Perioperative Assessment in

Elderly Surgical Patients :

Geriatrics point of view
Siti Setiati
 • Surgery is performed more frequently in the
elderly
• 40 to 64 y.o: 136 procedure per 100,000 people
• >65 y.o: 190 per 100,000
• 1/3 of all surgeries in the US are in patients > 65
y.o
• Elderly patients are often denied for surgery
Introduction because of the presumed higher mortality and
morbidity rates.2
• Age should not be the only parameter to be
considered when addressing eligibility for surgery.2
• Studies showed that medical problems that
increase with age are responsible for the increase
of perioperative complications among older
patients.2

1. Beliveau MM, Multach M. Perioperative care for the elderly patient. Med Clin N Am 2003;87:273–89.
2. Cheng S, Yang T, Jeng K, Lee J. Perioperative Care of the Elderly. Int J Gerontol 2007;1(2):89-97.
Age-Related
Changes
 Algorithm for Assessing Older
Patient for Surgery
• First, we have to determine if the patient have
decision-making capacity of not, such as altered
mental status, decrease cognitive function, etc
• If the patient is capable, then we can discuss the
treatment goals and choices with patients and
their families, if not, then we can discuss with the
families
• Assessing the goals of surgery and the risks
including the complications of the patients

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
 Decision Making Capacity
• Aging is not necessarily related to cognitive function and decision-
making capacity. Although impaired decision-making capacity is
common among older patients, age alone may not predict incapacity
due to neuropsychiatric disorders (dementia or delirium).
• The 4 legally relevant criteria for decision-making capacity are:
• The patient can clearly indicate his or her treatment choice.
• The patient understands the relevant information communicated by the
physician.
• The patient acknowledges his or her medical condition, treatment options,
and the likely outcomes.
• The patient can engage in a rational discussion about the treatment options.

Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF.. J Am Coll Surg 2012;215(4):453–66.
 Algorithm for Assessing Older
Patient for Surgery
• The benefit MUST ALWAYS outweigh the risks.
• If the risk is greater than the benefit, then
conservative or non-invasive procedure may be
the chosen treatment, to ensure quality of life
• If the benefit is greater than the risks, we can
continue to do the Geriatric Perioperative
Assessment and we still considering the risks
after the assessment

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
 Geriatric Perioperative Assessment
COGNITION Function Nutrition Frailty Polypharmacy

• Mini-Cog Test
• 3-item Recall
• Clock draw
• Identify risk factors for delirium
• Visual and hearing impairment
• Alcohol abuse
• Medications

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
 Risk Factors for Delirium

Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
 Recommendation ACS NSQIP/ AGS, 2015
• In any patient without a known history of cognitive impairment or
dementia, obtaining a detailed history and performing a cognitive
assessment is strongly recommended.
• If knowledgeable informants (eg, spouse or family members) are available,
interviewing them about the evolution of any cognitive or functional
decline in the patient is recommended.
• Careful documentation of the patient’s preoperative cognitive status is
strongly recommended because postoperative cognitive dysfunction is
common but difficult to quantify without record of the baseline cognitive
status.
• It is strongly recommended that the cognitive assessment be performed
early in the patient evaluation.

Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
 • Postoperative delirium incidence
was consistently higher in those with
cognitive impairment VS those
without.
• A total of 13 studies reported the
preoperative cognitive impairment as
a risk factor and meta-analysis of
these studies showed that patients
with cognitive impairment were
more prone to develop delirium
after hip fracture surgery (OR 3.21,
95 % CI 2.26–4.56)

Aging Clin Exp Res. 2017 Apr;29(2):115-126.

• Postoperatively, 46% of patients were determined to have developed
delirium by day 1 and/or day 2 after surgery. Bivariate analysis showed that
there was an ordered association between the number of depressive
symptoms and postoperative delirium: The greater the number of
depressive symptoms, the greater the incidence (p = .048) and the longer
the duration of postoperative delirium (p = .027).
 Geriatric Perioperative Assessment
Cognition FUNCTION Nutrition Frailty Polypharmacy

• ADL
• IADL
• Obtain history of falls
• Timed up and go test of more than 15 seconds
• Plan for in-hospital and post-discharge
rehabilitation therapy

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
 • In this multivariable logistic
regression analysis, patients
with a high TUG had a 3.1
times higher risk of major
complication within 30 days
post-operative (95%-CI =
1.1–8.6; p < 0.05)

