Operating on Patients Aged 80 and Over: New Review Outlines the Perioperative Pathway for the Oldest Adults

As operating rooms increasingly care for people in their eighties and nineties, a new narrative review in European Geriatric Medicine offers a detailed guide for helping the very old survive surgery, remain independent, and preserve cognitive function throughout the perioperative process. Written by a multidisciplinary group with expertise in perioperative medicine, geriatrics, anesthesiology, and critical care, the review brings together current evidence into practical recommendations for a group that has often been left out of clinical research. Its main conclusion is straightforward: age by itself is a weak predictor of surgical outcome, while the geriatric conditions that often accompany aging — frailty, cognitive decline, sarcopenia, and malnutrition — are much stronger predictors, and many can be improved if identified early.

The need for tailored care starts well before surgery begins. Even without obvious disease, aging changes organs in ways that reduce reserve and make it harder to maintain normal body function. A stiffer cardiovascular system limits the heart’s ability to cope with anesthesia, reduced kidney function slows drug and metabolite clearance, and changes in body composition alter how anesthetic medications are distributed and removed. The authors stress that these shifts make older adults especially vulnerable to both undertreatment and overtreatment: too little support can harm organs, while too much sedation or fluid can trigger delirium, kidney injury, or delayed recovery. The advisory from the American Society of Anesthesiologists recommends dosing based on physiologic rather than chronological age.

One of the review’s more surprising conclusions concerns preoperative testing. Even though older surgical patients often have several chronic conditions, one study found that only 12.9 percent had major abnormalities on preoperative blood tests, and those results did not predict postoperative complications. The authors warn that excessive testing can increase anxiety and delay urgent operations without improving outcomes. Instead, they support a selective approach in which history and physical examination determine which studies are truly needed. Resting electrocardiography is advised for patients 65 and older undergoing intermediate- or high-risk surgery, echocardiography is reserved for suspected valvular disease or unexplained shortness of breath, and routine stress testing before low-risk procedures is not recommended. In emergency surgery, where death and complication rates are much higher, evaluation should be limited to issues that will immediately affect care.

Cardiac risk assessment is a major focus, and the authors point to an important limitation. The Revised Cardiac Risk Index, long used in perioperative cardiology, relies on six factors including ischemic heart disease, heart failure, and high-risk surgery. But growing evidence suggests that in patients aged 80 and above, the tool may underestimate cardiac risk. To address this, current guidance supports biomarker monitoring: preoperative B-type natriuretic peptide testing for older adults facing intermediate- or high-risk surgery, plus high-sensitivity cardiac troponin before surgery and again at 24 and 48 hours afterward. The reason is simple — perioperative myocardial injury is often silent, and even small postoperative troponin rises are linked to higher short-term mortality. At the same time, the authors note that biomarker cutoffs have mainly been validated in mixed-age groups, so their best use in the oldest patients remains uncertain.

Beyond cardiac issues, the review describes frailty as perhaps the most important concept in modern geriatric perioperative medicine. Frailty is a state of reduced physiologic reserve and greater vulnerability to stress, and it predicts complications, longer hospitalization, institutionalization, loss of independence, and death more strongly than age alone. The Clinical Frailty Scale, a simple tool with good reliability among perioperative clinicians, is increasingly seen as suitable for routine use in preoperative assessment. Closely linked to frailty is sarcopenia, defined by low muscle strength, reduced muscle mass, and poor physical performance. A meta-analysis of 43 studies associated sarcopenia with a fourfold rise in postoperative complications and a doubling of 30-day mortality after gastrointestinal cancer surgery. Importantly, both frailty and sarcopenia should be treated as potentially modifiable. Multimodal prehabilitation that combines exercise, nutrition, and medication review has been shown in meta-analyses to improve muscle mass, strength, walking speed, and postoperative outcomes in frail older adults.

Nutrition is another major but often overlooked part of preparing older adults for surgery. Malnutrition affects up to 22 percent of hospitalized older adults and 30 percent of people in long-term care, and surgery can worsen it through catabolism, reduced appetite, gastrointestinal problems, fasting, and medication effects. The review notes that body mass index has limited value in this population because fluid retention and altered body composition can hide nutritional deficits. Validated screening tools help fill that gap: the Nutritional Risk Screening 2002, based on surgical trial data and endorsed by the American Association for the Surgery of Trauma; the simpler Geriatric Nutritional Risk Index; and the Mini Nutritional Assessment, which a recent meta-analysis of more than 200,000 geriatric orthopedic patients linked to complications and mortality. Patients at high risk should receive counseling, oral nutritional supplements, and, in severe cases, consideration of delaying elective surgery.

