Special Needs Population: Care of the Geriatric Patient Population in the Perioperative Setting

CONTINUING EDUCATION

Special Needs Population: Care of the Geriatric Patient Population in the Perioperative Setting 2.6 www.aorn.org/CE

KRISTEN A. OSTER, MS, APRN, ACNS-BC, CNOR; CYNTHIA A. OSTER, PhD, MBA, APRN, CNS-BC, ANP Continuing Education Contact Hours

Accreditation

indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Event: #15511 Session: #0001 Fee: Members $20.80, Nonmembers $41.60 The contact hours for this article expire April 30, 2018. Pricing is subject to change.

Purpose/Goal To provide the learner with knowledge specific to perioperative care of the geriatric patient population.

Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Conflict of Interest Disclosures Kristen A. Oster, MS, APRN, ACNS-BC, CNOR, and Cynthia A. Oster, PhD, MBA, APRN, CNS-BC, ANP, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

Objectives

Sponsorship or Commercial Support

1. Discuss the epidemiology of aging in the US population. 2. Explain the pathophysiology of aging. 3. Identify special considerations directly tied to age-related changes and conditions in the geriatric patient population. 4. Describe perioperative care of the older adult patient undergoing surgery.

No sponsorship or commercial support was received for this article.

Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2014.10.022 ª AORN, Inc, 2015

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Special Needs Population: Care of the Geriatric Patient Population in the Perioperative Setting 2.6 www.aorn.org/CE

KRISTEN A. OSTER, MS, APRN, ACNS-BC, CNOR; CYNTHIA A. OSTER, PhD, MBA, APRN, CNS-BC, ANP

ABSTRACT The geriatric population, defined as people 65 years of age and older, undergoing surgical procedures is a vulnerable population. Age, once considered a contraindication for a surgical procedure, is no longer a constraint for individuals requiring surgical intervention. However, older adult patients are at increased risk for developing a variety of complications. This article reviews age-related physiological changes and discusses the special needs of the geriatric population across the perioperative continuum of care. AORN J 101 (April 2015) 444-456. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/ j.aorn.2014.10.022 Key words: elderly perioperative patients, geriatric surgical patients, vulnerable population.

http://dx.doi.org/10.1016/j.aorn.2014.10.022 ª AORN, Inc, 2015

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n the United States, the geriatric population, defined as people 65 years of age and older, is projected to experience rapid growth during the next four decades.1 Age, once a contraindication for surgical procedures, is no longer a constraint for individuals requiring surgical intervention; 37% of all surgical patients are 65 years of age or older.2 However, the older adult patient is at risk for perioperative complications caused by age-related changes and comorbid conditions. The seriousness of complications often depends on patient-specific age-related changes and pre-existing conditions. The purposes of this article are to review age-related physiological changes and discuss the unique needs of geriatric patients across the perioperative continuum.

EPIDEMIOLOGY OF AGING The US population 65 years of age and older increased at a faster rate (15.1%) than the total US population grew (9.7%) between 2000 and 2010.3 Between 2010 and 2030, the number of US citizens aged 65 years and older is expected to grow 80% (from 40 million to 72 million).4 People born between 1946 and 1964 are largely responsible for this growth.1 Approximately one in five Americans will be older than 65 years in 2030.1,4 Furthermore, it is estimated that the population 75 years of age and older will increase by 77% between 2010 and 2030, accounting for almost half of the growth in the geriatric population.4 It is estimated that 88.5 million Americans will be aged 65 years and older by 2050, more than double the 40.2 million of 2010.1,5 The growth of the older population has implications for the US health care system. The higher demand for health care services by a population growing older contributes to increasing health care costs. Health care costs for those older than 65 years of age are three to five times higher than costs for those younger than 65 years of age.4 Adults older than age 65 years account for more than one-third of US community hospital stays, costing $157.7 billion.4 Many age-related chronic conditions require surgical management and comorbidities affect recovery after anesthesia and surgery. Many people who are 65 years of age and older are active and healthy and can tolerate surgical intervention without increased morbidity and mortality. However, older adults often experience progressively declining health and a number of comorbidities.4 Dealing with the wide range of health status in older adult patients is challenging for perioperative nurses.

