Optimising the frail older patient before surgery
"Medically optimised" is a phrase that gets used loosely. In practice, it means something specific: identifying the modifiable factors that increase a frail older patient's risk of complications, and addressing as many of them as possible before they go to theatre. It is not a single appointment or a blood test — it is a structured process, usually over several weeks, that changes the odds in the patient's favour.
Here is what that process actually involves.
1. Medication review and rationalisation
Polypharmacy is one of the most common — and most fixable — risk factors in older surgical patients. Optimisation means reviewing every medication against the planned procedure: which drugs need to be ceased or bridged perioperatively (anticoagulants, certain diabetic medications), which interact poorly with anaesthesia, and which can simply be stopped because they are no longer providing benefit. Deprescribing before surgery often does more for safety than any single additional test.
2. Treating what's undertreated
Frail older patients frequently present with chronic conditions that are technically managed but not well controlled — anaemia, poorly controlled diabetes, undiagnosed heart failure, or untreated depression affecting nutrition and engagement. Optimisation means actively correcting these where time allows, rather than accepting the patient's baseline as fixed.
3. Cognitive and delirium-risk planning
Establishing a cognitive baseline before surgery does two things: it identifies patients at high risk of post-operative delirium, and it gives the surgical and nursing teams a reference point to recognise delirium quickly if it occurs. For patients with known cognitive impairment, this also means having early conversations with family about what to expect.
4. Nutrition and functional reserve
Unintentional weight loss, low muscle mass, and reduced mobility all predict poorer surgical recovery. Where time permits, optimisation can include nutritional input, correction of deficiencies, and encouraging pre-operative activity — sometimes called "prehabilitation" — to build physiological reserve before the stress of surgery.
5. Realistic, shared planning
Optimisation also means an honest conversation about what surgery will and won't achieve for a particular patient, what recovery is likely to look like, and what support will be needed afterwards — before the day of admission, not after. This is as much a part of risk reduction as any clinical intervention.
Why this needs dedicated time
None of this fits comfortably into a 15-minute pre-admission slot. A geriatrician-led perioperative review takes the time to work through each of these areas, and coordinates the resulting plan directly with the surgical and anaesthetic teams — so that by the time a frail patient reaches theatre, the modifiable risks have actually been modified, not just documented.
For guidance on which patients warrant this kind of review, see When to refer an older patient for perioperative assessment. Referral details are on the How to Refer page.