-dwelling to hospice cohorts and have variable time frames (months to a decade). ePrognosis (Fig. 8.3) is an application that incorporates many of these models into a simplified step-by-step process in estimating mortality [18, 19]. By inputting patient demographic variables, one can get an estimate of mortality risk for patients in the realm of days to years based on location of care and other patient-specific factors.

Avoiding chronic debility, morbidity, and poor quality of life is often more important to older adults than staying alive. Understanding the patients’ hierarchy of what is important in their lives and their goals is a key component of shared decision-making in medicine and not solely regarding surgery. If a patient is not willing to live in a skilled nursing facility, even for a short period of time, it may not be helpful to have them undergo an elective procedure such as posterior spinal fusion that might require such a stay. Alternately, delineating that the patient highly values independence may lead one to recommend such a procedure that could improve their mobility and ability to participate in self-care for the long term. If a patients’ main goal is quality of life or comfort, then their acceptance of risk of discomfort or complications from a procedure with a lower potential to add quality years would be lower.

To find out a patient’s preferences , one can simply start by asking the patient the following question: Is one of the following goals more important to you than anything else: (1) Living as long as possible? (2) Keeping your ability to care for yourself and live independently? (3) Keeping comfortable, with minimal symptoms? If the discussion is not straightforward, consultation with a palliative medicine specialist, a geriatrician, or a provider who either has a strong rapport with the patient or with experience in goals of care discussions can be helpful [21].

An important part of the discussion of potential treatments is letting patients know what the potential next steps are and expected outcomes after a procedure, including recovery time in the hospital, estimated time in a rehabilitation facility, and frequency and timing of follow-up. Hospitalizations itself is commonly associated with functional loss in older adults . Hospitalization-associated disability is the loss of the ability to perform one of the basic activities of daily living (ADLs) and occurs between the onset of the acute hospitalization and discharge from the hospital [22]. Declines in ability to perform ADLs and mobility after hospitalization are common [23–27]. Age is the most important risk factor [28]. Thirty-five percent of patients declined in ADL function between baseline and hospital discharge in a prospective observational study of nearly 3000 patients aged 70 and older (mean age of 80) hospitalized to medical services. This rate of functional decline had a striking relationship with age, with rates exceeding 50% in patients aged 85 and older [28]. Similarly, in another prospective observational study in medical patients involving over 2000 patients, 40% of older adults continued to have a new or additional disability in ADL at 3 months post discharge compared to prior to admission. At 1 year, nearly a third of patients still had not recovered their prior function [23].

Striking reductions in mobility after hospitalizations for older adults are also seen. Nearly 500 hospitalized medical patients aged 70 and older followed prospectively showed that low mobility and bed rest were common [24]. Using average mobility level, scored from 0 to 12, the low mobility group was defined as having a score of 4 or less, high as higher than 8, and bed rest was assigned a score of 0. Complete bed rest episodes occurred 33% of patients. The development of new functional decline, becoming newly institutionalized, and having in-hospital death were all shown to have an inverse relationship with the initial level of mobility. In other words, the lower one’s mobility, the worse the outcomes.

Similar results were shown in a separate observational prospective study involving nearly 700 community-dwelling 65 years or older surgical and nonsurgical patients . On average, patients hospitalized for any reason experience decline in mobility [25]. Patients with a nonsurgical admission had little to no recovery of mobility to their baseline even after 2 years. Interestingly, surgical patients had better mobility before admission and recovered to at least their preadmission mobility within a year of hospitalization. The authors speculated that preoperative screening helped to determine the best candidates for surgical procedures.

Sager et al. developed a simple instrument to help identify patients at risk of functional decline following hospitalization. The Hospital Admission Risk Profile (HARP ) was developed and validated in two separate cohorts from four university and two private nonfederal acute care hospitals [29]. Using logistic regression analysis, the authors identified increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL were independent predictors of functional decline. A scoring system was developed for each predictor variable, and patients were assigned to low-, intermediate-, and high-risk categories (Table 8.4). The HARP reinforces the value of identifying prior cognitive function and physical function as markers of posthospitalization outcomes. Other authors have also demonstrated that including information from short multidimensional prognostic assessments identifies older adults most likely to develop hospitalization-associated disability [30, 31].