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Special Needs Populations: Older Patients

NORMAL AND PATHOPHYSIOLOGICAL CHANGES OF AGING To accurately assess and manage an older adult patient across the perioperative continuum, perioperative nurses must recognize pathophysiological changes that occur with aging. Human aging is viewed as a gradual and spontaneous process that begins at conception.6 The course of aging varies from individual to individual and is related to each person’s unique constellation of genetic, social, psychological, and economic factors. The perioperative nurse must have a clear understanding of the differences between age-related changes and changes that may be pathological in nature.

Cellular Changes Organ and system changes can be attributed to basic changes at the cellular level, and these changes influence all physiological processes. With advancing age, the number of cells is gradually reduced; furthermore, aging cells display a greater amount of damage compared with younger cells. Jackson7 reported that certain enzymes have protective properties that may slow the effects of cell aging. Lack of these enzymes in laboratory mice showed age acceleration and skeletal muscle loss. This may explain why lean body mass decreases while total-body fat as a proportion of the body’s composition increases in older adults.8 Cellular solids and bone mass decrease. There is less total-body fluid as a person ages. Extracellular fluid is fairly constant but intracellular fluid is decreased, making dehydration a significant risk for older adult patients.9

Neurological Changes Although intelligence does not diminish as age increases, brain size and cerebral perfusion decrease.10,11 The decline in brain size and cerebral perfusion may manifest as concentration difficulties, short-term memory loss, distractibility, slowed reaction time, decreased speed of performance, and difficulty organizing information.12 A reduction in the number of neurons and slowed nerve fiber conduction velocity decrease motor function, hearing, vision, and memory. Kinesthetic sense lessens and the response to changes in balance slows, which contributes to the increased risk for falling.9 The presence of dementia may mask acute neurological changes and further complicates the neurological examination.13 Changes occur in the hypothalamus, reticular formation, and sensory organs. The hypothalamus regulates body temperature less efficiently, making older patients susceptible to temperature extremes, which may result in hypothermia more

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easily. Sleep disorders are common and result from alterations in the sleep-wake cycle, circadian rhythm, and homeostatic factors affecting sleep regulation.14,15 Sensory organs become less efficient.9,16 Visual acuity is altered; elasticity of the lens of the eyes is altered, causing an inability to visually accommodate adequately. The visual field narrows, making peripheral vision more difficult. The pupil becomes less responsive to light because the pupil sphincter hardens while pupil size and rods decrease. Consequently, the threshold for light perception increases, making night vision difficult. Progressive hearing loss occurs as a result of age-related changes to the inner ear. Degeneration of the vestibular structures contributes to a loss of equilibrium and balance. Tactile sensation is reduced, with older persons less able to sense pressure, pain, and temperature. One of the major components of the physiological stress response is pain.17 However, the role of age in pain perception and tolerance is unclear. Evidence suggests an age-related increase in the pain threshold, altered pain quality, and diminished sensitivity to lower levels of pain.12

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Stiffening of the outflow tracts leads to increased afterload.19 Systolic blood pressure increases significantly, resistance to ventricular emptying increases, and ventricular hypertrophy occurs. The aging heart is less responsive to sympathetic stimulation and cannot compensate for an increased need for cardiac output by increasing the heart rate.10 Increased metabolic needs are met by increasing ventricular filling and stroke volume and increasing cardiac workload.24 Consequently, maintaining adequate circulating volume is crucial in older adult patients. Diastolic dysfunction is common.19 The aged myocardium has less efficient oxygen utilization; therefore, even mild hypoxemia can exacerbate underlying diastolic dysfunction in older adult patients.

