P re o p e r a t i v e O p t i m i z a t i o n a n d

Risk Assessment
Joseph A. Nicholas, MD, MPH

KEYWORDS
 Preoperative risk assessment  Preoperative care  Cardiovascular disease
 Geriatric fracture management

KEY POINTS
 Early hip fracture surgery is important for good functional outcomes.
 Most multiply comorbid geriatric patients can be safely optimized for surgery within
24 hours.
 Perioperative hypotension is common in older patients and should be anticipated and
prevented.
 Advanced preoperative cardiac testing (echocardiography, stress testing) does not seem
to improve outcomes and may inappropriately delay surgical repair.
 Preoperative cardiovascular medication management should be focused on preserving
intravascular volume status and pain control and minimizing polypharmacy.

INTRODUCTION

There has been increasing academic and professional interest in the optimal preoper-
ative risk assessment and perioperative care for older adults undergoing surgery.
Most surgical procedures occur in older adults,1 who as a group have higher rates
of perioperative complications than the general population, even after controlling for
comorbidities.2 In addition to increased comorbidity prevalence, geriatric patients
have unique physiologic risks3 and perioperative syndromes that often complicate
surgical outcomes.4 There has been increasing emphasis on the use of standard prac-
tices and the identification of specific quality indicators to improve outcomes in older
surgical patients.5 This article summarizes the current best practices for preoperative
risk assessment and preoperative optimization for older adults with osteoporotic
fractures.

IMPLICATIONS OF NORMAL AGING

Normal aging of the cardiovascular,6 pulmonary,7 and renal8 systems results in

physiologic changes that can significantly impact cardiopulmonary stability and

Conflict of Interest: None to declare.

Division of Geriatrics, Highland Hospital, University of Rochester School of Medicine, 1000
South Avenue, Box 58, Rochester, NY 14610, USA
E-mail address: Joseph_Nicholas@urmc.rochester.edu

Clin Geriatr Med 30 (2014) 207–218

http://dx.doi.org/10.1016/j.cger.2014.01.003 geriatric.theclinics.com
0749-0690/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
208 Nicholas

increase risk for perioperative complications. Normal cardiovascular aging results in

a less compliant, less responsive cardiovascular system with a higher propensity for
hypotension, conduction system defects, and pulmonary edema. Declines in lung
compliance, vital capacity, and diffusion capacity lower the threshold for hypoxemia
and hypercapnea and increase the impact of common perioperative pulmonary is-
sues, such as atelectasis, respiratory depression, and aspiration. Renal aging pro-
cesses often produce glomerulosclerosis, interstitial fibrosis, and hyalinization of
the afferent arterioles and place older adults at increased risk for acute kidney injury,
fluid retention, and electrolyte abnormalities. Taken together, these changes impair
the older adult from maintaining physiologic homeostasis in the face of acute peri-
operative stressors, such as pain, anesthesia, polypharmacy, and blood loss.9 As
different patients have different degrees of physiologic aging and impairment, stan-
dardized risk assessment, medical dosing, and clinical protocols can be challenging
to create.

PREOPERATIVE PRINCIPLES IN THE GERIATRIC FRACTURE PATIENT

Because there is a scarcity of prospective evidence for specific preoperative strate-

gies, most recommendations are drawn from expert opinion guidelines, extrapolated
data derived from younger patients and other surgical procedures, and the experi-
ence of high-performing geriatric fracture centers.10,11 These centers have used pre-
operative strategies designed to rapidly exclude absolute contraindications to
surgery and quickly optimize patients for fracture repair. Most of these centers focus
on geriatric principles of empiric symptom control, anticipation of hypotension and
delirium, and avoidance of polypharmacy, and do not routinely rely on subspecialty
consultation or advanced diagnostic testing. Important general strategies include
the following:
 Rapid optimization for early surgical fixation (<24–48 hours)
 Avoidance of perioperative hypotension
 Pain control
 Delirium prevention
 Prioritization of symptom control and functional status over extensive diagnostic
evaluation