Cognitive health and mental well-being are given equally careful attention. Cognitive screening should be part of routine preoperative evaluation, with the three-minute Mini-Cog offering a useful balance between speed and predictive value for postoperative delirium. The Montreal Cognitive Assessment and Mini Mental State Examination remain alternatives, though each has practical limitations. The review also identifies hearing and vision loss as independent delirium risk factors, citing a cohort study in which patients who did not have access to hearing aids and glasses during the perioperative period had more delirium and lower recovery scores. Depression, which may affect up to half of surgical patients, is associated with worse outcomes, yet screening is still inconsistent; in one prospective study in the United Kingdom, two-thirds of patients who screened positive accepted referral for mental health care. Sleep problems also contribute to poorer cognition, greater pain sensitivity, and a higher risk of falls.

Medication management is presented as a continuous task from admission through discharge. Polypharmacy, usually defined as taking five or more medications, is nearly universal in older surgical patients and often has an unfavorable balance of benefit and risk. The STOPP/START criteria and the American Geriatrics Society Beers Criteria offer structured ways to identify potentially inappropriate medicines and missed prescriptions, and a brief preoperative review can identify patients who may need geriatric input. Anticoagulants and antiplatelet drugs require special attention because clinicians must balance bleeding risk against the danger of thrombosis, a challenge made more complex in the oldest adults by declining kidney function, which can slow the clearance of agents such as dabigatran. Discharge is another chance to improve safety by reconciling medication lists and stopping drugs that were flagged earlier.

In the operating room and intensive care unit, the technical advice centers on stable blood pressure and appropriate anesthetic depth. Low blood pressure during and after surgery is linked to myocardial injury, acute kidney injury, stroke, and death, so prolonged or severe hypotension should be avoided whenever possible. Too deep an anesthetic state, especially when monitored with electroencephalography-based tools such as bispectral index, may delay recovery and contribute to neurocognitive problems. Regional anesthesia has not consistently shown better outcomes than general anesthesia for death or delirium, though it may reduce opioid use in selected patients. After surgery, enhanced recovery pathways — including early mobilization within 24 hours, carbohydrate-containing oral fluids up to two hours before surgery, and early removal of urinary catheters — have been shown in meta-analyses of older orthopedic and colorectal patients to lower complication rates and shorten hospital stays, although epidural pain control can increase the chance of urinary retention when catheters are removed early.

The final section addresses what happens after the patient leaves the hospital. Postoperative delirium affects as many as half of older surgical patients, compared with only 2 to 3 percent of the general population, and a systematic review of more than 20,000 patients linked it to higher mortality, longer hospital stays, discharge to facilities rather than home, and admission to intensive care. In the United States, its annual economic burden is estimated at about 164 billion dollars. Non-drug prevention strategies — including geriatric consultation, cognitive stimulation, maintaining sensory aids, and treating underlying causes — remain the preferred first-line approach, while antipsychotics raise safety concerns and benzodiazepines may worsen outcomes. Nearly 30 percent of older adults experience functional decline during the perioperative period, and for some it does not reverse. With no universally accepted post-discharge pathway and trials still ongoing, the authors conclude that individualized care plans created by interdisciplinary teams of surgeons, anesthetists, geriatricians, nurses, and rehabilitation specialists are essential rather than optional for a population that continues to grow.

Subject of Research: Perioperative management of very old surgical patients, focusing on frailty, geriatric syndromes, and individualized interdisciplinary care

Article Title: Perioperative care in older adults: a narrative review

Article References: Szczeklik, W., Pasieka, P., Piotrowicz, K., & Włudarczyk, A. (2026). Perioperative care in older adults: a narrative review. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01617-5

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Keywords: perioperative care, older adults, frailty, sarcopenia, delirium, preoperative assessment, cardiac risk, malnutrition, polypharmacy, prehabilitation, ERAS, geriatric surgery