Whether you're giving midazolam or sevofluorane, patients older than 65 will have different responses than their younger counterparts. The presence of co-morbid conditions and accompanying prescription drugs only accentuates the perioperative challenges you face every time an older patient undergoes a procedure in your facility. Here's how to ensure the best care possible for the elderly.

Reduced functional reserve
It's important to remember that blood vessels in the older body are less elastic; anticipate arthero-sclerotic diseases narrowing the blood vessels as well as sluggish response from their baroreceptors. Therefore, any drug you give an elderly patient is going to be carried through the vascular system much differently than it would in a 30-year-old. Drugs won't be excreted by the kidneys or metabolized in the liver as efficiently as in younger patients, resulting in higher circulating blood plasma levels. As a result, anesthetic drug effect may take longer to occur; this has patient positioning implications that will be discussed later.

The respiratory system is also compromised. There may be scarification in the lungs that has compromised the alveoli, therefore impairing oxygen exchange. Loss of musculature makes inhaling and exhaling less effective, affecting the exchange of oxgyen and carbon dioxide and potentially decreasing oxygen volume. These factors combine to make it more difficult to rid the system of inhaled anesthetic and increase the risk of post-op pneumonia.

Without proper planning, unexpected problems can combine to cause harm. Elderly patients have reduced functional reserve - the difference between maximum capacity and basal levels of function. In short, it's the safety margin available to the body to meet the additional demands of surgery, healing and convalescence. Because elderly patients have less functional reserve, they have less bounce-back after an insult (such as surgery), provide less wiggle room for error on the provider's part, and have impaired recuperative ability and lengthened time for achieving restoration of pre-operative status - that is, if it can be achieved.

What this means for anesthesia
The compromise of body systems in the aging body means that anesthetic agents take longer to take effect and are more potent once they do, not to mention more difficult to clear from the body (see "Anesthesia in the Elderly Patient" below). Plan on the effects of polypharmacy in the elderly. Be aware of drug-drug interactions between the anesthetic agents and analgesics. The practice of anesthesia in elderly patients is akin to newborn anesthesia; everything must be done very carefully and dosed precisely.

It takes longer for elderly patients' circulatory and respiratory systems to carry drugs through their bodies, sometimes significantly. Depending on your facility and anesthesia providers' preferences, regional blocks can sometimes be used as an alternative to general anesthesia. Recognize that spinal blocks can cause a drop in blood pressure in older patients, and restoring pressure with a fluid bolus is more tricky than in a younger person - who doesn't have heart failure looming. One advantage of using regional blocks is less sleepy patients. Nevertheless, an able caregiver who can ensure protective reflexes are intact must be present at discharge.

General anesthesia is still necessary and can't always be avoided. Remember the Joint Commission's focus on medication reconciliation as a National Patient Safety Goal; this is critical in the elderly patient. Many facilities provide their patients a small medication list card that they can carry with them at all times. You also need to obtain a thorough medical and anesthetic history, either the day before surgery via phone or through the anesthesia provider on the day of surgery upon patient arrival. Make sure any necessary cardiology clearances are complete, as well as endocrine clearances if the patient is diabetic, has a thyroid disorder or is immune supressed.

Administering anesthesia to elderly patients isn't necessarily a matter of changing the type of drugs given, but rather of titrating them precisely to effect. If performed carefully, with concomitant diseases in mind, it can be done with little sequelae. Periop-erative nurses must be aware of this precision as they do their part to provide care to elderly surgical patients. Here are some actions you can take to make the surgical experience a safer one for the elderly patient.

1 Conduct a thorough pre-op assessment.
Review these seven key areas.

• Concomitant disease states. Endo-crine (such as thyroid disease or Type II diabetes), heart or liver disease, COPD, smoking history, osteoporosis, heptatits and systemic diseases can affect the body's ability to manage incoming fluids and to transport drugs to organs effectively. Be aware that less-than-optimal circulation, prolonged anesthesia wake-up, prolonged immobility and sluggish venous return increase the risk of deep vein thrombosis and act accordingly.
• Cognitive status. Assess the patient at this time by asking for simple orientation questions such as time, date, place and plan for surgery. Establishing a baseline for assessing the patient will help post-operatively. Both family and patient can help you understand cognitive status. This would also be a good time to inform the family of possible post-operative confusion. Increasing age coupled with the effects of general anesthesia can cause temporary post-op delirium; families need to be made aware of this.
• Implanted devices. Because the elderly have often undergone previous procedures, there is a higher likelihood that implants ranging from pacemakers to total hips, shoulders and knees will be present in this population. This affects ESU dispersive electrode placement. Be fussy about the patient with a pacemaker. Don't create an electrical circuit that cuts through the generator. If the pacer is in the upper left chest and surgery is on the abdomen, don't place the pad on the right hip - this creates a direct line through the generator and could affect its programmed sensing. In addition, use a magnet over the pacer.
• Critical lab values such as BUN, creatinine clearance, glucose, Hgb and nutritional status. Look at blood glucose numbers and whether the patient is on a hypoglycemic agent (and the agent type). Surgery will stress the patient's physiology, resulting in higher-than-normal glucose levels, which you must monitor especially closely in diabetic patients. Be prepared to perform point-of-care glucose testing on all patients, even those not identified as diabetic - those with abnormally high fasting glucose may be undiagnosed. Emphasize to such patients that they need to see their regular doctors for more testing.