There are multiple other tools available to assess for functional status. As recommended by the American College of Surgery/American Geriatric Society Guidelines, one can quickly screen for functional status at baseline [14]. One can ask patients these four screening questions:

Deficits in any of these areas should prompt a more in-depth look at functional status and involvement of physical and occupation therapy as well as a geriatrician to further assess for reversible factors and help assess expected trajectory after surgery. A number of interventions have been implemented to reduce the incidence of hospitalization-associated disability. Many of these interventions are multidimensional addressing cognitive function, sensory impairment, mobility, nutrition and hydration, and limiting iatrogenesis [32].

Cognitive impairment is common among older adults and includes both dementia and mild cognitive impairment . The prevalence of dementia increases with age. In persons 71–79 years old, the prevalence is 5% and increases to nearly 25% in those 80–89 years old and 37% in those 90 years old and older [33]. Mild cognitive impairment (MCI ) is a state of cognitive function where the impact is not severe enough to interfere with essential daily tasks referred to as instrumental activities of daily living (IADLs) (e.g., medication management and finances). Dementia, however, is severe enough cognitive impairment that it impairs one’s abilities to manage their own IADLs and eventual basic ADLS (e.g., dressing, bathing, etc.). MCI is classified into two subtypes, amnestic and non-amnestic. Amnestic MCI is clinically significant memory impairment that does not meet the criteria for dementia. Non-amnestic MCI is characterized by a decline in function in other non-memory cognitive domains such language or visuospatial skills. The rate of progression of MCI to dementia is uncertain [34]. MCI prevalence widely varies because of differences in the definition of MCI and methods used to determine cognitive impairment and ranges from 3% to 42% in adults 65 years and older [33].

Older adults with cognitive impairment have higher postoperative mortality and are at higher risk of postoperative delirium with potential for chronic impact on cognition and postoperative cognitive dysfunction (Chap. 30, Postoperative Delirium and Cognitive Dysfunction) and institutionalization. A systematic review found that cognitive impairment (defined as a chart diagnosis of dementia) was an independent predictor of postoperative mortality with risk of death ranging from 1.8 to 5.8 times higher compared to those without cognitive impairment [21]. Delirium risk in those who are cognitively impaired increases by two- to seventeen-fold, and the risk of nursing home placement on discharge doubles in comparison to those who are cognitively intact [21]. A discussion of the increased risk of delirium , discharge to a skilled nursing facility, and mortality should be included as part informed decision-making for patients with cognitive impairment and their families.

Screening for baseline cognitive impairment can help identify individuals whom collateral informants are needed to ensure accurate history of medical history and medication list. A validated quick screening tool for cognitive impairment is the Mini-Cog [35]. This tool involves a three item recall and a clock draw (Fig. 8.4). Another useful validated clinical tool is the Ascertain Dementia 8-item Informant Questionnaire (AD8 ). The AD8 can be used in a questionnaire form and is filled out by informants rather than the patient [36]. The AD8 can be particularly helpful in seeking corroborative history for dementia and can be used clinically over the phone when informants may not be present. Those who have a history of cognitive impairment or a suspicion after screening should have collateral informants involved and strong consideration for referral to a geriatrician or other providers who can further assess their cognitive impairment.

