Older Adult Surgical Patients: Presentation and Challenges

Article Outline

• ABSTRACT
• Preoperative Assessment
  • Communication
  • Cardiovascular
  • Respiratory
  • Blood thinners
  • Renal
  • Diabetes
  • Delirium
• Intraoperative Care
  • Patient transfer
  • Communication
  • Skin care
  • Positioning
  • Other considerations
  • Response to anesthesia
  • Procedure completion
• Postoperative Care
  • Arrhythmias
  • CHF
  • Cognitive decline
  • GI complications
  • Hypertension
  • Pain
  • Renal impairment
  • Respiratory complications or compromise
  • Iatrogenesis
• Summary
• Examination
  • Older Adult Surgical Patients: Presentation and Challenges
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • Older Adult Surgical Patients: Presentation and Challenges
• Learner Evaluation
  • Older Adult Surgical Patients: Presentation and Challenges
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

The age of the population is increasing dramatically, and the age of the surgical population parallels that of the general population. This is occurring at a time when there are fewer health care providers with geriatric expertise in all disciplines.

All health care providers must be knowledgeable about the normal changes of aging and must understand communication challenges with older adult patients. Health care providers must understand the specific risks and benefits of surgery and perform a complete individualized preoperative assessment to improve older adult patients' outcomes. AORN J 90 (August 2009) 223–240. © AORN, Inc, 2009.

Key words:  geriatrics , gerontology , older adult surgical patient , surgical care , geriatric nursing

Aging is a process that begins the day a person is born. It involves chronological, physiological, and functional aspects. This process is a positive one, adding to the organism's function and abilities until about the age of 40. At that time, the changes become detrimental to life, causing a declining reserve in the body in addition to reducing efficiency of homeostatic mechanisms.

Overall, the physiology of aging has not changed in hundreds of years; however, chronological age has increased considerably. The average life span, the “age at which 50% of a population survives,”^1(p1143) has also increased. The maximum life span, “life span of the longest lived member of the population,”^1(p1143) has remained stable. Maximum life span of humans is approximately 125 years for women and slightly less for men.¹ However, the number of older adults surviving to their ninth decade and beyond has increased significantly as has the number surviving to 100 years of age. Projections of the US Census Bureau include that there will be an estimated 79,000 centenarians by the year 2010 and further growth of this age group to 601,000 by 2050.², ³, ⁴ This groundswell of aging adults has dramatic implications for the health care system and for all who care for this age group.

The health care system and providers in all disciplines are already being challenged to meet the unique needs of the older patient. The current system, which is focused on acute illness and reimbursement for procedural interventions, is unprepared to offer the coordinated care that frail older adult patients need in a variety of settings. In 2005, there was one geriatrician (ie, an MD with added qualifications in geriatrics) for every 5,000 Americans who were 65 years and older.⁵ The Alliance for Aging Research estimates the need for 36,000 geriatricians to deliver appropriate care for the 70 million adults who will be 65 years and older by the year 2030—or one geriatrician for every 1,945 older adults.⁴, ⁶, ⁷

There are only nine departments of geriatrics in the 145 medical schools in the United States.⁵ Few medical or nursing schools have required content in geriatrics. Those teaching programs without geriatrics programs offer as little as six hours of geriatric training electively.⁵ Currently, the trend for professionals in geriatric care is declining. Medical students demonstrate little interest in the specialty because geriatricians are paid less, and there is a general lack of prestige for these physicians in the current, highly technical health care system.⁴, ⁶

It is not possible for all providers to be experts in geriatric care. All clinicians, however, should have a basic knowledge and understanding of the normal changes of aging, other age-related issues, and the unique needs of the older adult patient to provide optimal care to all patients regardless of age.

Table 1 shows an overview of normal changes of aging and demonstrates how many organ systems have limited physiological reserves as a result of normal aging. The risk of iatrogenesis (ie, health care-acquired, inadvertent, and preventable induction of disease or complications) is dramatically increased by the resulting progressive loss of homeostatic reserves that occur with aging. In other words, a challenge to the homeostasis that may be tolerated with available reserve in a young person can overwhelm an older person.⁸, ⁹ Organ systems age at varying rates even in a single individual.

Table 1. Normal Changes of Aging

1 Smith CM, Cotter VT. Normal aging changes—Nursing standard of practice protocol: age-related changes in health. Hartford Institute for Geriatric Nursing, http://consultgerirn.org/topics/normal_aging_changes/want_to_know_more. Accessed June 28, 2009.

2 Dubin S. The physiologic changes of aging. Orthop Nurs. 1992;11(3):45–50.

3 Gruenewald DA, Brodkin KL. Physiology of aging. University of Washington, http://faculty.washington.edu/d_ruen/physiol.htm. Accessed June 4, 2009.

