From Clinic to Recovery · First Edition
Chapter 24 — Older Adults: Frailty, Delirium, and Goals of Care
Dr. Tamer Rushdy Elalfy · 11 min read
In this chapter
Age alone is a poor guide to surgical risk. Two patients of the same age can have very different reserves, and the more useful question is how frail a person is: how well their body and mind can withstand the stress of an operation and recover afterward. Frail older adults face higher risks of complications, loss of independence, and delirium, a sudden state of confusion that is frightening for patients and families and is often mistaken for dementia or “just old age.” This chapter covers frailty assessment, delirium prevention, and the conversations about goals of care that matter most for this group of patients.
Learning objectives After reading this chapter you should be able to:
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Table 24.1. Older adults and surgery at a glance.
| At a glance | |
|---|---|
| Key question | How frail is this patient, not just how old |
| Frailty tool | Clinical Frailty Scale (1 fit to 9 terminally ill) or an equivalent validated tool |
| Delirium | A sudden, fluctuating change in attention and awareness; common, often missed, usually reversible |
| Prevention | A non-drug bundle: orientation, glasses and hearing aids, early mobilization, sleep, hydration, and medicine review |
| The key counseling message | “We plan around what matters most to you and your family, and we work hard to protect your mind as well as your body.” |
STEP 1 Assessing frailty and explaining the plan
24.1 Frailty, not just age
Frailty is a state of reduced physiological reserve that makes a person more vulnerable to stressors such as surgery. A simple, widely used tool is the Clinical Frailty Scale, which assigns a level from 1 (very fit) to 9 (terminally ill) based on function and independence rather than diagnosis [1]. Best-practice guidelines recommend assessing frailty, cognition, function, nutrition, and the patient’s own goals before elective surgery in older adults [2]. A frail patient having major surgery benefits most from this assessment, because many risks can be reduced with preparation.
Script: assessing frailty and goals “Tell me about a typical day: what you do for yourself, what help you need, and how you get around.” “Have you had any confusion, memory problems, or falls recently?” “What matters most to you about this operation and your recovery?” |
24.2 Delirium: what it is and why it matters
Delirium is a sudden, fluctuating disturbance of attention and awareness, usually developing over hours to days. It is common after surgery in older adults, is frequently missed or mistaken for dementia, and is linked to longer hospital stays, loss of independence, and higher mortality [3]. It can present as agitation (hyperactive), as quietness and withdrawal (hypoactive, often missed), or as a mixture of both. Family members often notice the change first, because they know the patient’s usual self.
Script: explaining delirium to families “Sometimes after an operation, older patients become confused for a while: muddled, seeing things that are not there, or unusually sleepy or agitated. This is called delirium. It is common, frightening to watch, and almost always temporary. It is not the same as dementia, though it is more likely in someone who already has memory problems. You can help by sitting with your relative, bringing familiar objects, and telling us if anything seems different from their usual self.” |
24.3 Preventing delirium
Multicomponent, non-drug prevention programs, such as the Hospital Elder Life Program, reduce the incidence of delirium by about a third in trials and are recommended as first-line prevention [4, 5]. Figure 24.1 summarizes the bundle in a form that can be used on surgical wards. Sedating medicines, particularly benzodiazepines, and the use of bladder catheters and physical restraints should be minimized, because each increases the risk of delirium.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 24.1. A non-drug delirium prevention bundle for surgical wards, adapted from the Hospital Elder Life Program.
24.4 Family involvement and autonomy
Family involvement is often welcome and protective, but the patient’s own wishes come first. Ask the patient, with capacity, whom they want involved and how much they want shared, exactly as for any adult (Section 1.9). Some older patients prefer their children to make decisions; others wish to decide for themselves and are frustrated when family members speak over them in clinic. Address the patient directly, even when family are present, and check their own view.
24.5 Goals of care
For frail patients having major or high-risk surgery, a conversation about goals of care is part of good consent, not a separate, difficult subject to avoid. Ask what matters most: living as long as possible, remaining independent, avoiding time in intensive care or on a breathing machine, or comfort. Record whether the patient has an advance directive or a preferred decision-maker, and what should happen if a major complication occurs. These conversations should happen before surgery, calmly, and be revisited if the patient’s condition changes.
STEP 2 Preparation and recovery
24.6 Before the operation
- Frailty and function. Assess with a simple tool; involve geriatric medicine for frail patients having major surgery where available.
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Cognition. A brief cognitive screen helps interpret any postoperative change and supports consent discussions.
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Nutrition. Screen for malnutrition; many older patients benefit from nutritional support before major surgery.
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Medicines. Review for medicines that increase delirium or fall risk, and simplify the regimen where possible.
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Sensory aids. Make sure glasses and hearing aids travel with the patient and are used, not left at home.
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Goals of care. Document the conversation and the patient’s wishes.