EARLY SURGERY

Early surgical repair of acute hip fractures is associated with reductions in perioper-
ative mortality and postoperative complications, including pressure ulcers and
pneumonia.12 This reduction in mortality seems to be most prominent in frail patients
with functional dependency13 and suggests that weaker, more comorbid patients
are likely to benefit most from rapid optimization for surgical fixation. However,
this can be problematic for health systems and practice patterns that promote
extensive preoperative diagnostic evaluation of highly comorbid patients, whereby
comprehensive preoperative testing may lead to worse outcomes. This paradox
may be explained by the evidence that many preoperative test abnormalities fail
to correlate with postoperative complications,14 and that for frail patients, rapid de-
clines in functional, nutritional, and cognitive status associated with short-term
immobility, pain, and delirium significantly outweigh any potential benefits of specific
comorbidity evaluation and treatment. The need for efficient, focused, and goal-
directed preoperative risk assessment and optimization is essential for improved
outcomes.
 Preoperative Optimization and Risk Assessment 209

PREOPERATIVE RISK ASSESSMENT IN OLDER PATIENTS

Although preoperative assessment in younger adults is often focused on the eva-

luation of cardiovascular risk, there are several other predictors of perioperative com-
plications that should be considered in older adults. In addition to a qualitative
assessment of comorbidities, additional explicit attention to cognitive, functional,
and nutritional status is essential in the estimation of perioperative risk and anticipated
postoperative complications.15 In many instances, cognitive and functional status as-
sessments are superior to cardiovascular and other comorbidity scores in predicting
postoperative outcomes.16 The American College of Surgeons and the American Ge-
riatrics Society have collaborated to produce best practice guidelines for preoperative
assessment17 and strongly recommend several specific assessments, in addition to a
complete and thorough history and physical examination (Table 1).

Cardiovascular Evaluation
For the geriatric fracture patient, the cardiac evaluation should be focused on ruling
out serious active cardiac conditions, evaluating intravascular volume status, and
anticipating perioperative hypotension. Unlike the preoperative evaluation for elective
surgeries, whereby extensive testing for coronary artery disease and impaired

Table 1
Selected preoperative assessments for geriatric surgical patients

Assessment Area Clinical Importance Tools

Cardiac evaluation ACC/AHA guideline supports Resting electrocardiogram
proceeding to operating room Revised Cardiac Risk Assessment18
without further risk stratification (Goldman RCRI)
for patients without active cardiac
conditionsa
Cognitive Important to establish capacity for Mini-Cog
impairment consent ADL/IADL assessment (by proxy)
Helps establish accuracy of other
assessments (particularly reliability
of historical details, medication
compliance)
Helps predict delirium, complications,
and postoperative decline
Functional status Poor functional status is associated ADL/IADL assessment
with postoperative complications New mobility score (Parker
(including delirium) and after- mobility score)19
discharge needs
Functional status helps predict
functional outcome
Nutritional status Poor nutritional status is associated Body mass index <18.5
with increased risk for wound Albumin <3
complications and infections Unintentional weight loss >10%
over a 6-mo period
Polypharmacy Identify medications that may Beers criteria
contribute to perioperative STOPP criteria
complications (hypotension, Judicious prescribing of chronic
bleeding, delirium) antihypertensive, diabetic, and
other medications
a
Unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe
valvular disease.
210 Nicholas

ventricular function may result in changes in preoperative management and medical

clearance, timely repair of acute fractures and early time to surgery are central to
optimal postoperative outcomes. Other than a history and physical examination, cur-
rent American College of Cardiology/American Heart Association (ACC/AHA) guide-
lines only explicitly recommend a resting 12-lead electrocardiogram for the typical
geriatric patient undergoing orthopedic surgery. The only acute cardiac conditions
recognized by the ACC/AHA that warrant more extensive evaluation and treatment
before operative repair of hip fractures are unstable coronary syndromes, decompen-
sated heart failure, significant arrhythmias, and severe valvular disease, and a general
recommendation to restrict testing to patients for whom it will produce a significant
change in perioperative management (Table 2). Because acute hip fracture patients
require timely surgery to limit hemodynamic instability, pain, delirium, and immobility,
it is rare for advanced cardiac testing to be of benefit. Two retrospective reviews
concluded that preoperative echocardiography and stress testing did not prompt a
single instance of angiography, angioplasty, or cardiac surgery, but did increase sur-
gical delay, higher rates of invasive monitoring, and higher rates of acute medication
change.20,21
Orthopedic surgery is considered an intermediate-risk surgery based on rates of
major cardiac complications generally occurring in 1% to 5% of patients, although
this may underestimate the risk for frail older adults or in patients for whom more inten-
sive postoperative surveillance is performed. Although there are several comorbidity
and risk factor indices used for patient-specific risk quantification, none of these
have been validated in elderly patients in general and in hip fracture repair in particular.
Studies of hip fracture patients report a wide range of adverse cardiac event rates
(1%–10%),22 a range that likely reflects differences in myocardial enzyme surveillance
and case definitions.23
Specific issues surrounding b-blockade and other cardiovascular medication
management are addressed in the Preoperative Optimization section below.

