Frailty is a syndrome which transcends comorbidity and is characterized by fatigue, weight loss, and low functional activity levels[9]. The frailty phenotype is associated with significant perioperative morbidity and mortality[10, 11]. Frailty is more common in older surgical patients when compared to community dwelling older people. Recent studies in both cardiac and noncardiac surgical populations suggest that preoperative frailty is a predictor of complications such as infection, reintubation, pneumonia, hospital length of stay, institutionalization, and mortality (Table 9.3) [6, 12–15]. Frailty may be amenable to treatment with nutritional support, prehabilitation, rehabilitation, and vitamin supplementation [16, 17]. Therefore, preoperative identification of frailty is useful for risk stratification, discharge planning and may identify patients whose condition could be optimized prior to surgery [18].

Traditional frailty assessments are time consuming and require trained personnel [19] although short form screening tools have been developed and can be administered by a layperson making them more relevant to the preoperative evaluation when attempting to identify older frail patients [20]. While frailty screening is currently not the universal standard of care, such a holistic approach will likely become useful to identify patients at risk for adverse outcomes and allow not only for risk stratification, but to aid in patient and family counseling, and identify interventions to reduce postoperative complications. The reader is referred to Chap. 1 on Frailty for a full discussion.

Geriatric surgical patients are at high risk for polypharmacy and medication errors. This is compounded by frequent discrepancies between the surgical and anesthesiology medication records [21]. Polypharmacy is a strong predictor of such discrepancies [22]. Strategies to reduce discrepancies include encouraging patients to carry an updated medication list provided by their physician [22, 23] and medication reconciliation conducted by a clinical pharmacist at both hospital admission and discharge. Most chronic medications can be continued throughout the perioperative period while others may complicate intraoperative anesthetic management and affect postoperative outcomes. In this section we discuss the perioperative management of medications commonly used by older people.

Antihypertensive medications are commonly prescribed for older patients for blood pressure control. In most circumstances antihypertensive medications should be continued in the perioperative period, however, some antihypertensive medications require special consideration. Perioperative use of angiotensin converting enzyme (ACE) inhibitors /angiotensin receptor blockers (ARB) have been associated with protracted perioperative hypotension due to suppression of the renin-angiotensin-aldosterone-system (RAAS) preventing the normal hormonal and sympathetic response to surgical stress. However, the traditional practice of withholding ACE inhibitors and ARBs prior to elective surgery has recently been challenged because ACE/ARB related intraoperative hypotension has not been linked to adverse perioperative outcomes [24]. The 2014 ACC/AHA guidelines state that continuation of ACE inhibitors and ARBs is reasonable, and that if they are discontinued they should be restarted as soon as medically feasible [25, 26]. Generally, it seems reasonable to withhold ACE/ARB based on the patient’s presenting blood pressure, likelihood of intraoperative fluid shifts, and risk of hypotension in the light of either surgical or medical conditions. Beta blockers are another commonly prescribed class of antihypertensive drugs that were thought to decrease risk of perioperative cardiac events. However, the PeriOperative ISchemic Evaluation (POISE) trial demonstrated that the benefit of beta blockers on the incidence of perioperative cardiac events was off-set by an increased incidence of perioperative stroke [27]. Current ACC/AHA guidelines recommend continuing beta blockers in the perioperative period for patients who take them chronically (Class 1 evidence) [25].

Chronic use of antiplatelet drugs is common in older surgical patients to prevent thrombosis in patients with known history of atrial fibrillation, coronary artery disease, cardiac stents, or stroke. Prevention of thrombosis may be even more important in the perioperative period, which is characterized by a proinflammatory state which increases platelet activity and aggregation. However, the benefits of antiplatelet drugs must be balanced by the risk of intra and postoperative hemorrhage.

Depression affects 15–20 % of elders and is the most common psychiatric disorder in older people. Many older patients are prescribed antidepressant medications and consequences of their use in the perioperative period should be considered preoperatively [32]. Older generation antidepressants such as monoamine oxidase inhibitors (MAO-I) may interact with medications (e.g., meperidine and ephedrine) administered in the perioperative period leading to increasing anesthetic requirements, hypertensive crises, and potentially to life threatening hyperthermia and coma. It is unclear how long or whether patients should discontinue use of MAOIs prior to surgery. Although traditional recommendations have been to discontinue these agents for 2 weeks to 30 days before surgery, many of these recommendations were not based on high quality studies. There is some concern that doing so may result in significant morbidity or even mortality in patients who depend on these medications for the management of their depression. The newer generations of antidepressants such as serotonin reuptake inhibitors (SSRIs) tend to have fewer side effects and are generally continued throughout the perioperative period. However SSRIs are associated with platelet dysfunction and bleeding [33, 34] and this risk should be balanced with the risk of postoperative depression [35]. Accordingly, it is important to identify older patients taking antidepressants prior to surgery so that a treatment plan can be developed between the patient and primary care provider or psychiatrist.