Perioperative / Pre-operative Care and Assessment of the Elderly

Perioperative care of an older person means three things — pre-operative risk assessment and optimisation, intra-operative safety, and post-operative recovery. It is a team job involving the physician, surgeon and anaesthetist.

Age above 70 raises the risk of complications and death after major non-cardiac surgery. But the actual mortality is low even beyond 80 years if the surgery is planned.

Comorbid conditions matter far more than age itself. The type of operation, the local complication rate, and whether surgery is emergency or elective decide the outcome.

Emergency surgery carries a much higher risk than elective surgery. Wherever possible, stabilise the patient and operate electively.

Always ask first whether the operation is appropriate. The risk–benefit ratio must be weighed against the patient's goals, life expectancy and functional status.

Optimise underlying disease before non-emergency surgery: cardiovascular disease (especially heart failure), lung function, kidney function, diabetes, thyroid disease (often occult), anaemia, nutrition, and hydration/volume status — the last is especially important in patients on diuretics.

Cardiac conditions that greatly increase risk are: myocardial infarction within 6 months, pulmonary oedema, angina (especially unstable), and severe aortic stenosis.

The Revised Cardiac Risk Index (Lee index) uses six factors — ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, renal insufficiency (creatinine >2.0 mg/dL), and high-risk surgery.

Assess exercise tolerance. The classical bedside test is the ability to climb one flight of stairs. Poor exercise capacity predicts poor outcome.

Order tests only if the result will change management. Pre-operative pulmonary function tests and arterial blood gases are rarely of prognostic value. Non-invasive cardiac testing is reserved for intermediate- and high-risk patients.

Coronary revascularisation (CABG or PCI) should be done only if it is indicated independently of the planned surgery — not merely to 'get the patient through' the operation.

Plan the drug chart carefully — some drugs are continued, some withheld, and some need dose adjustment.

Three prophylactic measures have documented value: beta-blockade in appropriately selected patients, antithrombotic (VTE) prophylaxis, and antimicrobial prophylaxis.

Frailty independently predicts post-operative complications, longer hospital stay and discharge to a nursing facility (Makary). It is assessed by weight loss, weak grip strength, exhaustion, low physical activity and slow walking speed.

Pre-operative impaired cognition, recent falls, low albumin, greater anaemia, functional dependence and multiple comorbidities predict higher mortality at 6 months (Robinson).

Four items independently predict post-operative delirium — prior stroke or TIA, low MMSE score, abnormal serum albumin, and a high Geriatric Depression Scale score (Rudolph). Preventing delirium is a core aim of perioperative care.

In cardiac surgery, frailty is scored by Katz ADL ≤4 of 6, low grip strength, 5-metre walk ≥6 seconds, 6-minute walk <150 metres, timed get-up-and-go ≥15 seconds, and cognitive impairment. Frailty gives a two- to four-fold rise in operative mortality.

Regional anaesthesia is not clearly superior to general anaesthesia in older people. It may need added sedation, can cause significant cardiovascular changes, and does not clearly reduce DVT or blood loss. The choice must be individualised.

After cardiac surgery the most feared complication is stroke, usually embolic. Risk factors are cerebral atrophy, reduced cerebrovascular reserve, and atherosclerosis of the aorta or neck vessels. Screen with carotid duplex; severe ascending aortic atheroma raises neurological events to 10%.

Confusion of uncertain cause or early dementia is a relative contraindication to cardiac surgery, as open-heart surgery may worsen it. Late referral independently worsens both operative risk and late outcome.

In the elderly the aim of cardiac surgery is relief of symptoms and improvement in quality of life, not longevity. After cardiac surgery 84–94% of octogenarian survivors continue living independently and 83–98% would undergo the operation again.

A comprehensive geriatric consultation completes the assessment — medication review, functional assessment, environmental and caregiver assessment, and a discussion of advance directives.

2024 AHA/ACC/Multisociety Perioperative Guideline (JACC 2024; Circulation 2024) — the fourth major revision, superseding the 2014 guideline. It uses a stepwise algorithm and stresses a multidisciplinary, shared decision-making approach.

Timing definitions were redefined: emergency = less than 2 hours (was 6 hours); urgent = 2–24 hours; time-sensitive = up to 3 months (was 1–6 weeks); elective = can be delayed indefinitely.

'Active cardiac conditions' are back in the algorithm — acute coronary syndrome, decompensated heart failure and unstable arrhythmia. Elective surgery must be postponed until these are treated.

A new step called 'risk modifiers' was added: severe valvular disease, pulmonary hypertension, congenital heart disease, prior PCI/CABG, recent stroke, cardiac implantable electronic device, and frailty. Frailty is now formally part of the cardiac risk pathway.

Functional capacity should be measured, not estimated. The METS study showed that clinician-estimated exercise capacity does not predict complications; the Duke Activity Status Index (DASI) does. DASI >34 indicates low risk. Basel-PMI and MET-REPAIR showed that inability to climb two flights of stairs predicts cardiac complications and death.

Cardiac biomarkers are a new step. BNP or NT-proBNP (ACC/AHA preference) or troponin (ESC preference) may be measured in elevated-risk patients with poor exercise capacity. BNP <92 ng/L or NT-proBNP <300 ng/L means low risk and no further testing.

Post-operative troponin surveillance may now be considered in high-risk patients, even without symptoms — a change from 2014 (myocardial injury after non-cardiac surgery, MINS).

Revascularisation before surgery is recommended only for acute coronary syndrome or left main stenosis >50%. Coronary CT angiography is accepted as an alternative to pharmacological stress testing.

Medication guidance (2024): continue beta-blockers if already on them but never start on the day of surgery (start ≥8 days before); continue statins; do not start clonidine; withhold ACE inhibitors/ARBs 24 hours before if taken for hypertension but continue for HFrEF; withhold SGLT2 inhibitors 3–4 days before surgery to prevent euglycaemic ketoacidosis.

Blood pressure: consider delaying surgery if BP ≥180/110 mmHg; maintain intra-operative mean arterial pressure ≥60–65 mmHg and treat post-operative hypotension promptly.

GLP-1 receptor agonists: the 2023 ASA advice to hold them was replaced by 2024 multisociety guidance (AGA, ASMBS, ASA, ISPCOP, SAGES) — a risk-based, shared decision-making approach; most patients can continue, with a 24-hour clear-liquid diet and gastric point-of-care ultrasound if aspiration risk is a concern.

Prehabilitation (structured exercise, nutrition and psychological preparation for 4–6 weeks before major elective surgery) reduces complications and length of stay in frail older adults; combined with ERAS protocols and the American College of Surgeons Geriatric Surgery Verification standards, which mandate routine screening for frailty, cognition, delirium risk, nutrition and goals of care.

Indian context: around 10.5% of India's population is now 60 years or older (LASI/NSO projections). Pre-operative anaemia, undiagnosed diabetes and malnutrition are highly prevalent and correctable; surgical packages are covered under PM-JAY, and NP-NCD/NPHCE services support pre-operative optimisation at the primary level.