Pulmonary Changes The aging lung is less able to defend against illness. Age-related changes in structure and function, along with the presence of chronic disease, affect respiratory function. Structural changes in the chest make it difficult for the older patient to ventilate.25

Tactile sensation is reduced, with older persons less able to sense pressure, pain, and temperature.

Cardiovascular Changes

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Cardiovascular disease is the leading cause of death in the United States and accounts for more than 40% of deaths in patients older than 65 years.18 Aging alters the cardiovascular system both physiologically and structurally. Degenerative changes affect the anatomical, histological, physiological, and electrophysiological performance of the heart.19 Myocytes are progressively lost and myocardial collagen is increased.20 Thus, the heart muscle loses efficiency and contractile strength and cardiac output decreases. The cardiac muscle stiffens and thickens as a result of increased myocardial interstitial fibrosis.19,21 Connective tissue and fat replace autonomic tissue; the resulting fibrosis causes conduction abnormalities, producing high rates of sick sinus syndrome, atrial arrhythmias, atrioventricular blocks, and bundle branch blocks.21,22 Systolic and diastolic blood pressure increase with age to compensate for increased peripheral resistance and decreased cardiac output. Reduced cardiac output places the older adult patient at risk when faced with increased metabolic demand.23

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Chest wall compliance decreases as changes to the ribs and vertebrae cause immobility. Osteoporosis and calcification of the costal cartilage make the trachea and rib cage more rigid. The anterior-posterior chest diameter increases. Inspiratory and expiratory muscles are weaker, requiring additional effort and energy to breathe. Consequently, older adults often use accessory muscles to breathe. There is blunting of cough and laryngeal reflexes. The number of cilia in the lungs decreases, the bronchial mucus gland hypertrophies, and the ability to expel pooled mucous and debris declines. Pooling of secretions along with decreased immunoglobulin A (IgA) levels put older adults at higher risk for developing pneumonia.26 Age-related lung function changes also occur. The number, elasticity, and surface area of alveoli decrease, thereby reducing the area available for gas exchange.19,21 In addition, the oxygen-carrying capacity of the blood is reduced because of lower hemoglobin levels. Thus, lower partial pressure of oxygen in arterial blood (PaO2) levels occur;9

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PaO2 lessens by as much as 15% between ages 20 and 80 years, suggesting a normal range as low as 60 mm to 80 mm Hg in older adult patients.9,19 In contrast, there is no age-related change in the partial pressure of carbon dioxide in arterial blood (PaCO2); therefore, hypercarbia should be considered pathological.19 These alterations leave the older adult patient less able to respond to hypoxia and hypercapnia, increasing the potential for quick decompensation. The presence of a chronic disease can complicate respiratory function. Obstructive lung diseases affect expiratory flow rates and obstruct the airways. Restrictive lung diseases result in a loss of functioning alveoli, a loss of lung volume, and decreased chest wall compliance. These pathophysiological changes can further compromise respiratory function of an older adult patient.

Gastrointestinal Changes The gastrointestinal tract is altered by the aging process at all points.27,28 Older adults report decreased feelings of hunger and increased feelings of satiety, suggesting that satiety hormones increase with advancing age while the hunger hormone, ghrelin, decreases.29,30 Older adults frequently report altered swallowing caused by oropharyngeal dysmotility.31 Decreased esophageal motility can be attributed to degenerative muscular changes. Age-related changes in the stomach include gastric mucosa atrophy, decreased gastric acid and digestive enzyme secretion, and decreased motility.29 Consequently, older adults are not able to accommodate large amounts of food. The muscle and mucosal lining of the small intestine atrophy, villi thin, and the number of epithelial cells decreases, leading to malabsorption of fats and vitamin B12. Thus, older adult patients may become undernourished, weak, and debilitated. The mucosa of the large intestine atrophies, connective tissue proliferates, and atherosclerotic vascular changes occur.27 Internal and external sphincter tone decrease, which may lead to incontinence. In addition, slower transmission of neural impulses reduces the awareness of the need to defecate and may account for the increased incidence of constipation. The liver becomes smaller in weight and volume with age. Diminished hepatobiliary functions accompany moderate declines in medication metabolism capability.32 Liver function test results often remain within normal limits. Less efficient cholesterol metabolism increases the incidence of gallstones. The ducts of the pancreas become dilated and distended. Impaired insulin secretion from the beta cells along with increased peripheral insulin resistance make the older adult patient at higher risk for glucose intolerance and type 2 diabetes.33

