With increasing age comes also an increased risk or susceptibility for certain diseases, including those that follow with added comorbidity, use of drugs and lifestyle risk factors. In most of the emergency general surgery conditions, the mortality also increases severalfold with each decade of age [5]. The biology of aging and its molecular hallmarks have been reviewed previously [6]. For surgeons it is of paramount importance to acknowledge that aging comes with specific concerns and added physiological challenges to specific organ systems and for the capacity to recover after an insult [7].

Specific disease patterns emerge with increasing age. For example, the risk of fractures increases with age, and age- and gender-specific patterns demonstrate types, complexity, and need for operative treatment for long-bone fractures [12]. Further, risk of ruptured abdominal aortic aneurysms (rAAA) also demonstrates an age-specific increase [13], as does the risk of perforated peptic ulcer [14].

With an aging population, it is necessary to find tools to evaluate risks for morbidity and mortality related to emergency surgery. The concept of frailty is described as “a state of reduced physiological reserve associated with increased susceptibility to disability” [15]. Frailty has been associated with worse outcome after surgery [16]. Frailty can be seen as a biological syndrome of decreased reserve or, as an accumulation of deficits in terms of medical, social, and functional deficits [16]. No available scores exist for the emergency setting. Existing scores have been investigated, but these either fail to predict accurately the outcome or they are cumbersome to use in a clinical setting. Scores developed for elective evaluation have been investigated for emergency abdominal surgery [17]. Among the six instruments, the Vulnerable Elders Survey (VES-13) predicted the 30-day mortality and morbidity best. In general, mortality increase with increasing age, higher ASA score, need for emergency procedures, and for palliative surgery associated with a malignancy [18]. Thus, the use of documented variables together with a clinical acumen are the best predictors at present.

Indeed, treatment elderly, frail patients is complicated, and organizing the treatment of geriatric patients has been a topic of debate. Specialized geriatric surgical units have been proposed as a solution [19]. Further, elderly surgical patients experience failure-to-rescue events at much higher rates than their younger counterparts, particularly for infectious and pulmonary complications [20]. Increased attention to the role of organizational dynamics in hospitals’ ability to rescue these high-risk patients will establish high-yield interventions aimed at improving patient safety [21].