IMPORTANCE Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential. OBJECTIVE To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. EVIDENCE ACQUISITION A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. RESULTS This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1 422 433 patients) and 26 that examined factors associated with surgical complications (n = 136 083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio HR, 1.26 95% CI, 1.06-1.49 to 5.77 95% CI, 1.55-21.55), 10% to 17% for malnutrition (adjusted odds ratio OR, 0.88 95% CI, 0.78-1.01 to 59.2 95% CI, 3.6-982.9), and 11% to 41% for institutionalization (adjusted OR, 1.5 95% CI, 1.02-2.21 to 3.27 95% CI, 2.81-3.81).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 95% CI, 1.0-9.99 to 13.02 95% CI, 5.14-32.98). CONCLUSIONS AND RELEVANCE Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making.