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Special Needs Populations: Older Patients

Renal Changes Several structural and functional changes occur in the kidney and are caused by reduced renal blood flow and a progressive decrease in glomerular filtration rate (GFR).31 By age 80 years, renal blood flow decreases 50% because of the combined effects of decreased renal tubular mass and atrophied arterioles.21-23 Between the ages of 30 and 85 years, renal mass decreases 20% to 30% secondary to renal cortical loss, whereas 40% of nephrons become sclerotic.23,34 Older adult patients have a decreased capacity to concentrate urine, conserve sodium, and excrete hydrogen, leading to fluid and acid-base imbalances.24 Also, older adult patients have a higher likelihood of dehydration because of their inability to compensate for nonrenal loss of sodium and water. The GFR decreases approximately 45% by age 85 years.21-23 A decreased GFR can affect the older adult patient’s ability to metabolize medications cleared by the kidneys and affects medication half-life.23 Bladder changes occur with age and contribute to the development of urinary frequency, urgency, and nocturia. Bladder muscles weaken and bladder capacity decreases, making bladder emptying more difficult. Larger amounts of urine are retained and the urination reflex is delayed, resulting in stress incontinence.

Musculoskeletal Changes Aging affects the musculoskeletal system, with changes beginning at age 30 years.22 A musculoskeletal phenomenon associated with aging is senile sarcopenia, the loss of muscle mass.31 Senile sarcopenia is a primary cause of muscle weakness and reduced locomotor activity.35 Neuropathic processes; nutritional, hormonal, and immunological factors; and decreased physical activity contribute to the development of senile sarcopenia. The number of muscle cells decreases and cells are replaced by fibrous connective tissue. Consequently, muscle mass, tone, and strength lessen. Wu et al36 report that the loss of muscle mass dramatically increases (ie, more than four-fold) after the age of 70 years. Joints become stiffer as ligaments, tendons, and cartilage lose elasticity. Bone mass declines and bones weaken.22 Thus, older adult patients are more susceptible to fractures, tears, and dislocations. The intervertebral discs lose water, disc spaces narrow, and disc height decreases.37 The older adult patient assumes a position of flexion, the center of gravity shifts, and gait changes. All these changes can cause pain, impaired mobility, self-care deficits, and an increased risk for falls.

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stiffening, and elastin calcification.38 Atrophy of the epidermis slows healing, reduces barrier protection, and delays absorption of medications. Growth of the epidermal layer slows.9 The contact area of the dermis and epidermis decreases, causing easy separation of these layers. Thus, older adult patients are at risk for shear injuries. Changes to the dermis include decreased number of sweat glands, blood vessels, and nerve endings. These changes cause diminished thermoregulatory function and inflammatory responses and decreased tactile sensation and pain perception. The loss of subcutaneous adipose tissue results in the loss of protective padding and increases the vulnerability for pressure ulcer development. Skin injuries in older adult patients may take twice as long to re-epithelialize.22

SPECIAL CONSIDERATIONS FOR OLDER ADULTS The geriatric patient population has several special considerations directly tied to age-related changes and conditions. The

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too many forms of medications, use of over-the-counter medications, multiple dosing schedules, and appropriate medications for which the patient must take too many pills.46-48

As a result of the multiple comorbidities associated with aging, the geriatric population is most susceptible to the associated adverse health outcomes of polypharmacy.39 Age-related alterations in pharmacokinetics and pharmacodynamics contribute to adverse health outcomes of polypharmacy. The term pharmacokinetics relates to how the body absorbs, distributes, metabolizes, and eliminates medication, whereas the term pharmacodynamics describes the effect of the medication on the patient and how the medication interacts at the receptor site.49,50 Age-related changes at the receptor site modify the number of receptors, which alters binding capacity and biochemical reactions, thereby affecting medication pharmacodynamics.46,51 Older adult patients can

Inspiratory and expiratory muscles are weaker, requiring additional effort and energy to breathe. Consequently, older adults often use accessory muscles to breathe.

perioperative nurse caring for older adult patients must consider how polypharmacy, nutrition, and pain management affect the care of this vulnerable patient population.

