title: Preoperative assessment of the older patient: a narrative review.
abstract: OBJECTIVE
  Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential.
  
  
  OBJECTIVE
  To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed.
  
  
  METHODS
  A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years.
  
  
  RESULTS
  This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1,422,433 patients) and 26 that examined factors associated with surgical complications (n = 136,083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio [HR], 1.26 [95% CI, 1.06-1.49] to 5.77 [95% CI, 1.55-21.55]), 10% to 17% for malnutrition (adjusted odds ratio [OR], 0.88 [95% CI, 0.78-1.01] to 59.2 [95% CI, 3.6-982.9]), and 11% to 41% for institutionalization (adjusted OR, 1.5 [95% CI, 1.02-2.21] to 3.27 [95% CI, 2.81-3.81]).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 [95% CI, 1.0-9.99] to 13.02 [95% CI, 5.14-32.98]).
  
  
  CONCLUSIONS
  Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making.
authors.affiliation: Department of Surgery, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.
authors.forename: Lawrence B
authors.initials: LB
authors.lastname: Oresanya
authors.affiliation: Division of Geriatric Medicine, Department of Medicine, University of Nebraska Medical Center, Omaha.
authors.forename: William L
authors.initials: WL
authors.lastname: Lyons
authors.affiliation: Department of Surgery, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.
authors.forename: Emily
authors.initials: E
authors.lastname: Finlayson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D016330:Frail Elderly; D015577:Geriatric Assessment; D006801:Humans; D007258:Informed Consent; D016017:Odds Ratio; D057234:Preoperative Period; D018570:Risk Assessment; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000401:mortality