Patients older than 65 years undergo more than 55% of all surgical procedures performed.⁸ Chronic conditions associated with the older patient increase as the person ages.⁸, ¹⁰ Many of these diagnoses (eg, cataracts, arthritis, vascular occlusions, cancer) are treated surgically. Although older adults undergo more than half of all surgical procedures, they suffer a disproportionately high rate of morbidity and mortality.⁸ Three-quarters of all postoperative mortality is in adults older than 65 years, as is the majority of postoperative morbidity.⁸

Careful preoperative assessment and care—in addition to individualized preoperative, intraoperative, and postoperative plans of care for older adult patients—can reduce the risks of complications and death. Researchers report that surgical complication rates for older patients are at or below 3%; this number is highly dependent on the particular surgery performed.⁸ Surgical risks have been decreased by advances in surgical technology, such as minimally invasive techniques and increasing numbers of outpatient procedures.⁸, ¹⁰ Patients who are more advanced in age are more successfully undergoing surgical procedures than in the past and are resuming pre-illness status and function. Currently, the benefits outweigh the risks of surgery in most situations because of advances in care.⁸, ¹⁰

Multiple chronic conditions, either direct (ie, issues surrounding the problem related to the surgery) or indirect (ie, considerations related to pre-existing chronic conditions or medications), that are commonly seen in the older patient influence preoperative assessment, intraoperative care, and postoperative recovery. This necessitates thorough and individualized care for older adult patients, optimally offered using a multidisciplinary approach.

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Preoperative Assessment 

Assurance of accurate communication is essential in providing care to any patient in any setting and is particularly important when performing a preoperative assessment. Never assume that just because an older adult patient's support person (eg, spouse, sibling, caregiver) understands what is going on, the patient also understands.⁹

The preoperative assessment of the older adult patient must include at a minimum the cardiovascular, respiratory, and renal systems; the perioperative effects of diabetes; and cognitive state. Other systems may be included based on clinical assessment of the individual patient.

Communication 

Older adult patients face additional challenges in terms of normal changes of aging that affect their ability to take in and interpret visual, auditory, and sensory stimuli. The older adult patient may have multiple challenges with communication, both compensated (eg, conductive hearing loss effectively treated with hearing aids) and uncompensated (eg, sensory neural loss, which cannot be aided). Health care facilities should have equipment readily available that effectively enhances communication for visually and hearing impaired patients. All staff members should be aware of available assistive devices and take the time to access and use them. For instance, hearing deficits may be ameliorated by placing a stethoscope, readily available to most clinicians, in the patient's ears.

Recent research has focused on a phenomenon called “elderspeak.” This type of communication features “simplistic vocabulary and grammar, shortened sentences, slowed speech, elevated pitch and volume and inappropriately intimate terms of endearment.”^11(p12) This is considered “infantilizing” of communication with older adult patients. Investigations in this arena clearly identify this issue as a problem. Patronizing interactions precipitate communication breakdown with cognitively intact older adults and result in measurable negative outcomes. Older adults exposed to negative stereotypes associated with aging perform worse when tested for memory and balance.¹² Self-perception and self-esteem declined in the presence of continued demoralizing interactions. In one study, individuals aged 50 years and older lived 7.5 years longer than their peers who were exposed to elderspeak.¹²

Communication patterns are well established and difficult to change. Elderspeak compromises the clinician's interactions with the older adult patient. Minimizing the use of elderspeak reduces stereotyped messages that older adults are weak, dependent, and incapacitated. Improved communication enhances the cognitive and functional abilities of older adults.¹² Care providers can experience increased job satisfaction as their relationships with their older adult patients improve.¹⁰

Cardiovascular 

There are specific recommendations related to cardiac care in the preoperative, intraoperative, and postoperative periods, which improve outcomes. Perioperative beta blockade has been found to be useful in patients at high or intermediate risk of cardiac complications undergoing emergent; vascular; cranial/maxillofacial; opthalmic; ears, nose, or throat; intrathoracic; intraperitoneal; orthopedic; or prostate surgery. Preoperative and intraoperative use of statins have been associated with lower perioperative mortality in patients with known or suspected coronary artery disease.¹³

Postoperative cardiac event risk is directly related to a patient's age. Guidelines developed by professional organizations to assist practitioners in determining the degree of cardiac risk for surgery are available at the Merck Manual of Geriatrics web site.¹⁴ Practice has migrated away from cardiac testing to medication treatment at the physician's discretion.¹⁵, ¹⁶, ¹⁷, ¹⁸ If a patient has suspected or is at high risk for a complication, prophylaxis may be implemented without cardiac testing. Older adult patients, especially those who have coronary artery disease (CAD) or a high risk factor profile, benefit from taking a beta blocker preoperatively. Aspirin and statin medications have been found to be beneficial in nonrandomized observations of high-risk patients.¹⁹ Cardiac revascularization is not recommended as a means to facilitate attempting another surgical intervention.⁹, ¹⁵, ²⁰

Poldermans et al²¹ examined more than 5,000 patients who underwent a coronary artery bypass graft (CABG) procedure. They determined that patients who took aspirin within two days of surgery decreased their risk of myocardial infarction (MI) and stroke by 50% and their risk of kidney failure by 75% without any increased risk of bleeding or gastritis. Researchers studying patients who underwent elective peripheral vascular surgery determined that the patients who used statins had an 80% reduction in the risk of postoperative death when compared with patients who did not use statins.²¹ Further studies of both therapies are needed, however.