Polypharmacy Polypharmacy, literally meaning “many pharmacies,” has a variety of descriptions, with no definition consensus in the literature.39,40 Some studies define polypharmacy as the use of four or more medications or up to seven or more medications, while others define polypharmacy as the use of one or more medications.40,41 Polypharmacy occurs with inappropriate or unnecessary prescribing, resulting in negative outcomes.42 Polypharmacy can occur in any age group; however, it is most prevalent in the geriatric population.43-45 Often, polypharmacy is recognized by  use of multiple medications,  multiple prescribers,  use of several filling pharmacies,

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exhibit either increased or decreased response to medications compared with younger patients. The benzodiazepines, antipsychotics, anticholinergics, and tricyclic antidepressants are medications that can be particularly problematic for older adult patients.52 Another concern for older adult patients is adverse medication interactions.49 Polypharmacy increases the likelihood of experiencing medication-to-medication interactions.53,54 The incidence of medication-to-medication interactions increases with age, the number of medications taken, and the number of prescribers involved in the patient’s care.55 Adverse medication interactions occur when two or more medications interact in a way that the effectiveness or toxicity of one or more medications is altered.49 The number of potential interactions increases as the number of medications increases. The potential toxicity of interactions between medications that have a narrow therapeutic index is especially high.46

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Nutrition The prevalence of malnutrition in older adult hospitalized patients is estimated to be as high as 39%.56,57 Protein-energy malnutrition is estimated to be as high as 62% of hospitalized older adult patients, with an additional 47% at risk for malnutrition.58,59 Malnutrition is associated with numerous factors, including cognitive and functional status decline, infections, malignancy, pressure ulcers, recent orthopedic surgery, and cerebrovascular accidents.56 Orsitto et al60 reported that older adult patients with mild cognitive impairment and dementia had a significantly higher frequency of being at risk for malnutrition or being malnourished than patients with normal cognition. Furthermore, the lack of adequate food intake while hospitalized is a main contributing factor to malnutrition and is a risk factor for geriatric mortality.61 Nutritional status is influenced by lack of appetite associated with underlying medical conditions, treatments, and medications. Polypharmacy along with medication side effects such as nausea, dry mouth, decreased appetite, and metallic taste contribute to poor nutrition among older adult patients.62

Pain The American Pain Society defines pain as a sensory and emotional experience associated with tissue damage.63,64 McCaffery65 adds that pain is whatever the experiencing person says it is and exists whenever he or she says it does. Findings from the 2011 National Health and Aging Trends Study66 found overall prevalence of pain in the previous month in adults aged 65 years and older was 52.9%, thereby afflicting 18.7 million older adults in the United States. Patel et al66 reported that pain prevalence was significantly higher in women and older adults with obesity, musculoskeletal conditions, and depressive symptoms. In addition, they reported that 74.9% of older adults reported multiple sites of pain.66 Pain in older adults can be classified by onset and duration or by pathophysiological mechanism.67 Acute pain has an abrupt onset and can be severe, but lasts for only a short time. Chronic pain persists for three months or longer with mild to severe intensity. Pain can be classified by pathophysiological mechanisms, as well. Nociceptive pain is caused by mechanical, thermal, or chemical noxious stimuli to the nociceptors found in fasciae, muscle joints, and other deep structures. Neuropathic pain is associated with insults to the nervous system, such as diabetic neuropathies and neuralgias. The role of age in pain perception is not clear; some evidence suggests a reduced sensitivity to thermal and mechanical pain in older adults.68-70

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Special Needs Populations: Older Patients

PERIOPERATIVE NURSING CONSIDERATIONS The perioperative nurse should design an individualized plan of care for the older adult patient undergoing surgery. Often the plan depends on the older adult patient’s level of cognitive and physical function. Perioperative care consists of three separate phases, including the preoperative, intraoperative, and postoperative phases. Special nursing considerations over the continuum of perioperative care are provided in Table 1.