Cognitive Impairment
Cognitive impairment and dementia are highly prevalent in geriatric fracture pa-
tients24 and are predictive of negative outcomes, including mortality, delirium,
increased length of stay, and functional decline.25 Patients without a known diag-
nosis of cognitive impairment can be screened in the preoperative setting. Although
most comprehensive screening and diagnostic tools for cognitive impairment are too
cumbersome or inappropriate for use in the acute preoperative setting, a history of

Table 2
Active cardiac conditions that may warrant surgical delay for further evaluation and
treatment

Conditions Clinical Examples and Issues

Unstable coronary syndromes Unstable angina
Acute myocardial infarction
Decompensated heart failure New onset
Class IV
Significant arrhythmias Unstable tachycardia (rapid atrial fibrillation, supraventricular
tachycardia, ventricular tachycardia)
High-grade heart block (Mobitz II or third-degree AV block)
Severe valvular disease Suspected aortic valve area <1 cm2 (if it will change
perioperative management)
 Preoperative Optimization and Risk Assessment 211

activities of daily living/instrumental activities of daily living (ADL/IADL) deficiencies26

or brief cognitive assessments in patients without delirium may provide an adequate
assessment for clinical purposes. IADL deficiencies that may correlate with a diag-
nosis of dementia include impairments in telephone use, handling of finances, and
medication self-administration.27 The Mini-Cog is a brief cognitive assessment
limited to a 3-item recall and a clock drawing test; this test is often not valid in the
preoperative setting of the acute fracture patient in light of the high prevalence of
delirium.

Functional Status
Good functional status predicts good outcomes and low rates of complications. Func-
tional status is commonly assessed in older adults by obtaining historical features
summarized as ADL/IADL, and deficits in these areas are associated with worse func-
tional outcomes. Requiring assistance with getting out of a bed or chair, bathing and
dressing, meal preparation, or shopping should prompt a full ADL/IADL assessment
(Table 3). The New Mobility Scale has been designed and validated in geriatric hip
fracture patients and can predict mortality and functional outcomes.19 Additional his-
torical features related to functional status include a history of falls, and the presence
of vision, hearing, or swallowing deficits.
In addition to the ADL/IADL estimation of functional status, high degrees of func-
tional capacity during moderately strenuous activities as measured by metabolic
equivalents (METs) may also predict low perioperative cardiac complications. Extrap-
olating from ACC/AHA algorithms targeting elective surgery candidates, patients who
are able to complete tasks requiring more than 4 METs (Table 4) are anticipated to
have low rates of cardiac complications and would be unlikely to benefit from
advanced cardiac testing.

Nutritional Status
Malnutrition is highly prevalent within hip fracture patients28 and is suggested by low
body mass index, low serum albumin, or significant unintentional weight loss.17
Weight loss in older adults is disproportionately lean muscle mass and often reflects
underlying sarcopenia.29 Poor nutritional status should be identified on admission,
to allow for appropriate assessment and treatment to begin as soon as possible in
the postoperative period.

Polypharmacy
The risks of polypharmacy for acutely hospitalized geriatric patients are significant.
Many medications that have been chronically tolerated in the stable outpatient

Table 3
Activities of daily living and instrumental activities of daily living

ADLS IADLs
Bathing Using telephone
Toileting Grocery shopping
Dressing Transportation
Transferring Cooking
Continence Housekeeping
Feeding Taking own medications
Handling own finances
212 Nicholas

Table 4
Exercise capacity and implications

Metabolic
Equivalents Activities Implications
1 MET Eat, dress, use toilet Advanced cardiac testing only if it will result
in change in management
4 METs Climb one flight of stairs No advanced cardiac testing recommended,
Light work around the house prior orthopedic surgery
(dusting, dishes)
10 METs Strenuous sports (swimming,
skiing, singles tennis)

setting can become dangerous in the dynamic setting of the perioperative period,
and new drug interactions and other adverse reactions emerge. It is important
for the geriatric fracture team to avoid conflating the long-term benefits of many
chronic medications with the short-term risks of hypotension, renal failure, delirium,
and sedation that can occur if medications are not adjusted and, when necessary,
discontinued.

