Background: Enhanced recovery programs reduce complications, yet adults aged 65 years or older 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 Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Medline was searched from inception through September 2024 for English-language studies evaluating protocol components in older adults (65 years and older), prioritizing surgical populations. Evidence was narratively synthesized and certainty characterized descriptively using Grading of Recommendations Assessment, Development, and Evaluation.

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 underrecognized delirium (27% positive vs 12% documented); Nursing Delirium Screening Scale 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% to 50% of inpatient falls resulted in injury, increasing costs by 61% and length of stay by more than 12 days, whereas 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, although systematic reviews reported heterogeneity. Standardized bowel regimens achieved ~95% return of bowel function by postoperative day 3 at an estimated cost of $17.

Conclusions: Across heterogeneous but supportive evidence, each component demonstrates associations with reduced complications, shorter length of stay, and lower healthcare use. Embedding these age-specific processes within existing enhanced recovery pathways offers a pragmatic, evidence-informed framework for improving surgical outcomes in older adults.