**2.6 The geriatric patient**

With the aging of the population and the improvement of surgical and anesthesia techniques, the prevalence of elderly patients undergoing hip replacement is growing. In this scenario, the assessment of the functional status become essential, preferably through comprehensive geriatric measures to identify patients at risk and/ or to predict postoperative complications. It is strongly recommended to assess the level of independence using validated tools such as *basal and instrumental activities of daily living*. Comorbidities and multiple morbidities become more frequent with aging and are related to increased postoperative morbidity and mortality. It is very useful to assess multiple morbidities using age-adjusted scores, such as the *Charlson comorbidity index* [32, 33]. Elderly patients also take various combinations of drugs (mainly anticholinergics or sedative-hypnotics) increasing the risk of pharmacological interactions with other drugs administered during the hospital admission such as sedative, analgesic, etc. Moreover, these multiple associations often induce unwanted symptoms such as fatigue, anxiety, and delirium, increasing perioperative mortality [34]. It is recommended to consider appropriate perioperative drug adjustments by systematically performing the *BEERS Criteria* for the evaluation of multiple preoperative therapy [35]. Cognitive impairment and depression are common and often underestimated. They can affect patients' ability to understand, thus hindering the full comprehension of the informed consent. The multidimensional geriatric evaluation and teamwork with orthopedics and geriatrics is fundamental. Sensory impairment weakens communication and is associated with postoperative delirium (POD). The assessment of sensory disability should be performed, and the time spent in the perioperative setting without sensory aids should be minimized. Furthermore, malnutrition is relatively common in the elderly, and its impact is often an underestimated factor leading to complications [36]. Malnutrition may also coexist with obesity, further increasing the negative impact on prognosis. Moreover, obesity is associated with an increased risk of kidney damage [37]. The assessment of the nutritional status is very important in order to reduce the duration of hospitalization and shortening the recovery time and must be performed in patients at risk before invasive maneuvers are performed. Finally, as fragility is a known state of extreme vulnerability, frailty assessment in a structured and multimodal way such as the *Fried Score* or the *Edmonton Frailty Scale*, avoiding single surrogate measurements, is also strongly recommended.
