PERIOPERATIVE RISK STRATIFICATION AND OPTIMIZATION IN ELDERLY SURGICAL PATIENTS: A REVIEW OF MODERN STRATEGIES AND BIOLOGICAL MARKERS IN THE ERA OF VALUE-BASED HEALTHCARE
DOI:
https://doi.org/10.31435/ijitss.1(49).2026.5189Keywords:
Geriatric Surgery, Frailty Syndrome, Value-Based Healthcare, Prehabilitation, Postoperative DeliriumAbstract
Background: The aging of the global population has triggered an unprecedented rise in complex surgical procedures for patients aged 80 and over. Traditional risk assessment models frequently fall short of identifying the true biological vulnerability of older adults. This study provides a critical analysis of contemporary risk stratification methods, with a particular emphasis on frailty syndrome, multimorbidity, and inflammatory-nutritional biomarkers.
Methods: We conducted a structured narrative review of literature from 2015 to 2025, indexed in PubMed, MEDLINE, and EMBASE. The analysis included 33 high-impact publications, including the latest 2025 American Society of Anesthesiologists (ASA) guidelines, EAES/SAGES consensus statements, and results from multicenter snapshot studies (SNAP-2, SNAP-3). A narrative synthesis was chosen to allow for a broader pathophysiological interpretation of data characterized by high biological heterogeneity.
Results: Our analysis confirms that frailty syndrome is a more potent predictor of 30-day mortality than chronological age (RR=3.71; 95% CI:2.89-4.77 [Tjeertes et al., 2020]). The data revealed a significant discrepancy between early mortality (approximately 2.0%) and 1-year mortality (13.4% [Gill et al., 2022]), suggesting that surgical trauma often serves as a "tipping point" that initiates a cascade of functional decline.
Biomarkers are essential for identifying this "biological frailty." Specifically, hypoalbuminemia (<35 g/L) is linked to a substantial increase in the risk of postoperative pneumonia (RR=6.18 [Tian et al., 2022]), while a C-reactive protein-to-albumin ratio (CAR≥1.5) doubles the risk of postoperative delirium (OR=2.11 [Kim et al., 2023]). Furthermore, modern multimodal prehabilitation programs effectively reduce complication rates (OR=0.64; 95% CI:0.45-0.92 [McIsaac et al., 2025]).
Conclusions: Effective care for geriatric patients requires the implementation of a hybrid model, one that integrates the traditional ASA classification with structured frailty assessments, such as the Clinical Frailty Scale (CFS), and biochemical profiling. The primary goal of treatment has shifted toward disability-free survival. Achieving this requires personalized care through comprehensive prehabilitation and a robust shared decision-making (SDM) process. The proposed four-layer model offers a practical framework for modern risk stratification in geriatric surgery.
References
Bohl, D. D., Shen, M. R., Hannon, C. P., Fillingham, Y. A., Darrith, B., & Della Valle, C. J. (2017). Serum albumin predicts survival and postoperative course following surgery for geriatric hip fracture. Journal of Bone and Joint Surgery, 99(24), 2110–2118. https://doi.org/10.2106/JBJS.16.01620
Chan, R., Ueno, R., Afroz, A., Billah, B., Tiruvoipati, R., & Subramaniam, A. (2022). Association between frailty and clinical outcomes in surgical patients admitted to intensive care units: A systematic review and meta-analysis. British Journal of Anaesthesia, 128(2), 258–271. https://doi.org/10.1016/j.bja.2021.11.018