24.7 After the operation
Use the delirium prevention bundle for every at-risk patient, not only those who develop symptoms. Encourage family presence, familiar objects, and a normal day-night routine. Treat pain, constipation, urinary retention, and infection promptly, since each can trigger or worsen delirium. If delirium develops, identify and treat the underlying cause, keep the patient safe, reorient gently and repeatedly, avoid restraints where possible, and use medicines only for severe agitation that risks safety, at the lowest dose, for the shortest time. Falls risk should be assessed and mobility encouraged with support rather than by restricting movement.
STEP 3 Questions patients and families ask
“Is my relative too old for this operation?”
Age alone does not decide this. We look at fitness, independence, and other health problems, and we will be honest about the risks and benefits for this specific person.
“Why did my mother become confused after the operation?”
This is called delirium. It is common after surgery in older adults, is usually temporary, and we are treating the cause and supporting her through it [3].
“Will the confusion be permanent?”
Usually not. Most people recover fully over days to weeks, though recovery can take longer in people who already had memory problems.
“Can I stay with my relative in hospital?”
Yes, where possible. Family presence helps prevent and ease delirium, and we welcome it.
“Should we decide this together as a family, or should Mum decide?”
We follow what your mother wants. If she has capacity, the decision and how much to involve you are hers to make.
“What if something goes seriously wrong during the operation?”
We will talk this through beforehand, so we know what matters most to you and can act accordingly.
STEP 4 Risks, warning signs, and consent
24.8 Additional risks
Table 24.2. Additional risks for frail older adults. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Delirium after major surgery in frail patients | Up to about 1 in 5, higher with greater frailty [3] | “Confusion after the operation is common in people of your age and fitness.” |
| Common | Slower recovery of strength and independence | [unit data] | “It may take longer to get back to normal than for a younger person.” |
| Less common | Falls, pressure injuries, and loss of independence after hospital stay | [unit data] | “We work to keep you moving safely to prevent this.” |
| Rare but serious | Permanent decline in function or memory after a major complication | [unit data] | “Rarely, a serious complication can permanently affect your independence.” |
24.9 Checklist
Before surgery ☐ Frailty, cognition, function, and nutrition assessed. ☐ Goals-of-care conversation held and documented. ☐ Patient’s wishes about family involvement confirmed directly with the patient. ☐ Medicines reviewed for delirium and fall risk. ☐ Glasses, hearing aids, and walking aids arranged to accompany the patient. ☐ Delirium prevention bundle planned for the ward stay. |
24.10 Warning signs
Table 24.3. Green, amber, and red warning signs for older adults after surgery.
| Level | Signs | What to do |
|---|---|---|
| Green | Mild tiredness or slower thinking for a few days, improving | Expected. Keep up normal routines and the prevention bundle. |
| Amber | New confusion, drowsiness, or agitation Not eating or drinking, or a fall without injury | Tell the nursing staff or call the clinic the same day. |
| Red | Sudden severe confusion with safety concerns A fall with injury, or loss of consciousness Signs of a stroke: sudden weakness, facial droop, or slurred speech | Call for urgent help or an ambulance now. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients and families. Add your unit’s name, phone numbers, and review date before use.
PATIENT AND FAMILY GUIDE Surgery for Older Adults: Protecting Mind and Body For patients and the family members supporting them. |
About delirium
Some older patients become confused for a while after an operation. This is called delirium. It is common, frightening to see, and almost always temporary. It is not the same as dementia.
How family can help
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Visit often and bring familiar objects, like photos.
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Make sure glasses and hearing aids are worn.
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Gently remind the person of the day, time, and where they are.
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Tell the nurses if your relative seems different from usual.
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Encourage eating, drinking, and getting out of bed with help.
1. What to expect
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Recovery may be slower than for a younger person. This is normal.
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Mild tiredness or slower thinking can happen for a few days.
2. Staying safe at home
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Keep walking aids, glasses, and hearing aids close by.
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Clear rugs and clutter to prevent falls.
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Eat regular meals and drink enough fluids.
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Take medicines exactly as prescribed.
3. Getting back to normal
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Recovery is individual. Follow the specific guide for your operation in this book for timelines.
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Build up activity gradually, with support if needed.
Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Mild tiredness or slower thinking for a few days, improving | This is normal. Keep up normal routines. |
| AMBER | New confusion, drowsiness, or agitation; not eating or drinking; a fall without injury | Tell the nurse or call us today. |
| RED | Sudden severe confusion with safety concerns; a fall with injury; sudden weakness, facial droop, or slurred speech | Call for urgent help or an ambulance now. |
My contacts Surgical team: ______________________ Geriatric team: ______________________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495.
2. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; American College of Surgeons NSQIP; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.
3. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922.
4. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.
5. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg. 2015;220(2):136-148.e1.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.