Introduction

Geriatric Essentials

• Preoperative evaluation aims to identify intraoperative risk and risk of postoperative complications common among the elderly (eg, delirium).
• Overall, age predicts surgical risk much less well than general health, although certain comorbidities that become more common with aging and some physiologic age-related changes may increase risk.
• Among the elderly, the most important surgical risk factors are usually cardiac disorders, particularly coronary artery disease.
• Other risk factors common among the elderly include poor general health, inactivity, undernutrition, dementia, thromboembolic disorders, pulmonary disorders, diabetes, thyroid disorders, use of certain drugs, and renal insufficiency.
• Risk of surgical complications depends on the surgical procedure as well as on patient factors.

Preoperative evaluation should include general medical assessment (history, physical examination, laboratory tests) and systematic identification of comorbidities (eg, cardiac, pulmonary, and thyroid disorders; undernutrition; dementia; diabetes; renal insufficiency) and other surgical risk factors (eg, use of certain drugs). The goals are to correct the few that are reversible and to take appropriate surgical precautions. Before emergency surgery, there may not be time for complete evaluation and correction of risk factors; however, even incomplete evaluation and correction can reduce surgical risk. Preoperative evaluation often involves requesting a medical or geriatric consultation. Additional consultation with social workers, discharge planners, or psychiatrists may be warranted; these services may be coordinated through the geriatric consultation.

Informed consent and advance directives: Before surgery, the surgeon explains the procedure, including benefits and possible complications, to the patient. Then the patient is asked to sign an informed consent agreement.

If a patient cannot understand the surgical risks and benefits because of dementia, delirium, shock, intoxication, or other reasons (eg, emergency surgery), permission for surgery is granted according to the patient's advance directives or by a surrogate (a person appointed by statute to make health care decisions for another person). In cases of extreme emergency, lifesaving treatment often proceeds without consent. Advance directives (eg, living wills, durable power of attorney for health care) are completed while a patient still has the capacity to make health care decisions. Before surgery, these directives should be documented, and the name of the patient's surrogate should be recorded.

Nursing issues: Coordinated and comprehensive preoperative nursing care can help alleviate a patient's fears and enhance postoperative function. By assessing a patient's function before surgery, nurses may be able to identify subtle impairments that could affect postoperative function. For example, if a patient has some difficulty controlling urination before surgery, the risk of incontinence may be increased after surgery because of impaired mobility, drowsiness, or other factors.

Nurses can reinforce and amplify what is said by the surgeon and anesthesiologist, teaching patients and family members what to expect before, during, and after surgery. After surgery, nurses can encourage patients to get out of bed and to become mobile as soon as possible (often hours after surgery); nurses also prepare patients for their rehabilitation program, which is designed to help them quickly regain function. Nurses help prevent and identify potential postoperative problems, such as urinary incontinence, sleep problems, pressure ulcers, and inadequately treated pain. For example, nurses should ask patients or their caregivers which analgesics have been used in the past and how effective those analgesics were. At discharge, nurses should make sure that patients are given and understand their care plan, which is designed to optimize function.

This topic was last updated March 2006.