BETTER WITH AGE Your perioperative team must step up its efforts when caring for older patients.

The results of surgery in the elderly are typically worse than surgery in younger age groups. Some hospitals and surgery centers achieve excellent results with geriatric patients, but data from across the country show that being elderly is a risk factor for surgery. They experience more complications, longer lengths of stay, longer times in the OR and recovery, and more deaths. Here are practical steps we can take to protect our older patients.

In pre-op
You typically do routine blood tests and listen to the heart and lungs, perhaps ask for EKGs and chest X-rays, and consult with a cardiologist or internist to ensure patients are stable for surgery. A more comprehensive pre-op clinical evaluation of elderly patients presenting for elective surgery could also include a test for frailty, which involves assessing handgrip strength and gait speed, and historical questions about weight loss and energy level. A timed-up-and-go test is a simple alternative.

Also test for cognition, using a mini-cog test, which involves having patients recall 3 words and draw an accurate clock face, including numbers and hands, for a specified time. Conduct a hearing screening and an assessment of instrumental activities of daily living to determine patients' executive functioning.

We also conduct caregiver burden interviews to understand the burdens the elderly place on their loved ones' lives. (We follow up 6 months post-op to see if surgery made the burdens greater or lesser.)

Pre-op staff should carefully review patients' medications and give clear instructions on exactly which medicines they can take and which ones to stop after surgery.

This more exhaustive evaluation, which can be done on patients older than 75 years, should take nurses or nurse practitioners an extra 15 minutes to complete.

Ideally, you'll input the results of the pre-op assessment into an electronic health record, so caregivers can access the information throughout the patients' stay. That's important because after an operation, patients who might appear cognitively impaired might be exhibiting behavior that matches baselines measured in pre-op.

In the OR
The elderly lose body heat rapidly because their skin is extremely thin, so properly warming these patients is essential in order to stave off hypothermia (see "The Unintended Consequences of Unintended Hypothermia" on page 46). It's a good idea to use forced-air warming for surgeries lasting any significant length of time.

Local and regional anesthesia is typically used more often in elderly patients, although deep sedation is sometimes required, even for these inhalational-anesthesia-avoiding techniques.

Employ "just right care," which involves paying particular attention to the wishes of individual patients. Quality of life is more important to many elderly patients than length of life. For example, most patients of advanced age would opt for less invasive cancer surgery with less of a chance of cure compared to a more invasive operation that might extend their lives.

Whenever possible, surgeons should try to perform less stressful surgery that accomplishes the same clinical goal. They should focus on spending a little extra time in the OR and truly focus on their technique to ensure patients won't have bleeding problems during recovery.

In PACU
Nurses should have access to the entire pre-op evaluation, so they know the patients' baseline levels of consciousness, function and frailty. Patients who fail the cognition test are at increased risk of post-op delirium — hallucinations, changing levels of consciousness and potential agitation — and are more likely to remain in the PACU for extended periods.

Elderly patients who retain urine or are severely constipated are also at increased risk of delirium. Post-op pain increases delirium risk, too, but the elderly might not be able to express the discomfort they're feeling. In fact, post-op pain sometimes manifests as agitation.

Nurses should take extra care with patients who are cognitively impaired heading into surgery in order to prevent delirium. Let the family be at the bedside early in the recovery phase and try to keep the patient oriented with large, easily seen clocks.

Patients who are kept overnight should be assigned to quiet rooms so their normal sleep patterns remain intact. My facility, Sinai Hospital in Baltimore, Md., recently renovated 19 rooms specifically for geriatric patients. The renovation included larger clocks, warm wall colors, muted lighting, floors with less glare and signage with larger print. Outpatient settings can include the same elderly-friendly design features in their recovery spaces.

The more extensive pre-op evaluation helps recovery room staff know which patients are more likely to face potential issues once they're discharged home.

Consider hospitalizing a patient if the caregiver burden interview reveals the family was already under a great deal of care-related stress before the operation, or if the patient is exceptionally frail or cognitively impaired. In fact, these patients might not be suitable for surgery in the outpatient setting.

FACILITY FOCUS
The Sinai Center for Geriatric Surgery

TARGETED CARE Joann Coleman, RN, clinical coordinator at the Sinai Center for Geriatric Surgery, performs pre-operative testing on an elderly patient.

When I came to Sinai Hospital in Baltimore, Md., I asked the administration to create a center for geriatric surgery. The idea was to take better care of elderly patients, teach other facilities about what we're doing and how we can all do better. It's both a clinical/ patient care mission and an academic mission.) The Sinai Center for Geriatric Surgery has been open for about a year. It's virtual: The elderly travel along the same surgical circuit that all patients do, but our perioperative staff focuses on their unique clinical needs and sensitivities. Among the many successful case outcomes I've achieved: lung surgeries performed on a 104-year-old woman who was kept overnight and on a 100-year-old man who was discharged the day of surgery and several patients who were turned down for surgery by other centers.

— Mark Katlic, MD, MMM, FACS