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Chapter 31: Geriatric Anesthesia

PREOPERATIVE ASSESSMENT

To promote quality improvement in geriatric surgical care, extensive best practice guidelines have been issued by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the American Geriatrics Society (AGS). These guidelines provide a systematic approach to perioperative geriatric care. In particular, they require the care team to confirm that the patient’s wishes regarding treatment preferences and advanced directives are understood and documented. A checklist to ensure optimal preoperative assessment in the geriatric surgical patient is suggested (Table 31–1).

Table 31–1.Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient
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Table 31–1. Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient

In addition to conducting a complete history and physical examination of the patient, the following assessments are strongly recommended:

  • Assess the patient’s cognitive ability and capacity to understand the anticipated surgery.

  • Screen the patient for depression.

  • Identify the patient’s risk factors for developing postoperative delirium.

  • Screen for alcohol and other substance abuse/dependence.

  • Perform a preoperative cardiac evaluation according to the American College of Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery.

  • Identify the patient’s risk factors for postoperative pulmonary complications and implement appropriate strategies for prevention.

  • Document functional status and history of falls.

  • Determine baseline frailty score.

  • Assess patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk.

  • Take an accurate and detailed medication history and consider appropriate perioperative adjustments. Monitor for polypharmacy.

  • Determine the patient’s treatment goals and expectations in the context of the possible treatment outcomes.

  • Determine patient’s family and social support system.

  • Order appropriate preoperative diagnostic tests focused on older adult patients.

Reproduced with permission from Chow W, Rosenthal R, Merkow R, et al. Optimal preoperative assessment of the geriatric surgical patient: A best practice guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012 Oct;215(4):453–466.

A cognitive assessment such as the Mini-Cog examination is recommended for patients who do not have a history of dementia or cognitive impairment. Depression screening should also be conducted. Frailty, reflecting a decrease in functional reserve capacity and an inability to respond to the physiological challenges presented by the stress of surgery, can be assessed using one of several scoring systems.

AGE-RELATED ANATOMIC & PHYSIOLOGICAL CHANGES

CARDIOVASCULAR SYSTEM

Distinguishing between changes in physiology that accompany normal aging and changes in physiology from diseases common in the geriatric population is important (Table 31–2). Changes in the cardiovascular system that accompany aging include decreased vascular and myocardial compliance and autonomic responsiveness. In addition to myocardial fibrosis, calcification of the valves can occur. Older adult patients with systolic murmurs should be suspected of having aortic stenosis. However, in the ...

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