PREOPERATIVE OPTIMIZATION

Because almost all geriatric fracture patients require urgent fracture fixation for
optimal outcomes, preoperative optimization is often of more practical consequence
than preoperative risk assessment and should be the primary focus of the entire care
team (emergency, orthopedics, medicine, and anesthesiology providers). There are
5 domains that typically require assessment, treatment, and monitoring to success-
fully optimize fracture patients and minimize intraoperative complications, as
follows:
 Assurance of adequate intravascular volume
 Medication adjustment in anticipation of intraoperative hypotension
 Judicious continuation of b-blockers and other antiarrhythmic/chronotropic
drugs for selected patients
 Pain control
 Prevention of polypharmacy and excessive testing

Preoperative Fluid Management

Almost all geriatric fracture patients will benefit from intravascular volume restora-
tion. In addition to acute blood loss, fracture patients typically have little oral intake
in the hours before fracture repair, are on chronic cardiovascular medications that
promote hypotension and diuresis, and receive intravenous analgesic and anesthetic
medications that result in vasodilation. This finding is true even in patients with
known ventricular dysfunction, because adequate ventricular filling pressures are
necessary to maintain cardiac output. The risks of intraoperative hypotension likely
exceed the risks of excessive volume administration, in terms of clinical con-
sequence and reversibility. For these reasons, liberal administration of isotonic intra-
venous fluids is necessary for the optimization of most patients and should be
titrated with close clinical attention for pulmonary edema. Clinically significant acute
congestive heart failure is not frequently reported in geriatric fracture centers,
emphasizing preoperative hydration.20
 Preoperative Optimization and Risk Assessment 213

Medication Management
Medications that promote hypotension (Table 5) should be withheld in the preoper-
ative period, with an exception for chronic chronotropic medications, including b-
blockers, and antihypertensives with known withdrawal consequence (eg, clonidine).
In light of ongoing acute blood loss, and the reduction in blood pressure that results
from most analgesics and anesthetics, most patients will not uniformly tolerate or
benefit from continuation of chronic antihypertensive or afterload-reducing medica-
tions. Angiotensin-converting enzyme (ACE) inhibitors and receptor blockers have
been associated with acute kidney injury in the perioperative setting,30,31 and
some advocate for routine cessation of ACE-I/angiotensin-receptor blockers in the
preoperative period.32,33 Although the long-term efficacy of ACE inhibition or
blockade in managing chronic systolic cardiac dysfunction and diabetic nephropathy
has been well established, use in the immediate perioperative period is likely compli-
cated by impairment of renal compensatory mechanisms in the face of rapidly fluc-
tuating intravascular volume status. Short-term cessation or dose attenuation in this
setting is not known to cause harm and likely prevents acute kidney injury in some
patients. When used for rate control for chronic stable tachyarrythmias, nondihydro-
pyridine calcium channel blockers (eg, diltiazem or verapamil) may need to be
continued in the perioperative setting, but these benefits need to be weighed against
the risks of hypotension. Dihydropyridine calcium channel blockers (eg, amlodipine,
felodipine) should be withheld if hypotension is anticipated or demonstrated. Loop
diuretics are typically withheld in the immediate preoperative and postoperative
period, until perioperative blood loss and intravascular volume have stabilized.
Depending on their indications, antiplatelet and anticoagulant therapy are typically
withheld and/or reversed in the preoperative period, to minimize blood loss.
Condition-specific details for patients at high risk for thromboembolic disease (me-
chanical valve replacement, atrial thrombus) are considered elsewhere in this issue.
Other noncardiac medications are also important to adjust and monitor in the

Table 5
Common preoperative medication considerations

Medications Clinical Considerations Strategies

Antihypertensives May promote excessive
hypotension in perioperative
settings
Diabetic agents Risk for hypoglycemia with low
enteral intake
Chronic opiate therapy Increased tolerance may
require higher opiate doses
for pain control
Sudden cessation may
precipitate withdrawal
Antiplatelet and Typically held until
anticoagulant agents postoperative bleeding is
controlled
Hold nonchronotropic
medications until patient
demonstrates a need
postoperatively
Continue home b-blockers,
avoid hypotension
Hold oral agents, reduce long-
acting insulin doses, and
closely monitor blood
glucoses
Monitoring for pain control,
sedation, or withdrawal
Consider nonpharmacologic
adjunctive therapy (nerve
blocks, rapid surgical
fixation)
214 Nicholas