Chen, C., Chen, X., Chen, J., Xing, J., Hei, Z., Zhang, Q., Liu, Z., & Zhou, S. (2022). Association between preoperative hs-CRP/albumin ratio and postoperative SIRS in elderly patients: A retrospective observational cohort study. The Journal of Nutrition, Health & Aging, 26(4), 352–359. https://doi.org/10.1007/s12603-022-1761-4
Deiner, S. G., Marcantonio, E. R., Trivedi, S., Inouye, S. K., Travison, T. G., Schmitt, E. M., Hshieh, T., Fong, T. G., Ngo, L. H., & Vasunilashorn, S. M. (2024). Comparison of the frailty index and frailty phenotype and their associations with postoperative delirium incidence and severity. Journal of the American Geriatrics Society, 72(6), 1781–1792. https://doi.org/10.1111/jgs.18677
Devereaux, P. J., & Sessler, D. I. (2015). Cardiac complications in patients undergoing major noncardiac surgery. New England Journal of Medicine, 373(23), 2258–2269. https://doi.org/10.1056/NEJMra1502824
Dillon, S. T., Vasunilashorn, S. M., Ngo, L., Otu, H. H., Inouye, S. K., Jones, R. N., Alsop, D. C., Kuchel, G. A., Metzger, E. D., Arnold, S. E., Marcantonio, E. R., & Libermann, T. A. (2017). Higher C-reactive protein levels predict postoperative delirium in older patients undergoing major elective surgery: A longitudinal nested case-control study. Biological Psychiatry, 81(2), 145–153. https://doi.org/10.1016/j.biopsych.2016.03.2098
Elfrink, A. K. E., Alberga, A. J., van Berge Henegouwen, M. I., Scheurs, W. H., van der Geest, L. G. M., Verhagen, H. J. M., Dekker, J. T., Grünhagen, D. J., Wouters, M. W. J. M., & Klaase, J. M. (2022). Outcomes after major surgical procedures in octogenarians: A nationwide cohort study. World Journal of Surgery, 46(10), 2399–2408. https://doi.org/10.1007/s00268-022-06642-6
Fagard, K., Geyskens, L., Van den Bogaert, B., Willems, S., Flamaing, J., Wolthuis, A., & Deschodt, M. (2025). Frailty screening in older patients undergoing elective colorectal surgery: Comparative study of seven screening instruments. Journal of the American Geriatrics Society, 73(4), 1060–1072. https://doi.org/10.1111/jgs.19317
Fowler, A. J., Wahedally, M. A. H., Abbott, T. E. F., Prowle, J. R., Cromwell, D. A., & Pearse, R. M. (2023). Long-term disease interactions amongst surgical patients: A population cohort study. British Journal of Anaesthesia, 131(2), 258–268. https://doi.org/10.1016/j.bja.2023.04.041
Gill, T. M., Vander Wyk, B., Leo-Summers, L., Murphy, T. E., & Becher, R. D. (2022). Population-based estimates of 1-year mortality after major surgery among community-living older US adults. JAMA Surgery, 157(10), Article e223303. https://doi.org/10.1001/jamasurg.2022.5155
Keller, D. S., Curtis, N., Burt, H. A., Ammirati, C. A., Collings, A. T., Polk, H. C., Jr., Carrano, F. M., Antoniou, S. A., Hanna, N., Piotet, L. P., Hill, S., Cuijpers, A. C. M., Tejedor, P., Milone, M., Andriopoulou, E., Kontovounisios, C., Leeds, I. L., Awad, Z. T., Barber, M. W., ... Francis, N. (2024). EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults. Surgical Endoscopy, 38(8), 4104–4126. https://doi.org/10.1007/s00464-024-10977-7
Kilhamn, N., Eriksson, J., von Oelreich, E., Fagerlund, M. J., Oldner, A., & Larsson, E. (2026). Age, ASA physical status and surgical outcomes: Insights from a nationwide cohort study. Anaesthesia, 81(2), 188–200. https://doi.org/10.1111/anae.16723
Kim, H. J., Lee, S., Kim, S. H., Lee, S., Sim, J. H., & Ro, Y. J. (2023). Association of C-reactive protein to albumin ratio with postoperative delirium and mortality in elderly patients undergoing hip fracture surgery: A retrospective cohort study in a single large center. Experimental Gerontology, 172, Article 112068. https://doi.org/10.1016/j.exger.2022.112068
