II. Epidemiology

  1. Patients over age 65 years old undergo 5 million major surgeries each year in the U.S.

III. Evaluation: Is Surgery Indicated?

  1. Assess the Surgical Risks (patients underestimate risks)
    1. See Surgical Risk for Cardiac Event (procedure risk factors)
    2. See Revised Cardiac Risk Index (individual patient risk factors)
    3. Surgical Risk Calculator (ACS NSQIP)
      1. https://riskcalculator.facs.org/RiskCalculator/
  2. Assess the Surgical Benefits (patients overemphasize benefits)
    1. Is the priority extending Life Expectancy at any cost?
      1. Surgery may extend life, but result in Nursing Home Care
    2. Is the priority maintaining functional capacity and independence?
      1. Foregoing surgery may allow for continued status quo function
    3. Would the patient be better served with palliative measures?
  3. Will the patient have adequate Life Expectancy to realize the surgical benefits?
    1. See Comorbidity-Adjusted Life Expectancy
    2. See Four Year Prognostic Index
  4. May life saving measures (Resuscitation, intubation, ventilation)
    1. If DNR status is suspeneded for surgery, when is it to be reinstated?

IV. Evaluation: General

  1. See Preoperative Exam
  2. Cardiac evaluation
    1. See Preoperative Cardiovascular Evaluation
  3. Respiratory evaluation
    1. See Preoperative Respiratory Risk Modification
  4. Medications
    1. See Preoperative Guidelines for Medications Prior to Surgery
    2. See Medication Use in the Elderly
  5. Tobacco Abuse
    1. See Tobacco Cessation
    2. Tobacco use is associated with higher perioperative mortality, worse function, greater complications
  6. Alcohol Abuse and Alcohol Withdrawal risk
    1. See Alcoholism Screening
    2. Abstinence is recommended 4-8 weeks before surgery
    3. Stay alert for perioperative Alcohol Withdrawal
      1. See Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

V. Evaluation: Neurologic Status

  1. Dementia
    1. See Mini-Cognitive Assessment Instrument (screening)
    2. See Saint Louis University Mental Status (SLUMS)
  2. Delirium
    1. See Delirium for risk factors
    2. See Confusion Assessment Method Short Form
    3. Delirium results in greater complications including infections, patient falls and longer hospital stays
    4. Prevention includes keeping eyeglasses and Hearing Aids available to patient and frequent reorientation
    5. Other prevention includes early mobilization after surgery, adequate analgesia, nutrition and hydration
  3. Decision Making Capacity
    1. See Medical Decision-Making Capacity
    2. See CURVES Capacity Assessment Tool
    3. Consider surrogate decision maker
  4. Major Depression
    1. Patient Health Questionaire 2 (PHQ-2, screening only)
    2. See Geriatric Depression Scale
    3. Major Depression is associated with worse functional recovery and skilled nursing facility transfer

VI. Evaluation: Functional Status

  1. Assess Activities of Daily Living
    1. See Activities of Daily Living Scale (Katz ADL Scale)
    2. See Instrumental Activities of Daily Living (Lawton IADL Scale)
    3. Consider "Prehabilitation" with physical therapy and occupational therapy before surgery
  2. Assess Mobility and Fall Risk
    1. See Fall Prevention in the Elderly
    2. See Get Up and Go Test
    3. See Frailty
    4. Employ similar methods to the ADL assessment above
  3. Assess Nutritional Status
    1. See Geriatric Nutrition Checklist
    2. See Subjective Global Assessment of Nutritional Status
    3. Mini Nutritional Assessment
      1. https://www.nestle.com/asset-library/documents/library/events/2010-malnutrition-in-older-people/mna_mini_english.pdf
    4. Poor nutrition is associated with poor Wound Healing, post-op infection, mortality and longer hospital stays
    5. Consider dietitian Consultation and perioperative Nutritional Supplementation

VII. Evaluation: Disposition after surgery

  1. Evaluate Family Support
  2. Consider skilled nursing facility arrangements
    1. Lack of family support
    2. Reduced patient functional capacity, comorbidities, neurologic status

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