A complete medication reconciliation should be completed for every patient undergoing a surgical procedure, regardless of age. As patients age, the potential for medication interactions increases. In order for the surgeon to adequately prepare a patient for a surgical procedure, a full list of medications, including over-the-counter and herbal supplements should be reviewed (Principle V).

The American Geriatrics Society and American College of Surgeons recommend all nonessential medications that may increase surgical risk be discontinued prior to surgery, as well as medications that pose the potential to interact with anesthetics. Herbal medications should be stopped at least 7 days prior to any procedure, due to the unstudied (or understudied) nature of their interactions with anesthetics and other medications administered in the perioperative period.

The AGS/ACS also relies on the use of the Beers Criteria for Potentially Inappropriate Medications to identify medications that may cause issues in the perioperative period. The Beers Criteria is the product of a systematic review that examines medication-related events and adverse reactions in the United States and creates a list of medications to completely avoid in older adults, medications to avoid when patients have particular syndromes or disease states, and medications to use with caution in older patients. New to the 2015 update, the Beers Criteria now also provide a list of drug-drug interactions that are associated with medications other than anti-infectives, as well as non-anti-infective medications that should be avoided or dose reduced due to kidney function (creatinine clearance) [9].

Approximately 30 % of the population over the age of 65 falls each year. Multiple studies have investigated different interventions to prevent falls, particularly in the postoperative population. The programs investigated with both home- and group-based exercise programs, as well as home safety interventions and modifications aimed at decreasing falls. Guidelines from the American and British Geriatric Societies recommend an exercise component fall prevention programs [10].

Whenever possible, environmental modifications should be performed as part of a fall risk assessment [11]. These modifications should be made to allow patients to safely perform their activities of daily living (Principles III and V). In addition, visual impairment should be addressed to both prevent falls and promote the completion of daily activities. Two studies showed that patients undergoing immediate cataract surgery experienced a lower rate of falls, compared to those undergoing delayed surgery. However, other studies that included vision correction in their programs experienced mixed results, including one study showing an increased risk of falling with vision correction interventions. Ultimately, vision problems should be formally addressed, but the data supporting the various available interventions is mixed [12].

A thorough medication reconciliation and review should be performed to help eliminate medication-related fall risk. Elimination of certain classes of medications has been shown to have a significant effect on fall risk reduction. Specifically, the removal of psychotropic medications from a patient’s regimen has been shown to have a positive effect on fall risk reduction. Additionally, if a medication cannot be completely eliminated, reduction in dose should be considered.

Malnutrition is one of the most common conditions to affect the older population [13]. A sad truth is that a malnourished state may exist in an individual for a significant period of time before physical manifestations appear. Despite the multitude of screening tools available to the clinician, the Mini Nutritional Assessment (MNA) was developed for assessing older patients and is the recommended assessment as part of the comprehensive geriatric assessment [13]. In a multinational retrospective study of older patients, the MNA was able to identify that more than two-thirds of the 4507 patients identified were either malnourished or at risk for malnutrition. Additionally, the study showed that a patient’s nutritional state declines as their need for care increases [13].

The European Society for Parenteral and Enteral Nutrition (ESPEN), in their guideline statement for enteral nutrition in geriatric patients, recommends a complete nutritional assessment of all geriatric patients. Additionally, a nutritional plan should be developed that provides adequate supplementation of necessary nutrients. Generally speaking, patients require 1 g/kg/day of protein and approximately 30 kcal/kg/day of energy (calories from carbohydrate and fat) daily. Micronutrient deficiencies should be supplemented appropriately, based on individual needs and deficiencies (Principles II, III) [14].

Patients should be evaluated for their ability to tolerate oral intake. Some patients, while they can eat and drink, are at increased risk for aspiration. Patients with coughing or choking, difficulty initiating swallowing, a globus sensation (perception of something being stuck in the throat), drooling or inability to handle oral secretions, noted regurgitation, or any other problem should be formally evaluated for their ability to take oral nutrition. Some older patients may be in a physical state that simply does not permit adequate independent oral intake. Current guidelines recommend against initiating supplementary enteral nutrition via a nasogastric or gastrostomy tube purely due to financial or time-saving means. If enteral nutrition is appropriate for a patient, but they are unable to tolerate oral intake, percutaneous access is superior to nasogastric feeding. In an analysis by the Cochrane group, it was shown that while enteral feeding and supplementation (via any means) is superior regarding increasing energy and nutritional intake, due to formulations, taste alterations, and other side effects (nausea, diarrhea, cost), percutaneous feeding tubes have greater compliance and tolerability [14].

Ultimately, if a patient is competent to make their own medical decisions (see: goals of life/care), there should be a thorough discussion regarding nutritional status and how it affects the disease process, surgical treatment and healing, and possible placement of a feeding tube.

Patients are at an increased risk for decline in function and disability following a hospitalization. Prospective data has shown that older patients are at risk for suffering both a decline in their ability to perform their activities of daily living (dressing, eating, bathing, toileting, transferring) and developing new deficits while hospitalized. A study of 2293 patients, all 70 years and older, showed that 35 % of the cohort experienced a decline in functional status over the course of a hospitalization. Of this group, 23 % failed to recover back to their baseline function [15].

Patients who are at increased risk for functional decline are those of advanced age, deemed “frail,” suffering from cognitive impairment, of poor mobility or suffer a functional impairment, suffer from depression, or suffer –from another “geriatric syndrome” (e.g., falls, pressure ulcers, malnutrition, etc.) (Principle II). Hospitals and extended care facilities have implemented programs to help prevent functional decline in older patients. Special nursing and rehabilitation units have been developed particularly for older patients. The Nurses Improving Care of Health System Elders (NICHE) program [16] has been developed to provide tools that allow for specialized care of elderly patients. These tools help address specific problems that affect the patient experience and patient outcomes. Families are engaged to help prevent a further decline in function and ultimately help provide the best care possible to patients.

As part of a geriatric preoperative evaluation , determination of functional status is important. This helps track, and prevent, a loss of function. The Karnofsky performance score (KPS) is a 100-point scale that allows quantification of a patient’s functional status. The continuum spans from a score of 100 (totally independent, no care needs) to 0 (dead). In addition to grading a patient’s functional status, the score is also helpful in identifying those patients who are at risk of loss of functional status (Principles I, II, III, V, VI) [17].

A similar scale that is used to evaluate a patient’s functional status has been developed by the Eastern Cooperative Oncology Group (ECOG) . Used in many research trials, the ECOG score is a 0–5 scale that, similar to the Karnofsky performance score, ranges from 0 (fully active, at pre-disease performance status) to 5 (dead) (Table 35.2) [18]. Studies have shown that the two scores are similar in their utility, assessment, and prognosis [19]; however, the ECOG score has been shown to better evaluate a patient’s general prognosis [20].