Priorities in perioperative geriatrics

Perioperative care of the geriatric patient is complex. Older patients are at increased risk for a host of complications, and it is probably easier to precipitate these complications than to prevent them. This precarious state is a function of decreased functional reserve, variable response to stress, and the number of comorbidities. Nevertheless, we have learned a great deal that can guide future research. Rather than focus attention on the choice of anesthetic technique or on short-term outcomes, improvement in patient outcomes will be better served by studies that yield better risk stratification in the elderly. Pertinent patient risk factors will, to some extent, probably be surgery specific. Subsequently, it can be determined whether identified risk factors are amenable to therapy and whether such intervention improves the outcome. An essential element of both types of investigations will be a focus on preoperative functional status and on outcomes appropriate to the geriatric population rather than just major cardiopulmonary morbidity and mortality. Outcome is determined by the interaction of patient factors and the challenges introduced by surgery. Surgical impact varies widely by type, so development of comprehensive care strategies for specific types of surgery common in the elderly is indicated. This focus is more likely to generate positive results and practical guidelines than pooling elderly patients undergoing differing types of surgery. Developing comprehensive clinical pathways specific to the care of the elderly patient undergoing specific types of surgeries is indicated. It is likely that these approaches would be defined and initiated by multidisciplinary care teams so that preoperative, intraoperative, and postoperative management could be integrated. This approach could serve as a foundation for developing comprehensive evidence-based geriatric perioperative care and might have particular value in including prevention of delirium and pneumonia, in pain management, and in improving functional status on discharge. In these investigations, the anesthesiologist has a unique role, because we contribute significantly to preoperative assessment and intraoperative and postoperative management for every patient undergoing every type of surgery.