preoperative period, including chronic diabetic medications and chronic opiate and
benzodiazepine therapy (see Table 5).
b-Blockers
Since the initial publication of data supporting the widespread use of b-blockers in the
perioperative setting, several subsequent studies have suggested a more nuanced
approach in patients undergoing noncardiac surgery, with many studies failing to
confirm benefit.34–36 The cardioprotective benefits of b-blockade contrast with the
risks of hypotension in the acute perioperative setting, particularly in frail patients
with such a physiologic tendency. There are no trials dedicated to studying the impact
of b-blockers specifically, or postoperative blood pressure control in general, in
patients older than 75 years. In the PeriOperative Ischemia Study Evaluation (POISE)
trial,37 the largest randomized trial of perioperative b-blockade, patients with age
greater than 70 years, and those with hypotension had increased rates of stroke and
death. In addition, there is a unique risk for exaggerated hypotension in the acutely
bleeding hip fracture patient, and at least one retrospective analysis suggests that
b-blocked patients do not tolerate surgical anemia as well as non-b-blocked patients.38
Current ACC guidelines recommend continuing chronic b-blocker therapy in surgical
patients, but also to avoid hypotension and bradycardia.39 A recent meta-analysis40
of secure randomized trials concluded that the risks of routine b-blockade outweighed
any benefit in the general population, although this analysis was dominated by studies
using relatively high doses of medications (100 mg metoprolol) in naive patients.
Some geriatric fracture centers have reported low rates of cardiovascular complica-
tions using protocols that include low-dose b-blockade (25 mg metoprolol).10
Pain Control
Prompt and adequate pain control is an essential component of preoperative optimi-
zation and the prevention of complications.41 Adequate preoperative pain control is
associated with delirium prevention, reductions in myocardial stress and oxygen de-
mand, and improved stability for surgical repair. The major components of expert pain
control include the use of parenteral opiates and timely surgical repair and can be sup-
plemented by local nerve blocks and other anesthetic techniques.
Laboratory Testing
Recommended preoperative laboratory testing for the typical geriatric hip fracture
patient is limited to a small number of laboratory tests and essential radiographic
studies (Table 6). Extensive testing is unlikely to benefit most patients and can

Table 6
Recommended preoperative tests for geriatric fracture patients

Test Indications
Complete blood count Evaluate for anemia, provide baseline to quantify
additional blood loss
Prothrombin time/International For patients on warfarin therapy, or at risk for
normalized ratio malnutrition, malabsorption, or liver disease
Electrolytes, renal function, albumin Evaluate for acute and chronic kidney disease,
malnutrition, acute electrolyte abnormalities
(eg, hyponatremia, hypercalcemia)
Electrocardiogram For patients with risk factors for atherosclerosis
or cardiomyopathy or history of arrhythmia
 Preoperative Optimization and Risk Assessment 215

promote complications by delaying optimization efforts, pain control, and surgical

repair. Some commonly used preoperative tests (urinalysis, chest radiography)
are of unclear clinical benefit and are unlikely to be beneficial for asymptomatic
individuals.42,43

NONOPERATIVE MANAGEMENT

Compared with nonoperative management, surgical repair of hip fractures is associ-

ated with reduced mortality, improved functional status, and reduced complications.44
Even for patients with limited life expectancy or patients with an inability to ambulate
before fracture, surgical repair of hip fracture can offer improvements in pain control,
edema, blood loss, and quality of life. For the small group of patients with excessive
perioperative risk of mortality, nonoperative management can be considered, partic-
ularly if patients are likely to expire in the perioperative or immediate postoperative
period, or if pharmacologic pain control is adequate during care needs.
Despite having higher short-term mortality rates, nonoperatively managed patients
who survive 1 month seem to have 1-year mortality rates similar to those undergoing
operative repair,45,46 and a small minority can regain the ability to self-transfer and
ambulate with assistive devices.47
Decisions for nonoperative management should reflect a confluence of the patient’s
goals of care, life expectancy, quality of life with pharmacologic pain control, and a
realistic assessment of perioperative risk. Explicit discussions regarding end-of-life
care and prognosis are typically warranted in these cases.

SUMMARY

Multiply comorbid geriatric fracture patients generally benefit from rapid optimization
and surgical repair. Preoperative evaluation should be focused on exclusion of a small
number of contraindications to acute surgical repair, and rapid optimization of intra-
vascular volume status, pain control, and anticipation of hypotension. Extensive pre-
operative testing and consultation does not seem to be beneficial to most geriatric
fracture patients and may be associated with surgical delay.

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