Kim, S., Brooks, A. K., & Groban, L. (2015). Preoperative assessment of the older surgical patient: Honing in on geriatric syndromes. Clinical Interventions in Aging, 10, 13–27. https://doi.org/10.2147/CIA.S75285
Li, P., Zhang, Z. R., Chen, D., Zhi, H., Hu, J., Xie, P., Wen, L., & Yan, S. T. (2025). The relationship between preoperative hypoalbuminemia and postoperative subsyndromal delirium in elderly hip fracture patients: A prospective study. Frontiers in Medicine, 12, Article 1631585. https://doi.org/10.3389/fmed.2025.1631585
Ma, J., Xin, Q., Wang, X., Gao, M., Wang, Y., & Liu, J. (2015). Prediction of perioperative cardiac events through preoperative NT-pro-BNP and cTnI after emergent non-cardiac surgery in elderly patients. PLOS ONE, 10(3), Article e0121306. https://doi.org/10.1371/journal.pone.0121306
McIsaac, D. I., Taljaard, M., Bryson, G. L., Beaulé, P. E., Gagné, S., Hamilton, G., Hladkowicz, E., Huang, A., Joanisse, J. A., Lavallée, L. T., MacDonald, D., Moloo, H., Thavorn, K., van Walraven, C., Yang, H., & Forster, A. J. (2018). Frailty as a predictor of death or new disability after surgery: A prospective cohort study. Annals of Surgery, 267(2), 307–314. https://doi.org/10.1097/SLA.0000000000002967
McIsaac, D. I., Gill, M., Boland, L., Hutton, B., Branje, K., Shaw, J., Grudzinski, A. L., Barone, N., & Gillis, C. (2021). Prehabilitation in adult patients undergoing surgery: An umbrella review of systematic reviews. British Journal of Anaesthesia, 128(2), 244–257. https://doi.org/10.1016/j.bja.2021.11.014
McIsaac, D. I., Kidd, G., Gillis, C., Branje, K., Al-Bayati, M., Baxi, A., Grudzinski, A. L., Boland, L., Veroniki, A. A., Wolfe, D., & Hutton, B. (2025). Relative efficacy of prehabilitation interventions and their components: Systematic review with network and component network meta-analyses of randomised controlled trials. BMJ, 388, Article e081164. https://doi.org/10.1136/bmj-2024-081164
Nipper, C. A., Lim, K., Riveros, C., Hsu, E., Ranganathan, S., Xu, J., Brooks, M., Esnaola, N., Klaassen, Z., Jerath, A., Arrington, A., Wallis, C. J. D., & Satkunasivam, R. (2022). The association between serum albumin and post-operative outcomes among patients undergoing common surgical procedures. Journal of Clinical Medicine, 11(21), Article 6543. https://doi.org/10.3390/jcm11216543
Puzianowska-Kuźnicka, M., Walicka, M., Osińska, B., Rutkowski, D., Gozdowski, D., Czech, M., Durlik, M., & Franek, E. (2016). In-hospital mortality in a 4-year cohort study of 3,093,254 operations in seniors. World Journal of Surgery, 40(7), 1552–1560. https://doi.org/10.1007/s00268-015-3400-2
Ramadan, O. I., Rosenbaum, P. R., Reiter, J. G., Jain, S., Hill, A. S., Hashemi, S., Kelz, R. R., Fleisher, L. A., & Silber, J. H. (2023). Redefining multimorbidity in older surgical patients. Journal of the American College of Surgeons, 236(5), 1011–1022. https://doi.org/10.1097/XCS.0000000000000659
Rosen, C. B., Roberts, S. E., Wirtalla, C. J., Ramadan, O. I., Keele, L. J., Kaufman, E. J., Halpern, S. D., & Kelz, R. R. (2023). Analyzing impact of multimorbidity on long-term outcomes after emergency general surgery: A retrospective observational cohort study. Journal of the American College of Surgeons, 236(2), 303–314. https://doi.org/10.1097/XCS.0000000000000303
Saetang, M., Kunapaisal, T., Chatmongkolchart, S., Yongsata, D., & Sukitpaneenit, K. (2025). Association of frailty with intraoperative complications in older patients undergoing elective non-cardiac surgery. Journal of Clinical Medicine, 14(2), Article 593. https://doi.org/10.3390/jcm14020593
