Scoping Review for the American College of Surgeons Geriatric Surgery Verification Program Perioperative Older Adult Enhanced Recovery Program

BACKGROUND: Enhanced recovery programs reduce complications, yet adults aged ≥65 continue to experience disproportionate postoperative morbidity. The American College of Surgeons developed a 7-component older adult perioperative protocol-delirium prevention and screening, minimization of potentially inappropriate medications, fall prevention, aspiration precautions, incentive spirometry, and bowel regimen-requiring evaluation of its evidentiary foundation. STUDY DESIGN: Scoping review conducted per PRISMA-ScR. MEDLINE was searched from inception through September 2024 for English-language studies evaluating protocol components in older adults (≥65), prioritizing surgical populations. Evidence was narratively synthesized and certainty characterized descriptively using GRADE. RESULTS: Sixty-seven studies were included. Multicomponent delirium prevention reduced postoperative delirium incidence (relative risk reduction 33.2%) and duration (0.4 vs 0.7 days), with reductions from 24% to 11% reported in vascular populations. Routine screening identified under-recognized delirium (27% positive vs 12% documented); Nu-DESC demonstrated 93% sensitivity and 93% specificity. Polypharmacy and potentially inappropriate medications were associated with higher mortality, complications, and readmission. Fall prevention showed the strongest evidence (3 high-, 3 moderate-certainty studies); 30-50% of inpatient falls resulted in injury, increasing costs by 61% and length of stay by >12 days, while structured programs avoided $14,600 per 1,000 patient-days. Aspiration prevention reduced pneumonia (5.1% to 0.9%); aspiration accounted for up to 80% of pneumonia in older adults. Incentive spirometry improved pulmonary outcomes in multiple trials, though systematic reviews reported heterogeneity. Standardized bowel regimens achieved ~95% return of bowel function by postoperative day 3 at an estimated $17 cost. CONCLUSIONS: Across heterogeneous but supportive evidence, each component demonstrates associations with reduced complications, shorter length of stay, and lower healthcare utilization. Embedding these age-specific processes within existing enhanced recovery pathways offers a pragmatic, evidence-informed framework for improving surgical outcomes in older adults.