Adults age 65 and older ("older adults") are the fastest growing segment of the United States population, and their number is expected to double to 89 million between 2010 and 2050. 1 Based on these evolving demographics, it is expected that there will be a concurrent rise in the demand for a variety of surgical services, including vascular surgery (with a projected growth of 31%) and general surgery (with a projected growth of 18%). 2 Older adult surgical patients often require a different level of care than younger patients during the perioperative period. Many have multiple chronic illnesses other than the one for which surgery is required, and therefore are prone to developing postoperative complications, functional decline, loss of independence, and other untoward outcomes. In order to provide optimal care for the older surgical patient, a thorough assessment of the individual's health status and a plan of care during the perioperative period designed to look for and address any identified deficits is essential. To assist clinicians with this assessment and subsequent care, in 2010, the American College of Surgeons (ACS) partnered with the American Geriatrics Society (AGS) and the John A Hartford Foundation to develop guidelines for the optimal surgical care of older adults. The first part of these guidelines, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)/American Geriatrics Society (AGS) Best Practices Guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient 3 was published in 2012. This resource defined 9 assessment categories: cognitive/behavioral disorders, cardiac evaluation, pulmonary evaluation, functional/performance status, frailty, nutritional status, medication management, patient counseling, and preoperative testing. The second part of these guidelines, presented here, targets the rest of the perioperative period, beginning in the immediate preoperative period and extending through the postoperative period and discharge transition. These guidelines build on the domains of geriatric care and proposed geriatric competencies established by previous work and are designed to provide a framework for thinking about the complex issues around perioperative care in this patient population. 4,5 GERIATRIC SURGERY EXPERT PANEL, LITERATURE REVIEW, AND GUIDELINES DEVELOPMENT Similar to the preoperative assessment guidelines, the optimal perioperative management guidelines leveraged the expertise of a 28-member, multidisciplinary panel representing the American College of Surgeons (ACS), American Society of Anesthesiologists, American Geriatrics Society (AGS), the ACS Geriatric Surgery Task Force, and the AGS Geriatrics for Specialists Initiative. This document is divided conceptually into 3 domains: the immediate preoperative, intraoperative, and postoperative periods. A literature review of MEDLINE was performed for each domain in order to identify systematic reviews, metaanalyses, practice guidelines, and clinical trials between