Sieber, F. E., McIsaac, D. I., Deiner, S., Azefor, T., Berger, M., Hughes, C., Leung, J. M., Maldon, J., McSwain, J. R., Neuman, M. D., Russell, M. M., Tang, V., Whitlock, E., Whittington, R., Marbella, A. M., Agarkar, M., Ramirez, S., Dyer, A., Blanck, J. F., ... Domino, K. B. (2025). 2025 American Society of Anesthesiologists practice advisory for perioperative care of older adults scheduled for inpatient surgery. Anesthesiology, 142(1), 22–51. https://doi.org/10.1097/ALN.0000000000005172
Swarbrick, C. J., Williams, K., Evans, B., Blake, H. A., Poulton, T., Nava, S., Shah, A., Martin, P., Partridge, J. S. L., & Moppett, I. K. (2025). Postoperative outcomes in older patients living with frailty and multimorbidity in the UK: SNAP-3, a snapshot observational study. British Journal of Anaesthesia, 135(1), 166–176. https://doi.org/10.1016/j.bja.2025.04.026
Tian, Y., Zhu, Y., Zhang, K., Tian, M., Qin, S., & Li, X. (2022). Relationship between preoperative hypoalbuminemia and postoperative pneumonia following geriatric hip fracture surgery: A propensity-score matched and conditional logistic regression analysis. Clinical Interventions in Aging, 17, 1519–1528. https://doi.org/10.2147/CIA.S352736
Tjeertes, E. K. M., van Fessem, J. M. K., Mattace-Raso, F. U. S., Hoofwijk, A. G. M., Stolker, R. J., & Hoeks, S. E. (2020). Influence of frailty on outcome in older patients undergoing non-cardiac surgery: A systematic review and meta-analysis. Aging and Disease, 11(5), 1276–1290. https://doi.org/10.14336/AD.2019.1024
van Koningsveld-Couperus, B. H., de Rooij, T., van Meeteren, N. L., Preckel, B., Hollmann, M. W., & Nieuwenhuijs-Moeke, G. J. (2025). Prehabilitation: A catalyst for transforming toward value-based, personalized perioperative health and care. Journal of Clinical Medicine, 14(19), Article 6747. https://doi.org/10.3390/jcm14196747
Vasunilashorn, S. M., Dillon, S. T., Inouye, S. K., Ngo, L. H., Fong, T. G., Jones, R. N., Travison, T. G., Schmitt, E. M., Alsop, D. C., Freedman, S. D., Arnold, S. E., Metzger, E. D., Libermann, T. A., & Marcantonio, E. R. (2017). High C-reactive protein predicts delirium incidence, duration, and feature severity after major noncardiac surgery. Journal of the American Geriatrics Society, 65(8), e109–e116. https://doi.org/10.1111/jgs.14913
Wang, J., Yu, H., Xu, X., & Guo, J. (2025). Bidirectional relationship between hypoalbuminemia and postoperative pneumonia in elderly hip fracture patients: A retrospective cohort study. Clinical Interventions in Aging, 20, 123–135. https://doi.org/10.2147/CIA.S523802
Wong, D. J. N., Harris, S., Sahni, A., Bedford, J. R., Cortes, L., Shawyer, R., Wilson, A. M., Lindsay, H. A., Campbell, D., Popham, S., Barneto, L. M., Myles, P. S., & Moonesinghe, S. R. (2020). Developing and validating subjective and objective risk-assessment measures for predicting mortality after major surgery: An international prospective cohort study. PLOS Medicine, 17(10), Article e1003253. https://doi.org/10.1371/journal.pmed.1003253
Zietlow, K. E., Wong, S., Heflin, M. T., McDonald, S. R., Sickeler, R., Devinney, M., Blitz, J., Lagoo-Deenadayalan, S., & Berger, M. (2021). Geriatric preoperative optimization: A review. The American Journal of Medicine, 135(3), 297–303. https://doi.org/10.1016/j.amjmed.2021.07.028
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Copyright (c) 2026 Kornelia Domagała, Małgorzata Anna Ziółek, Magdalena Maroszek, Kamil Szymczak, Bartosz Janik, Ariadna Bakier
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