Another prospective, randomized, controlled study investigated optimal preoperative care of patients who had CAD that was amenable to revascularization and who were scheduled to undergo elective vascular surgery.²⁰ Patients were assigned to one of three groups: revascularization by undergoing a CABG procedure, revascularization by undergoing angioplasty, or medical therapy alone. Surgical delay was caused by both surgical interventions, but no significant difference was identified in postoperative death, MI, cerebral vascular accident (CVA), or survival equal to or greater than 2.5 years when compared with the patients who were managed strictly by medical therapy. The researchers found that risk of perioperative MI was increased if surgery was performed within six weeks after angioplasty and stenting.

Antibiotic prophylaxis for bacterial endocarditis is strongly indicated in patients at highest risk, such as those with prosthetic cardiac valves, congenital heart disease, or a history of endocarditis. Moderate risk patients also should receive prophylaxis if the surgical procedure involves the respiratory tract, biliary or intestinal mucosa, prostate, or bladder.⁸, ²² Current updated guidelines may be found at the American College of Cardiologists web site.²³

Respiratory 

Identifications of risk factors for pulmonary complications fall primarily into two categories: patient-related and procedure-related. Patient-related factors are smoking, health status, body habitus, presence of chronic lung disease, and neurological and cardiovascular status. Procedure-related risk factors include site of incision, length of time in surgery, and anesthesia type. The presence of comorbidities is of more predictive importance than age. Pulmonary complications occurring postoperatively have prolonged hospital stays by as much as two weeks in the older age group studies.²⁴, ²⁵, ²⁶ Older adult patients with postoperative respiratory failure have a mortality rate of 40% compared with 5% for those without respiratory failure.²⁶

Harari et al²⁷ established a clinical prediction model using an investigation of more than 160,000 veterans electing noncardiac surgeries. The investigators assigned points to the individual patient based on the type of surgery; age by decade; functional status; and specific conditions of weight loss, general anesthesia, altered sensory input, blood urea nitrogen level, and receiving more than four units of blood. The investigators added the patients' individual points to generate a score, divided the sample into five strata of risk classes, and calculated complication rates for each risk level. The investigators determined that pneumonia rates were higher for those with higher risk scores. The patients with the lowest risk had pneumonia rates of 0.2% while the patients with the highest risk had pneumonia rates of 15.3%. The investigators suggested that the instrument scores could be helpful in guiding perioperative care.

Complications related to thromboembolic complications (eg, pulmonary embolism) are relatively common in the perioperative period. Common prophylactic courses of prevention are low-dose unfractionated heparin or low molecular-weight subcutaneous heparin. Anticoagulants can be withheld for as many as five doses in the preoperative period and resumed the first postoperative evening. There are some exceptions to this principle, however. Patients with artificial cardiac valves being treated with warfarin or those on aspirin can be treated with IV heparin during warfarin withdrawal. This replacement heparin should be withheld six hours preoperatively and resumed postoperatively.⁸, ¹⁸, ²⁸ Preoperative therapy can be reinstituted; however, heparin should be continued until therapeutic levels of warfarin are reached. Low molecular-weight heparin should be withheld 12 hours before surgery and may be resumed within 24 hours.⁸, ¹⁸, ²⁸

Blood thinners 

Historically, aspirin and antiplatelet agents have been withheld for one week before surgery. There is no standard or guideline to this effect, and more recent data indicate it is unnecessary to withhold these medications. Investigators found that lower rates of myocardial ischemia, CVA, and renal failure occurred in a nonrandomized study in which prescribed aspirin therapy was continued preoperatively in patients undergoing a CABG procedure.¹⁹, ²¹ There was no increased risk of bleeding in those continuing their therapy without interruption.¹⁹, ²¹

Renal 

Renal function declines with age. Renal and glomerular blood flow decreases with age but does so without a correlating increase in creatinine. This occurs because as renal function declines, muscle mass also declines, and creatinine is a by-product of muscle metabolism. The markers for renal function appear normal in spite of the dramatic decline in glomerular filtration rate. Dosage adjustments for renal impairment should be the standard for the older adult patient. In the absence of a 24-hour urine test for creatinine, clinicians may use creatinine clearance to estimate renal function in the older adult patient.²⁹, ³⁰, ³¹

Intravenous fluids must be meticulously managed because of the impaired ability of the kidney to maintain sodium and hydration equilibrium. The older adult patient has a decreased ability to respond to these volume changes. Secondary to the hypotonicity of 50% saline or water and their preference to diffuse to extravascular tissues, normal saline or packed red cells should be use for volume replacement. Postoperative renal failure increases in frequency because of impaired preoperative function coupled with the impaired renal reserve of the older adult. The effect of reduced cardiac output or exposure to nephrotoxic medications increases the older adult's susceptibility to postoperative renal failure.⁸

