A thorough medication history should be sought from all patients. This includes prescription medications and indication, over-the-counter medications, vitamins, and herbal supplements. Over 80 % of elder adults take at least one medication, and one-third take at least five medications. This becomes especially prevalent in those 75–85 years of age. Compounding potential adverse events related to medications, nearly half of all elders use at least one over-the-counter medication, and nearly half use some sort of dietary supplement [22]. Polypharmacy can be defined by either the absolute number of drugs taken or the use of medications without appropriate indication or the use of duplicate medications. Inappropriate prescribing may be present in half of older adults, and contributes to cognitive impairment, falls, incontinence, and impairment [23]. All unnecessary medications should be discontinued in the perioperative period.

When considering medication use in the perioperative period, consider the potential for withdrawal from the medication, potential progression of disease while the medication is not administered, and the potential for interactions with anesthetic agents. Abrupt discontinuation of medications may lead to complications from withdrawal syndromes which include selective serotonin reuptake inhibitors (SSRIs), beta-blockers, clonidine, statins, and corticosteroids. Other drugs such as tricyclic antidepressants, benzodiazepines, MAO inhibitors, and antipsychotics are generally deemed safe in the perioperative period and need not be discontinued. ACE inhibitors and angiotensin receptor blockers should be continued unless the only indication is for hypertension and this is well controlled [24]. Drug therapy may be predictive of postoperative complications, but withholding of regular medications, especially those used to treat cardiovascular disease, also increases complications. The rate of complications, especially cardiac, increases with the time the patient is off the medication. All essential medications discontinued at the time of surgery should be resumed as soon as safely possible during the postoperative period [25].

Recent enthusiasm for the use of perioperative beta-blockade has been tempered by the findings from a large-scale study which demonstrated that despite significant reduction in cardiac events and myocardial infarction, an increase in both stroke and death in patients treated with metoprolol was observed [26]. The current recommendations for perioperative beta-blocker therapy are:

Numerous studies of perioperative statin use in patients undergoing noncardiac surgery and coronary artery bypass grafting have been conducted, and the majority of these have shown that statins are beneficial in surgical patients, with reduction in mortality and myocardial infarction. Long-term mortality may also be improved by the use of statins in the perioperative setting. The current recommendations for the use of statins are:

Steroids should be continued when possible during the perioperative period. Withholding these drugs for 36–48 h before surgery is predictive of the need for stress dose steroids due to hypotension. When the routine dose of steroids is continued during the perioperative period, patients do not require stress doses of steroids. Stress dose steroid use is only required when patients are being treated for primary failure of the hypothalamic-pituitary-adrenal axis [28].

The use of supplements by patients has been found in 30 % of the surgical population, and use is increasing. These same studies have found that 70 % of the patients taking these preparations failed to disclose their use during the preoperative assessment unless specifically asked. Excessive bleeding, myocardial infarction, excessive and inadequate anesthesia, or interference with needed therapeutic drugs have been documented for these supplements [29]. These supplements have various durations of effect, but the safest measure is to discontinue use 7 days prior to surgery when possible and be aware of the potential complications so they may be managed adequately [24] (Table 10.2).

Cognitive impairment and dementia are increasingly prevalent in the elderly population. Cognitive impairment without dementia is estimated to occur in 22 % of patients age 71 or older. This prevalence is greater than that of dementia. Prominent subtypes include prodromal Alzheimer’s disease, cerebrovascular disease, stroke, and adverse effect of medication. These findings are significant, as 12 % of the patients found to have cognitive impairment will progress to dementia annually. More importantly, mortality increases from 8 % in the cognitive impairment without dementia to 11 % in the group with dementia [30]. The prevalence of dementia among persons older than 71 years is 14 %. The prevalence increases dramatically with age in this group, from 5 % in those aged 71–79 years, to 37 % in the over 90 cohort [31], and to greater than 40 % in those 100 years or older [32].

The presence of cognitive impairment dramatically increases postoperative complications and negatively influences short- and long-term outcome. Baseline cognitive impairment and dementia are strong predictors for delirium in the postoperative period [33–36], and thus increase the risk of postoperative functional decline [33] and mortality [36].