Huisman MG, et al. Screening for predictors of adverse outcome inonco-geriatric surgical patients: A multicenter prospectivecohort study. EJSO. 2015;41:844-51.
 Geriatric Perioperative Assessment
Cognition Function NUTRITION Frailty Polypharmacy

• Mini Nutritional Assessment

• Body weight, body height, BMI
• Assessing Albumin with or without pre-albumin levels
• Considering nutritional supplementation to patients with
malnourished condition
• Giving ONS to post-operative patients (such as from hip fractures) have a
significant effect to decrease mortality and complications
• Should be started by oral route with or without ONS, if possible. If not, enteral
nutrition is the second choice, followed by the parenteral nutrition
Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
 • Commonly used markers for
malnutrition in hip fracture studies
include albumin level, body mass
index (BMI), Mini Nutritional
Assessment (MNA) or its short form
(MNA-SF)
• Albumin, prealbumin, and transferrin
are partly affected by fluid shifts and
responses to injury and infection.
• However, MNA is more likely to predict
malnutrition-related outcomes than
BMI or albumin level

Paillaud E, Bories PN, Le Parco JC, Campillo B. Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up. Br J Nutr 2000;83:97-103.
Miu KYD, et al. Effects of Nutritional Status on 6-Month Outcome of Hip Fractures in Elderly Patients. Ann Rehabil Med. 2017;41(6):1005-12.
Prevalence of Nutritional Status in Hospital Setting
10,40%

22,08% 45,01%

22,51%

Normal (18.5-22.9 kg/m2) Overweight (23-24.9 kg/m2)

Obesity (>= 25 kg/m2) Underweight (< 18.5 kg/m2)

Setiati S, et al. Cut-off of anthropometry measurement and nutritional status among elderly outpatient in Indonesia: multi-center study. Acta Med Indones. 2010;42(4):224-230.
 • METHODS: A systematic literature search of 10 consecutive years, 1998-
2008, in PubMed, EMBASE, and Cochrane databases was performed.
• RESULTS: Of 463 articles found, 15 were included. The only significant
preoperative predictors of postoperative outcome in elderly general
surgery patients were serum albumin and ≥ 10% weight loss in the
previous 6 months.
• CONCLUSIONS: Both 2 preoperative parameters are open to discussion in
their use as a preoperative nutrition parameter. Nonetheless, serum
albumin seems a reliable preoperative parameter to identify a patient at
risk for nutrition deterioration and related
complicated postoperative course.

JPEN J Parenter Enteral Nutr. 2013 Jan;37(1):37-43.

 Geriatric Perioperative Assessment
Cognition Function Nutrition FRAILTY Polypharmacy

• Frailty is a clinical state in which there

is an increase in an individual’s
vulnerability for developing increased
dependency and/or mortality when
exposed to a stressor
• Tools of Frailty: FRAIL, FI-40
• Some markers:
• Mini-Cog score of 3 or less
• Albumin level of 3.3 g/dL or less
• More than 1 fall in the last 6 months
• TUG test of more than 15 seconds
• More than 3 comorbidities

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
Frailty

Frailty has been identified as a syndrome that meaningfully predicts

outcomes among older adults.

Adapted from Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. The Lancet. 2013 Mar;381(9868):752-62 & Lang P-O, Michel J-P,
Zekry D. Frailty Syndrome: A Transitional State in a Dynamic Process. Gerontology. 2009;55(5):539-49.
Layers of Frailty
Frailty

Frailty increase the risk of:

• 1.8- to 2.3x – mortality risk;
• 1.6- to 2.0x – risk of dependency;
• 1.2- to 1.8x – risk of hospitalization
• 1.5- to 2.6x – risk of physical disability;
• 1.2- to 2.8x – risk of fall and fractures
 Geriatric Perioperative Assessment
Cognition Function Nutrition Frailty POLYPHARMACY

• Almost 50% elderly received a potentially

inappropriate medication during their surgical
hospitalization.
• To minimize the risk of perioperative adverse drug
reactions, all preoperative medications should be
reviewed for appropriateness and potentially
inappropriate medications should be stopped
using START and STOPP criteria
• In addition, Beers List can also be used

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
 Perioperative Care for Several Symptoms