Diabetes 

Concurrent increases in the incidence of type 2 diabetes warrant specific perioperative considerations. Oral medications are commonly withheld the day of surgery. Metformin is almost universally withheld because it increases metabolic acidosis during stress. Frequently, physicians prescribe IV fluids containing glucose solution, which requires close monitoring of capillary blood glucose levels. Physicians then correct elevated blood sugar levels with IV or subcutaneous insulin until the patient can resume his or her preoperative diet.⁸

Patients with insulin-controlled diabetes should have an insulin drip until stable or continue the basal insulin at a reduced dose and have rapid acting insulin to cover prandial needs and correct elevated glucose. There is a lot of research about the increased morbidity and mortality of patients with elevated glucose intraoperatively as well as postoperatively.⁸, ⁹, ¹⁸ The most researched area regarding these risks and the benefits of tight glycemic control is during cardiovascular surgery.³²

Patients on corticosteroids may require “stress doses” of steroids perioperatively. Older adult surgical patients receiving more than 20 mg of prednisone per day for one week or longer or those with known adrenal insufficiency should be considered for perioperative administration of steroids. Currently, there are no clear guidelines on the appropriate dosage. Common treatment for a minor procedure is the equivalent of 24 mg of IV hydrocortisone on the day of surgery only. Moderate surgical stress warrants the equivalent of 50 mg to 75 mg/day of IV hydrocortisone in divided doses. The equivalent of 100 mg to 150 mg/day IV in divided doses may be required beginning within two hours of surgery and continuing for two to three days if the patient is being treated for primary autoimmune disease or secondary adrenal insufficiency.¹³ The preoperative maintenance regimen should then be resumed.⁸, ³³

Delirium 

The risk of delirium is high in older adult patients and especially in surgical patients. Delirium is poorly recognized and may be the only symptom of a life-threatening complication (eg, developing infection, severe metabolic abnormality, medication reaction). Delirium frequently is labeled incorrectly as dementia or depression. It is also incorrectly attributed to senescence (ie, the state of being old). Delirium is not a normal part of aging. Table 2 differentiates between delirium, dementia, and depression. The hypoactive form of delirium, which is exhibited as withdrawal and psychomotor slowing, is more common in the older adult patient and is easily overlooked.³⁴ Factors placing the older patient at higher risk for delirium, especially in noncardiac surgery. include

Table 2. Confusion in Older Adults¹, ², ³

1 Mangano DT; Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002;347(17):1309–1317.

2 Katlic M. Perioperative care of the elderly surgical patient. In: Rosenthal RA, Zenilman ME, Katlic MR, eds. Principles and Practice of Geriatric Surgery. New York, NY: Springer; 2001:92–104.

3 Ryan J, Zawada E. Renal function and fluid and electrolyte balance. In: Rosenthal RA, Zenilman ME, Katlic MR, eds. Principles and Practice of Geriatric Surgery. New York, NY: Springer; 2001:767–779.

Noncardiac surgeries that increase risk are intrathoracic surgical procedures or abdominal aneurysm procedures. Type of surgery is an important predictor of the incidence of delirium. Incidence ranges from 4% to 5% in cataract and urologic procedure to a high of 50% to 60% in infrarenal abdominal aortic aneurysm repair or hip fracture repair, especially when these are not performed on an elective basis.³⁴, ³⁵ Blood loss remains the most critical intraoperative risk factor for delirium.⁹, ²⁷, ³⁶

Delirium may be present in the preoperative period as a result of the diagnosis (eg, perforated diverticula, intra-abdominal abscess). The presence of preoperative delirium may necessitate admission to the hospital and may need to be addressed intraoperatively and postoperatively. Delirium is only recognized by 20% of physicians and 50% of nurses.³⁴, ³⁵ Thorough patient assessment is imperative to identify risk factors preoperatively and implement interventions that can reduce the incidence. Recent studies show that delirium is not a benign event. Delirious patients have a higher morbidity and mortality, experience longer hospital stays, and are discharged to higher levels of care than non-delirious patients.⁸, ³⁴, ³⁵, ³⁷

Delirium is not inevitable, even in patients at high risk. When risk factors are present, clinicians must be vigilant about

Immobility and use of restraints may precipitate a delirium episode. Nurses should encourage mobility as early as possible postoperatively. Researchers are finding restraints an ineffective intervention for preventing inadvertent equipment removal by patients.³⁸ Nurses should first use alternatives to restraints and should attempt to completely avoid using restraints at all.⁸ Nurses should endeavor to maintain the patients' own sleep and wake patterns. Enhancing sensory input by using adequate lighting, assisting the patient to maintain clean glasses, and ensuring that the patient's hearing aids are in place and turned on helps minimize the incidence of delirium. Clinicians should administer medications judiciously with a clear awareness of each medication's risk and side effects in older adult patients.