During the preoperative evaluation the presence and severity of cognitive impairment should be documented if possible. Numerous tests have been developed to screen for cognitive impairment, including the Mini-Mental State Examination (MMSE), the Memory Impairment Screen (MIS), and the Mini-Cog. These tests have shown a wide range in sensitivity and specificity, and more importantly for the acute care surgeon, the time and training required to administer ranges from 1.5 to 17 min [37]. The Mini-Cog, a brief screen that employs 3-item recall and a clock drawing task, has sensitivity and specificity of 99 and 96 % and can be administered in 3 min. This strikes the best balance between accuracy and ease of administration in the acute setting [38].

The incidence of delirium has been reported at 5–52 % in a number of studies including a broad selection of surgical patients [39]. The usual onset is 2 days following operation and persists an average of 4 days [36]; the occurrence of delirium results in increased length of stay in the hospital [36, 40, 41]. Patients are also more likely to experience functional decline and impairment in the performance of activities of daily living [33]. This results in a higher likelihood of discharge to a skilled nursing or rehabilitation facility [36, 40]. Finally, mortality rates are increased for both in hospital [41] and the months following discharge [36, 40, 42].

With its profound impact on morbidity and mortality, identification and prediction of postoperative delirium has been the subject of numerous studies. It is hoped that with identification of patients at risk, measures may be taken to mitigate delirium and prevent its consequences.

Once risk factors for delirium have been identified, those that can be corrected should (Table 10.3). In the postoperative period, numerous medications have been identified which contribute to delirium and should be avoided. These include meperidine, benzodiazepines, antihistamines, and anticholinergics. Opiates should be used with caution, but pain must be adequately controlled, as this too is a risk factor for delirium [46, 47]. Some studies have shown that preoperative geriatrics consultation has been helpful to reduce the incidence of delirium. Other small trials of prophylactic antipsychotic administration have had promising but conflicting results, and their use cannot be advocated at this time [48].

The incidence of depression in those aged 71 or greater is estimated to be over 11 %, based on the presence of major or minor depressive symptoms or current treatment for depression. Dementia and pain perception are associated with increased incidence [49]. Other risk factors for depression in the elderly are disability, new medical illness, poor overall health, and bereavement [50]. In studies of patients undergoing cardiac surgery, depression has been identified as a risk factor for mortality [51]. Preoperative depression is also associated with a longer recovery time due to delayed recovery in activities of daily living (ADL) and instrumental activities of daily living (IADL) [52]. Screening for depression may be accomplished using a variety of tools. The Patient Health Questionnaire-2 (PHQ-2) is a simple and reliable screening tool for depression in the elderly. Two questions are asked in this survey. First, “In your entire life, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least 2 weeks?” Second, “In your entire life, have you ever had a time, lasting at least 2 weeks, when you didn’t care about the things that you usually cared about or when you didn’t enjoy the things that you usually enjoyed?” A positive response to either of these questions is suggestive of depression, with 100 % sensitivity and 77 % specificity [53]. When positive, the patient should be referred for evaluation when time and the patient’s medical condition allow.

A 2005–2006 epidemiologic study on the use of alcohol and drugs of abuse demonstrated that 60 % of adults over age 50 used alcohol in the year prior to the survey, 2.6 % used marijuana, and 0.41 % used cocaine [54]. Furthermore, at-risk and binge drinking is also prevalent in the elderly population, with 13 % of men and 8 % of women reporting at-risk drinking, and 14 % of men and 3 % of women reporting binge drinking [55]. The effects of preoperative alcohol use include increased risk of pneumonia, sepsis, surgical site infection (SSI) and wound disruption, and longer length of stay. With the exception of SSI, all of these factors are associated with increased mortality [56]. Exposure to alcohol may also increase the stress response to surgery and increase morbidity [57].

All patients should be screened for alcohol misuse. A simple tool is the CAGE questionnaire. This involves four questions, and a positive answer to one or more is suggestive of alcohol abuse (Table 10.4).

When identified, patients with at-risk alcohol history should be supplemented with folic acid and thiamine (100 mg) daily. Care protocols should include frequent assessment for withdrawal and appropriate medications or alcohol administered to avoid withdrawal in the postoperative period.