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
Canadian Cardiovascular Society

Management of medications taken chronically and smoking before noncardiac surgery

ASA Withhold at least 3 days before surgery and restart ASA when the risk of bleeding
related to surgery has passed (ie, 8-10 days after major noncardiac surgery)
b-Blocker Continue the b-blocker during the perioperative period; however, if a patient’s
systolic blood pressure is low before surgery, physicians should consider decreasing or
holding the dose of the b-blocker before surgery
ACEI/ARB Withhold ACEI/ARB 24 hours before noncardiac surgery and restart ACEI/ARB on day
2 after surgery, if the patient
is hemodynamically stable
Statin Continue the statin during the perioperative period
Smoking Discuss and facilitate smoking cessation (eg, nicotine replacement therapy), ideally
starting 4 weeks before surgery

Can J Cardiol. 2017;33:17-32

Cardiac Perioperative
Screening
• In patients undergoing non-cardiac
surgery, various cardiac risk scoring
systems to delineate perioperative
cardiac risk have been investigated. The
multivariable, Revised Cardiac Risk
Index (RCRI), developed by Lee et al, in
1999, is the one most widely used
today.

Arora V, Velanovich V, Alarcon W. Int J Surg. 2011;9(1):23-8.

 Canadian
Cardiovascular
Society
 Pulmonary
Perioperative
Screening

• Post-Operative Pulmonary
Complications or PPC
contribute to the morbidity
• PPC associated with longer
LOS, re-hospitalization, and
higher 30-day mortality
• Identifying elderly patients
at risk of PPC is a must

Oresanya LB, et al. Preoperative Assessment of the Older Patient. JAMA. 2014;311(20):2110-2120
Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
Venous Thromboembolism
Prophylaxis
• It is important that older adult patients undergo
VTE risk stratification, which may involve the use
of a scoring tool
• Older adult patients should be stratified for VTE
and bleeding risk with a structured approach,
based on available methods and local
institutional norms, and a plan, including dosage
and duration, should be determined based on the
patient’s risk profile.
 Estimate Thromboembolic Risk
• Atrial Fibrillation
• Prosthetic Heart Valves
• Recent Venous/Arterial
Thromboembolism (past 3
months)

Douketis JD, et al. Perioperative Management of Patients Receiving Anticoagulants. 2019

 Estimate bleeding risk

• Type of surgery
• Comorbidities: Elderly, decreased renal function, medications affecting
hemostasis
• High  two-day risk of major bleeding 2-4% or low  two-day risk of major
bleeding 0-2%
• High: CABG, cholecystectomy, or any procedure lasting >45 minutes
• Patient-related risks can be quantified using HAS-BLED score
• HAS-BLED bleeding score more than 3 was most predictive variable for bleeding
Douketis JD, et al. Perioperative Management of Patients Receiving Anticoagulants. 2019
 Determine the timing of anticoagulant
interruption
• Anti-coagulant must be discontinued if the surgical bleeding risk is
high
• Patient with very high or high thromboembolic risk should limit the
period of stopping anticoagulant at the shortest possible interval
• NSAIDS, aspirin should be avoided to reduce the risk of bleeding,
however in case of recent stroke, the drugs can still be given
• In low-risk surgery, anticoagulant may still be continue as normal
• For those receiving vitamin K antagonists, INR should be not above
therapeutic range at the time of procedure

Douketis JD, et al. Perioperative Management of Patients Receiving Anticoagulants. 2019

Perioperative Laboratory Tests

Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
 Perioperative Imaging

Knittel JG. Preoperative Assessment of Geriatric Patients. Anesthesiology Clin 34 (2016) 171–183
 Comprehensive Geriatric Assessment
(CGA)
Assessment Assessment
Components Approach Outcomes
Aspects

Medical Condition Biospsychosocial Hospital Stay↓

Cognitive Function
Functional Status
Functional Status↑
Promotive-Preventive
Interdisciplinary
Quality of Life↑
Curative-Rehabilitative