Identification of preexisting cognitive impairment is not only important because it increases the awareness of postoperative delirium risk but also because the multicomponent nonpharmacologic interventions such as the Hospital Elder Life Program (HELP ) have the strongest evidence for preventing delirium. The strength of the evidence of multicomponent nonpharmacologic interventions for management of delirium is lower [37]. Nevertheless, multicomponent nonpharmacologic interventions are an integral part of caring for a patient at risk for delirium. HELP (Table 8.3) reduced the incidence of delirium in hospitalized medical older adult patients (mean age 80 year old) by 5% compared to those who received usual care. The number needed to treat is 20. The multicomponent nonpharmacologic interventions reduced the total number of days with delirium and the total number of episodes of delirium [12]. However, once an initial episode of delirium had occurred, the intervention had no significant effect on the severity of delirium or on the likelihood of recurrence placing emphasis on the importance of identifying those at risk for delirium then implementing preventative nonpharmacologic measures. Perhaps more importantly is that the HELP interventions have been shown to have a dose-response curve. Higher levels of adherence to the interventions resulted in reduced rates of delirium in a directly graded fashion [13].

Falls are common in older adults with one in three older adults falling each year [38]. In the inpatient setting, the rate of falls in older patients is between 3.4 and 5.2 per person year with over half of these falls resulting in serious injury including fracture and head injuries. Risk factors for falls in the inpatient setting include gait instability, agitated confusion (e.g., delirium), urinary incontinence, a history of prior falls, and use of psychotropic medications [39]. Screening for a history of falls and/or performing a mobility assessment such as the Timed Up and Go Test in the outpatient setting may identify older adults at risk for falls in the postoperative period and those who are more likely to be institutionalized after surgery. Screening for falls can be as simple as asking “have you fallen in the past year?” If a yes response is given, the individual is considered at increased risk of falling.

The Timed Up and Go Test (TUGT) is performed by having an older adult stand up from a chair, walk 10 feet, turn around, and return to the seat [40]. If it takes greater than 12 s, the patient is considered at increased risk of falls, and a more comprehensive geriatric assessment prior to elective surgery may be needed. Several small studies have found having an abnormal preoperative TUGT to be associated with an increase in postoperative institutionalization, length of stay, postsurgical complications, and one-year mortality [41, 42]. Inpatient care providers should be made aware in advance of those who are at increased risk of falls, so preventive strategies can be implemented. Successful strategies for preventing inpatient falls have included patient education and multifactorial interventions (with variation of interventions between studies) that target fall risk factors (e.g., therapy or exercise for decreased mobility, medication review). Further research is needed to elucidate which interventions are most effective.

The elderly are four times as likely as those under 65 years of age to be hospitalized due to a medication mishap [43]. This is in part due to the higher risk of polypharmacy in this population secondary to an increased number of medical conditions and greater number of physicians involved in their care [44]. Polypharmacy has been associated with adverse outcomes including risk of hospitalizations, falls and fall-related injury, weight loss, decline in functional and cognitive status, and mortality [45, 46]. The frequency of these geriatric syndromes as well as risk of adverse drug reaction (ADR) increases in proportion to the number of used medications [47]. In fact, polypharmacy has been recognized as the most important risk factor for an ADR . The risk increases from 13% for a person taking two medicines to 58% and 82% when taking five and seven or more medications, respectively [47–49].

While no consensus definition exists for the term “polypharmacy,” a threshold of five or greater concurrent medications is generally accepted [50–52]. Some studies and authors have tried to be more specific by using the term “inappropriate” polypharmacy when multiple medications are used to treat a single ailment or condition. The lack of consensus in defining polypharmacy has proven problematic when attempting to compare different strategies aimed at reducing medications and their associated clinical endpoints [52].

Believing that a patient is taking too many medicines does not help the clinician know which ones to stop [46]. Medical training often fails to supply providers with adequate knowledge and skills needed to prescribe appropriately to individuals who use multiple medications. As a result, physicians may inadvertently cause drug-drug-related problems. This is especially seen in older adults because of the multiple prescription medications and an inadequate understanding of pharmacology [53].

The term “deprescribing ” has been used to describe the complex process of planned and supervised tapering or ceasing of inappropriate medicines with the goal of managing polypharmacy and improving outcomes (Table 8.5) [54, 55]. This is especially important in the inpatient setting as polypharmacy is a preoperative risk factor for delirium and falls [56]. In addition, patients taking medications unrelated to their surgery are 2.5 more likely to develop postoperative complications [57, 58].