A randomized study that demonstrated the effectiveness of multicomponent interventions for treating or preventing delirium emphasized

These interventions reduced the incidence of delirium by one-third when compared with standard care for hospitalized medical patients. Initial studies are demonstrating the same benefit for surgical patients.³⁴ Untreated or undertreated pain, constipation, and electrolyte abnormalities also have been implicated in the incidence of delirium.³⁴ Perioperative MI always must be considered as well.³⁴

Other effective interventions to decrease the occurrence of delirium include family member involvement and presence throughout the preoperative, postoperative, and recuperative periods. Nurses should encourage family members and loved ones to remain with the patient around the clock, if at all possible. The importance of the availability of assistive devices cannot be overemphasized. Assistive devices that increase perceptual accuracy, such as hearing aids and glasses should be kept in place until it is absolutely necessary to remove them and replaced as soon as possible. Clinicians should avoid the use catheters and other movement-limiting equipment if possible or remove them as soon as medically appropriate. Avoidance of anticholinergic medications preoperatively, intraoperatively, and postoperatively or at a minimum using pharmacologic agents with the lowest anticholinergic profile is effective in delirium prevention.³⁴, ³⁹, ⁴⁰ Nurses should monitor the patient's pain level and schedule analgesics if the patient is not able to communicate his or her pain clearly. Clinicians should administer the lowest doses of narcotics for the shortest period of time to achieve comfort and should consider scheduling a basal dose of analgesia.⁸, ⁹, ³⁶

Assessment should include a reliable and valid delirium assessment instrument, such as the Confusion Assessment Method, which should be used on a regular basis.⁴¹ When identified, delirium should be considered an urgent finding. This acute change in mental status is caused by physiologic changes in the body. It occurs in patients who have no cognitive impairment or mild cognitive impairment, as well as in patients who have a diagnosis of dementia. Delirium increases the patient's length of stay, increases costs of hospitalization, decreases functional outcomes, and makes it more likely that the patient will require discharge to a higher intensity of care.¹⁸, ³⁰, ³⁶ Delirium impedes optimal patient outcomes and results in some degree of longer term impairment to the brain. Most importantly, it is a frightening occurrence for both patients and their family members. Patient education and frequent reinforcement of this education regarding delirium, its causes, and prognoses is essential in these high-risk patients. Clinicians should always assess for the risk of delirium during preoperative education.

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Intraoperative Care 

Maintaining the patient's dignity and independence is an essential component of caring for the older adult patient. Adding appropriate components to the immediate preoperative assessment will improve the circulating nurse's ability to enhance this dignity.

Patient transfer 

Many factors affect the patient's ability to participate in transferring from one piece of furniture to another. Frequently, more time is required to transfer an older adult patient from a bed, recliner, or wheelchair to the OR stretcher and then to the OR bed. To promote the patient's independence and dignity, the circulating nurse should plan for the transfer by assessing the patient's function, posture, gait, and degree of mobility or immobility.⁹, ²²

Communication 

An older adult patient should not be excluded from the established safety procedures, but the circulating nurse should ensure visual and auditory accuracy and validate understanding, which may require additional time for explanations.⁹, ²² To help promote comfort and confidence, the circulating nurse should allow the patient to keep assistive communication devices for as long as possible without jeopardizing patient safety. The circulating nurse should introduce the patient to all OR staff members and then should orient the patient to the OR environment. While the patient is being prepared in the OR, the circulating nurse should ensure that all staff members minimize conversation, which may interfere with the patient's ability to hear instructions; staff members also should try to avoid loud noises, especially if assistive devices have been removed, because these may be startling or disorienting.⁹, ²²

Skin care 

Care of the older adult patient's skin merits special attention (Table 3). The circulating nurse should avoid shearing movement because the fragile skin of older adults tears more easily than the skin of younger patients. The circulating nurse should ensure that prep solutions do not pool, which can cause egregious injury to the fragile skin of an older adult. The circulating nurse should avoid using routine surgical adhesive, silk tape, and even paper tape, if possible, opting instead for sensitive skin tapes, such as soft cloth surgical tape with hypoallergenic adhesive.

Table 3. Pressure Ulcer Injuries in the Perioperative Patient¹

1 Bailes BK. Perioperative care of the elderly surgical patient. AORN J. 2000;72(2):186–207.

Positioning 

Overall, the goal of positioning is to reduce stress and pressure on the older adult patient's spine and skin.⁸, ²⁸ Clinicians should protect the patient's bony prominences with additional padding. Many older patients have kyphotic spines, which benefit from additional support padding. The circulating nurse should be particularly vigilant about optimal body alignment and support of joints when an older adult patient is positioned after undergoing sedation or induction of anesthesia because the patient is not able to tell the nurse if he or she is experiencing discomfort from the position. If not contraindicated, the circulating nurse should place a pillow under the patient's knees to avoid postoperative stiffness that may limit early mobility. Heels are an often overlooked but vulnerable area that can benefit from extra padding.

Other considerations 

Other areas meriting focus in the early intraoperative phase include temperature monitoring, deep vein thrombosis (DVT) prophylaxis, and placement of electrosurgical unit (ESU) grounding pads. The older adult patient has impaired thermoregulation, which is easily compromised in the cool OR setting. When possible, the circulating nurse should use temperature-regulating blankets to provide comfort while the patient is aware as well as protection against hypothermia during the procedure, particularly if the patient is sedated.