Other key values include kidney and liver function, which will affect drug metabolism and clearance. Assess pre-albumin, serum albumin and total protein to determine nutritional status, which affects the body's ability to heal. Whether the patient doesn't have teeth (and therefore likely takes in fewer calories) and whether he is constipated or has diarrhea also impact nutritional status. Remember that albumin affects protein-bound drugs; less binding means freer circulating. This can negatively affect the very frail patients.

• Current medication regimen. Don't stop at diabetes medications. Make a special note for the following: drops for treating glaucoma, anti-psychotics, MAO inhibitors, narcotics for chronic pain, beta blockers, ACE inhibitors, anti-hypertensives, hypoglycemia drugs, anti-arrhythmic drugs, blood thinners and immunosuppressants. Consider possible drug interactions or added surgical risk to the patient. This is ultimately the anesthesia provider's domain, but you need to be knowledgeable about the regimen so you can advocate for her if you believe a medication choice to be problematic. Antibiotics aren't generally a problem; however, if taken for an ongoing infection, they can be. Investigate the reason for the antibiotic and confer with the surgeon and anesthesia provider if you see a problem.
• Consent, advance directives, DNR status. You may feel uncomfortable asking the patient about an advanced directive, but it's very important to be clear about the patient's wishes - as well as your facility's policy on DNR. Is it suspended in the OR? Does the patient understand what it means? Does the family? Make sure that the patient is competent to sign her own consent. This is a designation that the surgeon should pursue, if necessary, but don't overlook it.

2 Be present for intubation (and extubation).
Induction and emergence are the most vulnerable parts of surgery. Elderly patients' muscles, including those surrounding the esophagus and trachea, are more lax than younger patients', so aspiration and cardiac stimulation are risks. Be present and prepared for untoward and unexpected effects of anesthesia during these stages.

3 Position gently.
Because anesthetic agents take longer to reach effectiveness in the elderly, it's important that you wait until they're fully anesthetized before beginning to position them for surgery. Move limbs slowly and carefully, be cognizant of limited range of motion or the possibility of dislocation or fracture, and don't be afraid to ask for help.

Be diligent about maintaining skin integrity, especially when positioning on the fracture table and when using the McGuire hip positioner or candy cane stirrups. Elderly patients are more susceptible to pressure sores, injuries or fractures. The same rules apply when returning the patient to the pre-operative position for anesthesia emergence. When transferring the patient, make sure the skeleton is well aligned. When he is in the bed, check all bony prominences and document changes in skin integrity.

4 Use care when removing prep solution.
Be cognizant that older patients have very thin skin. Take care when removing prep solution or any tape that has been placed to hold the patient's position for the operative period. Use gentle cloths rather than rough towels. This is even more important for an immunosupressed patient on long-term prednisone.

5 Transfer patients with oxygen.
Ensure the oxygen tank is full and on for transfer to PACU. Collaborate with the anesthesia provider to determine the appropriate number of liters for each patient's needs.

6 Give post-op instructions.
Reassure the patient that the surgery is over and help her orient to time, place and event. If the patient has had general anesthetic, explain to her caregiver that temporary post-op delirium can occur, but should clear up in about three days. Ensure that someone will be caring for the patient for at least 24 hours post-op and remind them that the patient should not drive or make any major decisions for at least 24 hours, even if the procedure was a minor one, such as colonoscopy; some analgesics will remain in the patient long after discharge from your facility. Explain signs and symptoms of infection and that the doctor's office should be contacted if a marked change in mental status occurs. Give the usual wound care and medication instructions, taking this as another opportunity to reconcile medications.

Not going away
There's an overwhelming need for perioperative nurses to become geriatric specialists or to at least familiarize themselves with the knowledge needed to care for elderly patients. As the population ages, more and more surgical patients will be older than 65, and it's possible that the majority of surgical patients will soon be in this category. It's important that you take their needs into account - perhaps even allowing extra time in the schedule when elderly patients will be having procedures. This may translate into slower turnover times, but in the long run it's a much more realistic way to handle this burgeoning group. The physiological processes cannot be materially altered; they can only be handled to the best of your ability.