As life expectancy continues to rise, the healthcare system faces a critical challenge: safely managing the growing number of elderly patients undergoing surgery. In their comprehensive 2026 review, Tjeertes et al. present key updates on perioperative care for geriatric patients, with a strong focus on frailty assessment, shared decision-making, and outcome optimization.

The challenge of aging and surgery

Why are older adults more vulnerable?

Geriatric patients experience:

• Multiple comorbidities such as cardiovascular disease, diabetes, and dementia
  
• Reduced physiological reserve across all organ systems
  
• Increased susceptibility to postoperative complications such as delirium, infection, and functional decline

By 2050, more than 30% of Europe’s population will be over 65. The need for age-adapted perioperative strategies is more pressing than ever.

Understanding physiological changes with age

• Cardiovascular: increased arterial stiffness, impaired diastolic filling, heightened risk of arrhythmia
  
• Respiratory: reduced lung compliance, weakened cough reflex, aspiration risk
  
• Renal: decreased glomerular filtration, increased risk of drug toxicity
  
• Neurological: cognitive decline, vulnerability to delirium, reduced sensory perception

Frailty: a better predictor than age

Chronological age alone isn’t enough. Frailty, defined as reduced physiological reserve across multiple systems, is a stronger predictor of surgical risk.

Tools for frailty assessment:

• Clinical Frailty Scale (CFS): 9-point visual tool (see page 5) ranging from 1 (very fit) to 9 (terminally ill)
  
• Comprehensive Geriatric Assessment (CGA): gold standard, but resource-intensive
  

Frailty affects 23–53% of elderly surgical patients, depending on surgery type. It must be integrated into preoperative risk evaluation.

Step-by-step: how to optimize care for older surgical patients

1. Preoperative screening

• Assess cognitive function, nutrition, cardiopulmonary reserve, and polypharmacy
  
• Use frailty scales (CFS or CGA)
  
• Evaluate goals of care and resuscitation preferences
  

2. Prehabilitation programs

• Include physical training, anemia correction, and nutritional support
  
• Shows promise in reducing complications, even in frail patients
  

3. Multidisciplinary consultation

• Collaboration between anesthesiologists, surgeons, and geriatricians
  
• Improves outcomes and helps tailor risk-benefit analysis

4. Risk-adjusted surgical decision-making

• Consider both patient- and surgery-specific risks
  
• Balance potential benefits with the likelihood of functional recovery

Postoperative concerns in the elderly

Common complications:

• Delirium – highly prevalent and linked to worse outcomes
  
• Pneumonia and hypotension
• Renal insufficiency
  
• Functional loss and prolonged recovery
  

Enhanced Recovery After Surgery (ERAS) protocols are effective in reducing these risks and should be adapted to geriatric needs.

Advance care planning: reframing surgical intent

Surgery can be a gateway to important conversations about:

• End-of-life care
  
• Preferences on resuscitation and ventilation
  
• Quality of life versus survival
  

For frail patients with limited life expectancy, comfort and dignity may outweigh aggressive intervention. In carefully selected cases, nonoperative management offers humane, high-satisfaction outcomes.

Conclusion: redefining perioperative success

As the population ages, perioperative care for geriatric patients must evolve:

• Move beyond chronological age to assess frailty
  
• Employ multidisciplinary collaboration
  
• Integrate advanced care planning
  
• Customize prehabilitation and recovery protocols
  

Ultimately, success in geriatric surgery means more than survival; it means preserving dignity, function, and quality of life.

Reference: Tjeertes EKM et al. Perioperative care of the geriatric patient. Eur J Anaesthesiol. 2026;43:93-102.

Read more about geriatric patients in our Anesthesiology Module on NYSORA 360—an essential learning resource for residents with up-to-date, practical guidance across perioperative care.