Immobilization coupled with general anesthesia and a surgical time greater than two hours increases this risk of DVT. The circulating nurse can help reduce the risk of DVT by applying thromboembolism device (TED) hose and sequential compression devices on the lower limbs during surgery or as soon as possible postoperatively. The circulating nurse should place the ESU grounding pad on an area with significant muscle mass. Muscle mass declines, however, even in the healthy older adult patient, which affects ESU grounding pad placement. This, in addition to compromised vasculature, increases the older adult patient's risk of electrical burns.⁸, ¹⁸, ²⁸

Response to anesthesia 

During the procedure, it is essential that the anesthesia care provider closely monitor the older adult patient's response to anesthesia and the patient's fluid status based on the preoperative assessment. Older adult patients are more susceptible to changes in blood pressure, oxygen levels, fluid volume, and temperature fluctuations. Even in the healthy older adult, anesthesia results in physiological changes that have a greater negative effect. The older adult patient is less able to respond to changes in blood pressure because of the normal changes of aging and decreased adaptability of baroreceptor reflexes. Compensatory mechanisms, also blunted by aging, interfere with homeostatic maintenance, such as precipitous drops in blood pressure. Clinicians should slowly titrate medications until the degree of response or alteration of response is achieved. Anesthesia care providers should be aware that transition from spontaneous breathing to mechanically controlled ventilation can cause cardiac output to drop.¹⁸, ²²

Older adult patients have an increased risk of hypothermia when core temperature drops below 97° F (36.1° C).⁸ Oxygen requirements increase by 200% to 500% with shivering and place the patient at significant risk of myocardial damage.⁸ The anesthesia care provider should administer warm IV fluids and heated inhalation agents. The circulating nurse should remove any wet linens as soon as possible to avert further cooling by evaporation and should apply temperature-regulating blankets if possible.⁸, ¹⁸, ²²

Complications occur at a higher rate in the older adult patient and respiratory complications are involved in 40% of surgical complications and 20% of surgical deaths.¹⁷ Age-associated decline in ciliary motion, increased chest rigidity, and decreased lung compliance, especially in the presence of comorbid conditions such as chronic obstructive pulmonary disease, make this population extremely vulnerable to respiratory complications. General anesthesia exacerbates this risk. Serious consideration should be given to spinal, epidural, or local blocks as alternatives; furthermore, there is less myocardial depression and postoperative delirium with these options. Although the preferred method of anesthesia in this group is regional anesthesia, its use may be more difficult as a result of arthritic changes in the spine or discs. As anesthesia effects fade, there is an increased risk of MI, exacerbations of congestive heart failure (CHF), and urinary retention. The direct effects of anesthesia may wear off before the effects that maintain homeostasis in the older patient. Conscious sedation is also an option if the medication selected has a short half-life. With this method, there is less impairment of motor function; however, there is an increased incidence of delirium.⁸, ⁹

Procedure completion 

Clinicians cannot become any less vigilant with the older adult surgical patient as the procedure comes to a close. The anesthesia care provider and circulating nurse must monitor the patient for laryngeal spasm, vomiting, and small airway closure secondary to sedation, analgesia, or pain. Transfer to the postanesthesia care unit (PACU) also merits careful attention. The circulating nurse should assess the patient's skin where tape and other devices (eg, electrocardiogram leads) are removed or replaced. The nurses should assess the patient's skin carefully for any injury and precisely document the status of the patient's skin. The circulating nurse should ensure that the surgical dressing maximizes wound protection without placing the older adult patient's integument at risk. As the patient wakes up, the circulating nurse should reintroduce staff members frequently and reorient the patient to the OR. The circulating nurse should return the assistive devices (eg, glasses, hearing aids) as soon as possible and allow family members to be with the patient as soon as feasible.⁵, ¹⁸, ²²

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Postoperative Care 

There are a number of possible problems that merit monitoring in the postoperative period. It is essential for the PACU nurse to monitor the patient for signs and symptoms of

Arrhythmias 

Rhythm disturbances have the potential of leading to myocardial ischemia and heart failure. Supraventricular tachycardia, commonly seen in the older adult, occurs more commonly in patients with past episodes of supraventricular dysrhythmias, asthma, heart failure, and premature atrial activity observed on preoperative electrocardiogram. Frequency of this rhythm increases in those who undergo vascular, abdominal, or thoracic procedures.⁸, ⁹ If supraventricular tachycardia is observed, the nurse should attempt to restore sinus rhythm or control any rapid ventricular response using adenosine, beta blockade, or calcium channel blockers. The anesthesia care provider or surgeon may consider conversion of atrial fibrillation to sinus rhythm with cardioversion or pharmacologic agents. Frequently, patients will revert to sinus rhythm spontaneously within six weeks postoperatively. Persistent atrial fibrillation beyond one to two days increases the risk of thromboembolism and the primary care provider should evaluate the patient for the potential risks and benefits of anticoagulation.⁸, ¹⁸, ²⁶, ²⁸

