The physiological case for specialized care begins long before the first incision. Even in the absence of overt disease, aging produces organ-specific changes that erode physiological reserve and impair homeostasis. Cardiovascular stiffness reduces the heart’s ability to buffer the stress of anesthesia, declining renal function prolongs the elimination of drugs and their metabolites, and age-related shifts in body composition alter how anesthetic agents are distributed and cleared. The authors emphasize that these changes mean older patients are exquisitely sensitive to both under- and over-treatment: too little hemodynamic support risks organ injury, while excessive sedation or fluid loading can tip a fragile balance into delirium, kidney failure, or prolonged recovery. Dosing, the 2025 American Society of Anesthesiologists advisory makes clear, should be individualized according to physiological rather than chronological age.

One of the review’s most counterintuitive findings concerns preoperative testing. Despite the multiple comorbidities typical of geriatric patients, one study found that only 12.9 percent presented significant abnormalities in preoperative blood tests, and laboratory findings were not significant predictors of postoperative complications. Excessive testing, the authors warn, may increase distress and delay time-sensitive surgery without improving outcomes. Instead, the evidence supports a targeted approach: a thorough history and physical examination should guide which investigations are actually needed. Resting electrocardiography is recommended for patients aged 65 and over undergoing intermediate- or high-risk surgery, echocardiography is reserved for suspected valvular disease or unexplained dyspnea, and routine stress testing before low-risk procedures is explicitly not recommended. In emergency surgery, where mortality and complication rates are substantially higher, evaluation should focus only on factors that will immediately influence management.

Cardiac risk assessment occupies a central place in the review, and here the authors highlight a critical gap. The Revised Cardiac Risk Index, long the workhorse of perioperative cardiology, incorporates six variables including ischemic heart disease, heart failure, and high-risk surgery. Yet growing evidence suggests that in patients aged 80 and above, the RCRI may systematically underestimate perioperative cardiac risk. To compensate, contemporary guidelines recommend biomarker surveillance: preoperative B-type natriuretic peptide measurement for older patients facing intermediate- or high-risk surgery, and high-sensitivity cardiac troponin measured before surgery and at 24 and 48 hours afterward. The rationale is compelling—perioperative myocardial injury is frequently asymptomatic, and even modest postoperative troponin elevations are independently associated with increased short-term mortality. However, the authors caution that biomarker thresholds have largely been validated in mixed-age populations, leaving their optimal application in the oldest patients uncertain.

Beyond the heart, the review identifies frailty as perhaps the single most important concept in modern geriatric perioperative medicine. Defined as a state of decreased physiological reserve and increased vulnerability to stressors, frailty predicts postoperative complications, prolonged hospitalization, institutionalization, loss of independence, and death more powerfully than age itself. The Clinical Frailty Scale, a simple scoring tool with demonstrated interrater reliability among perioperative clinicians, is emerging as a candidate for routine incorporation into standard preoperative evaluation. Closely related is sarcopenia—low muscle strength, reduced muscle mass, and impaired physical performance—which a meta-analysis of 43 studies linked to a fourfold increase in postoperative complications and a doubling of 30-day mortality after gastroenterological cancer surgery. Crucially, both conditions should be regarded as potentially modifiable rather than fixed: multimodal prehabilitation combining exercise, nutritional optimization, and medication review has been shown in meta-analyses to improve muscle mass, strength, gait speed, and postoperative outcomes in frail older patients.

Nutrition emerges as another underappreciated pillar of preoperative preparation. Malnutrition affects up to 22 percent of hospitalized older adults and 30 percent of those in long-term care, and the surgical period compounds the problem through increased catabolism, reduced appetite, gastrointestinal dysfunction, fasting requirements, and the deleterious effects of medications. Body mass index, the review notes, has limited utility in this population because fluid retention and altered body composition can mask true deficits. Validated screening tools fill the gap: the Nutritional Risk Screening 2002, derived from surgical trial data and endorsed by the American Association for the Surgery of Trauma, the simpler two-parameter Geriatric Nutritional Risk Index, and the widely used Mini Nutritional Assessment, which a recent meta-analysis of over 200,000 geriatric orthopedic patients linked to postoperative complications and mortality. Patients flagged as high risk warrant preoperative counseling, oral nutritional supplements, and, in severe cases, consideration of postponing elective surgery.

Cognitive function and mental health receive equally detailed attention. Cognitive screening should be a routine component of preoperative evaluation, with the three-minute Mini-Cog offering a practical balance of brevity and predictive value for postoperative delirium, while the Montreal Cognitive Assessment and Mini Mental State Examination serve as alternatives with different practical constraints. The review also flags sensory deficits—hearing and vision loss—as independent predictors of delirium, citing a cohort study in which patients deprived of hearing aids and glasses throughout the perioperative period had higher rates of delirium and lower quality-of-recovery scores. Depression, present in up to half of surgical patients, is associated with worse outcomes, yet screening remains inconsistent; one UK prospective study found that two-thirds of patients who screened positive for depression accepted referrals to mental health care. Sleep disturbances, too, contribute to worse cognition, greater pain perception, and falls.

Medication management is framed as a continuous thread running from admission to discharge. Polypharmacy, commonly defined as five or more concurrent medications, is nearly universal among older surgical patients and carries a cumulatively unfavorable benefit-to-risk profile. The STOPP/START criteria and the American Geriatrics Society Beers Criteria offer structured ways to identify potentially inappropriate medications and prescribing omissions, and a brief preoperative review can flag high-risk patients for geriatric referral. Anticoagulants and antiplatelet agents demand particular care: interruption balances procedural bleeding risk against thromboembolic danger, a calculation complicated in the oldest patients by declining renal function that prolongs the elimination of agents such as dabigatran. Discharge represents a second opportunity, when prescribing physicians should reconcile medication lists and deprescribe what was flagged preoperatively.

In the operating room and intensive care unit, the review’s technical recommendations center on hemodynamic stability and anesthetic depth. Intraoperative and postoperative hypotension are associated with myocardial injury, acute kidney injury, stroke, and death, and prolonged or profound blood pressure drops should be avoided whenever possible. Excessive depth of anesthesia, monitored with electroencephalography-based tools such as bispectral index, may contribute to delayed recovery and neurocognitive complications. Regional anesthetic techniques do not show consistent superiority over general anesthesia for mortality or delirium, but may reduce opioid exposure in selected patients. After surgery, enhanced recovery protocols—early mobilization within 24 hours, carbohydrate-containing oral hydration up to two hours before surgery, and early urinary catheter removal—have been shown in meta-analyses of older orthopedic and colorectal patients to reduce complications and shorten hospital stays, though epidural analgesia raises the risk of urinary retention with early catheter removal.

The final and arguably most sobering section addresses what happens after discharge. Postoperative delirium affects up to 50 percent of older surgical patients, compared with 2 to 3 percent of the general population, and a systematic review of more than 20,000 patients linked it to increased mortality, prolonged hospitalization, non-home discharge, and intensive care admission; its economic burden in the United States is estimated at roughly 164 billion dollars annually. Non-pharmacological prevention—geriatric consultation, cognitive stimulation, sensory aid preservation, treatment of underlying causes—remains first-line management, while antipsychotics carry safety concerns and benzodiazepines may worsen outcomes. Nearly 30 percent of older patients experience functional decline in the perioperative period, and for some the decline is irreversible. With no universally recognized post-discharge pathways and ongoing trials still underway, the authors conclude that individualized care plans built by interdisciplinary teams—surgeons, anesthetists, geriatricians, nurses, and rehabilitation specialists—are not a luxury but a necessity for a population whose numbers will only 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

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01617-5

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