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Patients with frailty are at increased risk of adverse postoperative outcome. Older patients undergoing intermediate and high-risk surgery should be assessed for frailty using an established tool or scoring system.^243,244

Pathways of care providing proactive preoperative interventions for frailty, involving therapy services, social services, discharge teams and geriatricians or physicians with expertise in the assessment and management of frailty/ delirium should be developed.^233,245,246

Older patients should have access to a consultant or other autonomously practising anaesthetist experienced in the management of the older surgical patient to support shared decision making, patient optimisation and perioperative care. Opportunities for joint geriatric and surgical clinical governance should be considered as this model of care is superior to that delivered without this expert support. ^231,246,247

The risk of postoperative functional decline and complex discharge related issues should be considered. Procedures should be in place to identify complex patients at pre-assessment and complex discharge planning should begin then. This will require a multi-disciplinary team approach. Guidelines should be developed for the prevention, recognition and management of common postoperative geriatric complications and/or syndromes, including delirium, falls, functional...

Mechanisms for the early recognition of patients requiring specialist postoperative input from geriatrician led services and/or critical care should be developed. These should include patients at risk of or presenting with delirium, multiple medical complications, functional decline or those requiring complex discharge planning.

There is a high prevalence of recognised and unrecognised cognitive impairment amongst older surgical patients. This has implications for shared decision making, the consent process and perioperative management. Older patients should have preoperative cognitive assessment using established screening or diagnostic tools.²⁴⁸

Multicomponent interventions which reduce the incidence of delirium in elderly patients undergoing surgery should be considered. These include early mobilisation, avoidance of dehydration and avoidance of delirium triggering medications.^197,249,250

Provisions should be made for the assessment and management of pain in older people, and more specifically in those with dementia.^251,253

All staff managing patients in the postoperative period must be familiar with the arrangements determining mental capacity in the part of the UK in which they are working and pathways of care for patients with dementia.^{111,254,255,256}

Each department of anaesthesia should have a lead anaesthetist for patients with cognitive impairment with sufficient time identified for the role in their job plan.²⁴⁸