Survival ↑
Emotional Status Continuum of care
Continuous Rehospitalization↓
Hospital and Community-based • Treating Acute Phase
Nutritional Status Geriatric Care • Discharge Planning
• Home Care Patient Satisfaction↑
• Hospital: Sederhana, Lengkap,
Medication Sempurna, Paripurna • Care transfer from
Problems • Community: Social workers, nursing hospital to community Health Worker
home, elderly club, PUSAKA, Satisfaction↑
Puskesmas/Posyandu Lansia, Karang
Social Problems wreda, Panti Wreda Cost Effective
• CGA is USEFUL for identifying high-risk elderly patients undergoing
elective surgery. Functional impairments, such as dependency in
ADL/IADL, cognitive impairment, depression, polypharmacy, fall risk,
poor social support, and malnutrition, had a cumulative effect on
adverse outcomes, such as in-hospital death or post-discharge
institutionalization.
• It was also associated with in-hospital geriatric syndrome and
prolonged length of stay.
• We should pay special attention to preventing the development of
geriatric syndrome and adverse outcomes in this group.
THANK YOU
 ACP Guidelines of Bridging Warfarin Patients

1 Douketis JD et al. Chest.2012;141(S2):e326S-e350S.

2 Van Diepen S et al. Am Heart J. 2014;168(1):60-7.
 Determine whether to use bridging
anticoagulant
• Dabigatran: omit 2-3 days before surgical procedure in normal or mild
impaired renal function patients, 2-4 days with severe renal function
• Half-life: 12-14 hours normally
• Routine coagulation test: aPTT; but not necessarily needed
• Dabigatran should be resumed post-operatively in low-risk surgery or
2-3 days after high risk surgery, the use of bridging LMWH may be
used post-operatively

Douketis JD, et al. Perioperative Management of Patients Receiving Anticoagulants. 2019

 Determine whether to use bridging
anticoagulant
• Rivaroxaban or Apixaban: omit 2-3 days before procedure
• Half-life: 7-11 hours normally
• Routine coagulation test is not necessarily needed
• Rivaroxaban should be resumed post-operatively in low-risk surgery
or 2-3 days after high risk surgery, the use of bridging LMWH may be
used post-operatively

Douketis JD, et al. Perioperative Management of Patients Receiving Anticoagulants. 2019

Canadian Cardiovascular Society

Initiation of new medications and coronary revascularization before noncardiac surgery

ASA Do not initiate ASA for the prevention of perioperative cardiac events
b-Blocker Do not initiate a b-blocker within 24 hours before noncardiac surgery
a2-Agonist Do not initiate an a2-agonist for the prevention of perioperative cardiovascular
events
Calcium channel Do not initiate a calcium channel blocker for the prevention of perioperative
blocker cardiovascular events
Coronary Do not undertake preoperative prophylactic coronary revascularization for
revascularization patients with stable coronary artery disease

Can J Cardiol. 2017;33:17-32

 • Step 1: Determine the urgency of
surgery. If an emergency, then
determine the clinical risk factors.
• Step 2: If the surgery is urgent or
elective, determine if the patient has
an ACS. If yes, then refer patient for
cardiology evaluation according to the
UA/NSTEMI and STEMI CPGs.
• Step 3: If the patient has risk factors
for stable CAD, then estimate the
perioperative risk of MACE on the
basis of the combined
clinical/surgical risk. This estimate
can use the American College of
Surgeons NSQIP risk calculator
(http://www.surgicalriskcalculator.co
m).

Circulation. 2014;130:e278-e333.)
 • Step 4: If the patient has a low risk of MACE
(<1%), then no further testing is needed, and
the patient may proceed to surgery.
• Step 5: If the patient is at elevated risk of
MACE, then determine functional capacity
(using DASI or METs). If the patient has
moderate, good, or excellent functional
capacity (≥4 METs), then proceed to surgery
without further evaluation.
• Step 6: If the patient has poor (<4 METs) or
unknown functional capacity, determine
whether further testing will impact patient
decision making (e.g., decision to perform
original surgery or willingness to undergo
CABG or PCI, depending on the results of the
test) or perioperative care. If yes, then
pharmacological stress testing is appropriate.
• Step 7: If testing will not impact decision
making or care, then proceed to surgery or
consider alternative strategies.

Circulation. 2014;130:e278-e333.)
Antibiotic Prophylaxis
• Older patients may have compromised renal function and, as such,
may require particular attention to dosing
• Preoperative antibiotics should be given based on procedure, risk
factors, and the hospital’s unique pathogen profile within 60 minutes
before surgical incision.
• reduced risk of surgical site infections (SSIs) is well-established