Clinical issues - perioperative assessment and care

Overview

Perioperative assessment in older patients extends beyond standard anaesthetic fitness assessment to include frailty, cognition, and functional reserve - factors that independently predict postoperative complications beyond conventional cardiac/respiratory risk scoring
Frailty, more than chronological age alone, predicts postoperative complications, prolonged length of stay, and loss of independence after surgery

Physiological reserve declines with age even without overt disease - the same operative stress that a fit younger patient tolerates easily can precipitate delirium, functional decline, or organ dysfunction in a frail older patient with reduced reserve, even when standard cardiac/respiratory risk scores appear acceptable

Frailty assessment (e.g. Clinical Frailty Scale) alongside standard cardiac risk assessment better predicts postoperative outcome than cardiac risk scoring alone
Baseline cognitive assessment is valuable pre-operatively - it establishes a reference point for detecting postoperative delirium/cognitive decline and identifies patients at higher delirium risk
Medication review (particularly anticholinergic burden and drugs requiring perioperative cessation/bridging) should occur before, not just after, surgery

Orthogeriatric/perioperative geriatric co-management models (geriatrician involvement alongside the surgical team) improve outcomes in high-risk older surgical patients, particularly after hip fracture
Proactive delirium prevention measures (orientation, early mobilisation, sensory aid use, sleep hygiene, minimising unnecessary catheters/lines) started pre- and peri-operatively, not only once delirium develops
Goals-of-care discussion before major/high-risk surgery, particularly in frail patients, ensures the operative decision itself reflects the patient's values, not just technical operability

A "successful" operation by surgical criteria can still represent a poor outcome for the patient if it is followed by delirium, loss of independence, or failure to return to baseline function - perioperative outcome in this population is measured by more than surgical/anaesthetic complication rates alone

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