CHF 

When heart failure occurs, the etiology may be excessive fluid administration, new onset cardiac ischemia, or an arrhythmia. If the patient is at high-risk for CHF, pulmonary artery catheters offer more accurate assurance of optimal ventricular filling pressures than using physical examination and laboratory results. Although management of heart failure is tightly controlled within clinical practice guideline recommendations, no decrease in mortality has been demonstrated.⁸, ²⁴, ²⁸

Cognitive decline 

Practitioners have documented cognitive decline in some older adult surgical patients. This unique set of symptoms is a distinct entity from delirium and is differentiated by new onset learning and memory deficits. Researchers have identified this syndrome most frequently after CABG surgery that included the use of extracorporeal support.²⁶, ³⁵, ⁴², ⁴³ The cognitive changes may be observed for months after surgery in about 10% to 30% of patients.²⁶, ³⁵, ⁴², ⁴³ Episodes of hypotension and hypoxemia have shown no correlation.²⁶, ⁴² Although the type of anesthesia has been investigated as an etiology, anesthesia has not been implicated in new onset of cognitive decline. Prevention and treatment are similar in the perioperative period. This includes careful monitoring of all physiologic parameters that could indicate hypotension or decreased cerebral perfusion during surgery as well as correction of conditions that are implicated as etiologies.⁸, ⁴²

GI complications 

Gastrointestinal complaints are fairly common in the older adult patient, and baseline complaints may be magnified in the postoperative period. Intestinal motility may be altered dependent on the particular procedure performed, resulting in nausea, constipation, or diarrhea.

Nausea is often seen in the postoperative period as a result of anesthesia, narcotics, and other medications administered. The PACU nurse should treat nausea or vomiting with nonpharmacologic measures initially and if pharmacologic intervention becomes necessary, the nurse should avoid antiemetics that are highly anticholinergic.

Constipation, a frequent complaint during this time period because of altered diet, immobility, and administration of narcotics and other medications, should be assessed. The development of ileus and obstipation (ie, severe constipation caused by intestinal obstruction) may result in anorexia, nausea, and potentially vomiting.⁸, ²⁶ If narcotics are in use, the PACU nurse may administer a stool softener. The nurse should monitor the need for a laxative and administer it appropriately. If diet allows, the nurse should encourage the patient to consume prunes, prune juice, apple sauce, or bran.

Complaints of diarrhea merit assessment for fecal impaction. The surgeon may consider evaluation of stool for leukocytes or Clostridium difficile.⁸

Hypertension 

The PACU nurse should monitor the older adult patient for hypertension and, if it occurs, the nurse should assess the patient for a nonvascular cause, such as pain or urinary retention. The nurse should assess the patient's volume status and review previous fluid and medication administration. Parenteral antihypertensive agents should be considered for treating essential hypertension. Available parenteral forms of different classes of antihypertensives include beta blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and medications that block both alpha and beta adrenergic receptors.⁸, ¹⁸, ²² Topical agents (eg, topical nitroglycerin) also may be helpful in the postoperative period.

Pain 

There is a misperception that older adult patients have a higher pain threshold than younger patients. Older adult patients tend to be more stoic but still have the same pain management needs as any postoperative patient. Most postoperative pain is relieved only with narcotic analgesia. The oldest-old adult patients (ie, those older than 85 years) and cognitively impaired older adult patients are at high risk for undertreatment of pain and even non-treatment because of decreased communication ability coupled with clinician concerns regarding delirium and immobility. The PACU nurse should regularly assess the older adult patient's pain level and pain management goals at regular intervals as with younger patients. In the cognitively intact older adult patient, the same assessment instruments may be used to quantify the patient's pain. Patients with cognitive impairment who cannot accurately communicate their pain should be assessed using a tool designed for dementia patients such as the PAINAD (ie, Patient Assessment in Advanced Dementia)⁴⁴ or CNPI (ie, Checklist of Nonverbal Pain Indicators)⁴⁵ tools. The Wong-Baker FACES pain scale is not a valid pain assessment tool for a patient with cognitive impairment.²⁸, ⁴⁶

Treatment of pain with narcotic analgesics requires some modifications in care (Table 4). Cognitively intact older adult patients may be best treated with patient-controlled analgesia to enhance pain management while reducing narcotic use. Pain medication dosages should be adjusted to compensate for an older person's decreased hepatic function and reduced glomerular filtration rate. A rule of thumb is to halve the usual adult dose, at a minimum. The older adult patient already has slowed intestinal motility; combining that with immobility and narcotic administration requires careful attention to maintenance of bowel function. Simultaneous use of stool softeners with narcotics is advised. Less severe pain may be managed by alternating a nonnarcotic (eg, ibuprofen, acetaminophen) with the narcotics.

Table 4. Principles of Pain Management for the Older Adult Surgical Patient

1 Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Int Med. 1997;157(14):1531–1536.

The older adult patient should be assessed for response to analgesia at the same or closer intervals as the younger patient. The PACU should monitor older adult patients carefully because they are more likely to experience adverse medication effects. Adjunctive therapy (eg, massage, music therapy) also should be attempted either before narcotic administration or simultaneously, but nonsteroidal medications are usually avoided in the older adult patient because of impaired renal status.⁸, ⁹, ²⁷, ³⁰, ³¹

Renal impairment 

Postoperative renal injury has several possible mechanisms. Clinicians may consider the possibility of impaired renal blood flow if the patient's urine sodium level is less than 40 mEq/L with a ratio of urine to plasma creatinine greater than 10:1. Monitoring for oliguria (ie, reduced urine excretion); isosthenuria (ie, a condition in which the kidneys lack the ability to concentrate or dilute the urine); and increases in serum creatinine allows clinicians to identify postoperative renal impairment early. Urine sodium greater than 40 mEq/L may herald acute tubular necrosis.⁸, ⁹, ⁴⁷ Granular or epithelial cell casts may be found in urine sediment. The PACU nurse should monitor older male patients with prostatic hyperplasia for the development of obstructive nephropathy by assessing for a distended, palpable bladder.

When acute tubular necrosis is identified, all potentially nephrotoxic medications and medications excreted primarily by the kidney should be withheld and meticulous attention focused on maintenance of a euvolemic state (ie, maintaining a balance between the amount of fluid taken in and the amount of fluid excreted).⁸, ⁹, ²⁷, ²⁹ Although indwelling catheters are usually avoided in this population because of possible infection, the need for passive restraint, and discomfort, which may cause agitation and restlessness, the diagnosis of obstructive nephropathy dictates the need for an indwelling urinary catheter to minimize the risk of hydronephrosis and further renal function impairment. Dialysis indications are not different in this period and include hypervolemia, hyperkalemia, metabolic acidosis, or encephalopathy.⁵, ⁹, ³⁰

Respiratory complications or compromise 

Coughing and deep breathing exercises, use of incentive spirometry, and early mobilization all serve to reduce the risk of postoperative respiratory complications or compromise. Pulmonary function tests performed in the perioperative period in patients with established lung pathology is not currently recommended. Evaluation of dyspnea or wheezing of unknown etiology, however, may be supported.⁸, ¹⁶, ¹⁷, ²⁵

Iatrogenesis 

Older adult patients are at high risk for health care-associated complications. The major factor implicated in this risk is immobility. Clinicians should review the patient's medications regularly to identify opportunities to eliminate or reduce sedating or central nervous system-affecting pharmacologic agents. Clinicians should remove invasive or mobility-limiting equipment as quickly as possible to help prevent infection and the sequelae of immobility. Clinicians should resume the patient's preoperative diet as soon as possible and discontinue IV lines as soon as the patient's oral intake is adequate.⁸, ¹⁸

The ultimate goal of all of these interventions is preservation of mobility. This will reduce the risk of skin breakdown, muscle atrophy, stiffening of joints, bone demineralization, and DVT. Early and adequate mobilization improves the possibility that the older adult patient may return to his or her home. Even short periods of immobility increase the risk that the older adult patient may have to be discharged to a higher intensity of care. Dietary restriction may compromise nutritional and hydration status, which could require continued use of an IV line, but continued IV fluids have the potential to precipitate fluid overload and impaired oxygenation.

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Summary 

“Aging of the population of the United States has created the need to provide surgical care to increasing numbers of [older adults].”^15(p126) Aging should be differentiated from disease because normal changes of aging are not disease processes. Aging does, however, cause some natural losses of function and reserve. Furthermore, older adult patients often have a higher number of comorbidities, and illness and chronic disease increases surgical risk.

Surgery remains a viable, therapeutic option, however, for many older adult patients. Surgical and anesthetic advances have reduced mortality of older surgical patients. Although age should not be ignored, the individual patient must be assessed for his or her functional level, unique characteristics, and risk factors. Surgical team members must understand the unique issues related to the selection and preoperative evaluation of the older adult surgical patient.

The older surgical patient presents a management challenge because of the patient's risk factors, loss of reserve, and comorbid diseases. Surgical risk is greater in the older adult patient, but with careful preoperative assessment, the benefit should outweigh the risk. Attentive perioperative assessment and management minimizes complications, resulting in greatly improved outcomes and quality of life for older adult patients.

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Examination 

Older Adult Surgical Patients: Presentation and Challenges 

Purpose/Goal 

To educate perioperative nurses about the physiology of aging and applying this knowledge to caring for older adult surgical patients.

Behavioral Objectives 

After reading and studying the article on caring for older adult surgical patients, nurses will be able to

Questions 

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Answer Sheet 

Older Adult Surgical Patients: Presentation and Challenges 

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Session #1091

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Learner Evaluation 

Older Adult Surgical Patients: Presentation and Challenges 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about the physiology of aging and applying this knowledge to caring for older adult surgical patients.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

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What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

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• * Access verified June 6, 2009.