**2. Surgical assessment of the older patient**

The number of older people undergoing surgery, both open and laparoscopic, has been increasing over the years. This increase is mainly attributed to improvements in living conditions, longer life expectancy, advances in surgical, and anesthetic techniques, as well as changes in the expectations of both the patient and the clinician. Despite all this, older surgical patients remain at increased risk of developing adverse postoperative outcomes when compared to younger patients.

A thorough assessment of an older patient with colorectal cancer is, therefore, important in order to aid therapeutic decisions [3–8]. Functional levels vary widely. At one end of the spectrum are patients who are robust and able to tolerate surgical and oncological treatment well, while at the other end are patients who are frail and unable to tolerate even minor procedures without the risk of life-threatening complications.

Treatment decisions are clear at either end of this spectrum, but less clear otherwise. Formal assessments are, therefore, necessary to identify those at risk of functional decline and to determine the degree of frailty of these older patients. The results of these assessments may, thus, help in tailoring the treatment to the individual patient. When choosing between various treatment options, the quality of life is at least as important for these patients as the cancer-specific or surgical outcome [9].

A number of factors are taken into account during the assessment of the older patient with colorectal cancer. These include:


Elements of the CGA, especially comorbidity, functional status, frailty, and cognitive dysfunction, are consistently associated with adverse treatment outcomes such as toxicity and mortality.

It is beneficial for all older patients with cancer to receive a complete geriatric assessment. In fact, a meta-analysis by Ellis et al. in 2011 [3] has shown that patients

### *Surgery for Colorectal Cancer in Older People DOI: http://dx.doi.org/10.5772/intechopen.111510*

who received a formal CGA in secondary care were more likely to be alive and in their own homes at 12 months follow-up. However, a complete CGA is time-consuming. Studies show that frailty screening methods are useful in the selection of those patients who will benefit from a complete CGA or further assessment. These frailty screening methods include:


The concept of 'frailty' continues to develop and expand. Criteria used by Fried et al. [15] include an assessment of weight loss, physical exhaustion, physical activity level, grip strength, and speed of walking. Any degree of frailty measured by the Hopkins Frailty Score [16] has been linked to a worse postoperative outcome after surgery for colorectal cancer. Core features of frailty include impairments in multiple and interrelated systems, resulting in a reduced ability to tolerate stressful events. This is associated with an increase in vulnerability to severe complications with cancer treatment, which may then lead to an increase in overall mortality [17, 18].

Wieland and Hirth recommend that the CGA should include the following [19, 20]:


5% weight or a body mass index less than 19, should be assessed and managed appropriately in conjunction with the dieticians;


Multidisciplinary team working involves specialties such as oncologists, surgeons, gastroenterologists, radiotherapists, anesthetists, radiologists, and pathologists. This has become essential in the management of elderly patients with cancer. It is recommended that older patients with colorectal cancer should be treated in hospitals, where the expertise is available to provide the most favorable surgical and oncologic treatment outcomes.

Balducci [25] studied the role of CGA in the selection of treatment for cancer. Patients were placed into three groups depending on the severity of frailty symptoms and signs:

