4 Ways to Adapt ERAS for Older Adults

Enhanced recovery after surgery (ERAS) is a protocol for surgical patients gaining traction in hospitals across the US because of the strong evidence-based benefits ERAS promises, including rapid recovery and less postoperative complications.

Developed by a Danish surgeon, ERAS has become a standard of care in many health care organizations across Europe and Asia, providing more opportunity for research in applying ERAS to different patient populations, including older adults.

Investigating ERAS Outcomes for Older Adult Patients

“The research suggests older adults can achieve significant benefits from participating in ERAS,” according to May Karam, BSN, RN, MHA, CNOR, a perioperative nurse and President of the European Operating Room Nurses Association.

She cites several studies finding that ERAS protocol is beneficial for older patients in abdominal, orthopedic, and minimally invasive procedures, despite the higher risk for co-morbidities with this population and a higher risk for postoperative complications following these procedures.

For example, a 2015 study by Pedziwiatr et al compared patients over 80 with patients below age 55 undergoing laparoscopic surgery under ERAS protocol and found no difference in length of stay, complications or recovery of different functions between age groups.

In a randomly controlled trial from China by Jia et al, patients over age 70 undergoing open colorectal surgery also found better outcomes with ERAS when compared to non-ERAS patients in the same age group, including benefits such as decreased cardiac and pulmonary complications and a reduction in delirium from 13% to 4%.

Adapting ERAS for Older Adults

While many studies suggest ERAS needs no modification for older adults, Karam says her experience in caring for older adults through ERAS, as well as some research suggests older adults can benefit from increased education and preparation for ERAS, as well as several postoperative modifications to help achieve optimal outcomes.

She suggests four important adaptations to ERAS protocol to consider for older adults:

1. Build in extra time for patient education—All patients play an active role in their successful outcome through ERAS and older adults are no exception. Karam says a little extra time with older adults to explain their role in ERAS, such as preoperative physical training and postoperative ambulation can make a big difference. “Make sure older adult ERAS patients are well-prepared to actively participate as this will reduce their stress and support a quick recovery—be patient,” Karam suggests.


2. Plan for an extra day or two in postoperative recovery—Older adults may be afraid to go back home early, Karam cautions. Several studies show older adults may need one or two more days for postoperative recovery when compared to young adults within the ERAS protocol.


3. Carefully assess the older adult patient’s health status—Potential co-morbidities, multiple medications and general infirmities owing to advanced age can increase risks for ERAS elderly patients, Karam notes. For example, patients with diabetes on insulin present slightly higher risk and this should be taken into account.


4. Modify instructions— All written information and resources on ERAS should be clear and adapted for easy reading, such as larger font size and clearer identification and focus on key aspects of ERAS. Karam suggests “any written instructions must be clearly printed for easy reading and should be verbally reinforced to ensure patient understanding.”

As with all ERAS patients, Karam stresses the value of teamwork between the various teams and stakeholders involved in a patient’s ERAS surgical care experience, including the patient, surgeon, nurses, physiotherapists, pharmacist, and more. “Effective communication at all times between each provider and care team is essential to achieve the best outcomes under ERAS and this focus is even more important for older adult patients.”

Additional Resources

Read this 2015 study by Pedziwiatr et al comparing older adults to younger adults undergoing laparoscopic surgery for colorectal cancer under ERAS.

Read this 2014 study by Jia et al on reduced postoperative delirium in ERAS elderly patients.

Find more in this 2018 review of ERAS in older adults by Ljungqvist et al.

Resources for Members

Free AORN Journal articles

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Patient‐Centered Care‐Enhanced Recovery After Surgery and Population Health Management

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