Preoperative Nursing Considerations The preoperative period consists of the time before surgery and focuses on preparing the patient physically and mentally for the surgical procedure. During the preoperative period, the nurse gathers patient information to establish a baseline, identify risk factors, and develop a plan of care to ensure safety of the patient throughout the perioperative experience. The preoperative RN’s assessment should include assessing the patient’s cognitive and sensory function; visual and hearing acuity; muscle mass, muscle weakness, impaired balance, and fall risk; nutritional status and preoperative fasting status; and general baseline health status. The preoperative nurse should assess the patient’s cognitive and sensory function before the informed consent process begins. Determining an older adult patient’s cognitive capacity is an important part of the informed consent and advanced directives determination process. Cognitive assessment occurs during observations and conversations with the older adult patient throughout preoperative care interactions.71 Observation and conversation with the older adult patient provides the nurse with information about the patient’s decision-making ability by expressing a choice, understanding the nature of the surgical procedure, and appreciating the risks. “Teach-back,” whereby the patient explains in his or her own words what has been explained, is a strategy the preoperative nurse can use to assess understanding and cognitive function of the older adult patient.72 The presence of dementia and other cognitive changes associated with age may require informed consent to be obtained from the medical power of attorney. Decreased visual and hearing acuity requires the preoperative nurse to assist the patient in using glasses and hearing aids so the patient can clearly understand preoperative instructions.73 The nurse should face the patient, speak slowly and clearly, decrease background noise, and increase voice volume only if other interventions are ineffective at facilitating hearing.74 Loss of both visual and hearing acuity also can increase the older

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Table 1. Perioperative Nursing Implications for Care of the Geriatric Patient Population Perioperative Continuum  Allow the patient adequate time to complete necessary tasks (ie, moving, talking)  Demonstrate effective communication so the patient can understand the situation  Assess the patient’s need for sensory aids (eg, hearing aids, glasses)  Assess the patient’s cognitive functioning and implement appropriate plan of care  Assess the patient for risk factors associated with falls and implement necessary precautions  Assess the patient’s functional status and ability to perform activities of daily living (ADLs)  Complete a medication reconciliation to identify potential age-related medication metabolism concerns and medicationto-medication interactions  Allow for adequate time and use appropriate resources to successfully complete perioperative education  Assess whether a designated support person is needed when providing perioperative education

Preoperative Care

   

   

Assess the patient’s cognitive and sensory function before the surgeon begins the informed consent process Determine the need for a designated support person or power of attorney to complete the informed consent process Discuss advanced directives and code status to identify the patient’s wishes Review medication reconciliation form to identify potential polypharmaceutical risks to include use of o multiple medications, o multiple prescribers, o several filling pharmacies, o too many forms of medications, o over-the-counter medications, or o multiple dosing schedules Document baseline physical assessment parameters, including cardiac rhythm and oxygen saturation level Document a detailed skin assessment with notation of areas of dryness, lesions, or bruising Document preoperative fasting status and assess for dehydration, malnutrition, and hypoglycemia Identify social support to determine whether the patient has home assistance to complete ADLs

Intraoperative Care

       

Allow patient to keep sensory aids to improve communication and decrease confusion until procedure begins Position patient carefully with consideration of risk factors associated with the procedure and the patient’s comorbidities Protect and pad the patient’s boney prominences to mitigate the risk for pressure ulcer development Determine the presence of limited mobility and range-of-motion problems that may require a slide board to move the patient to the OR bed and determine the need to modify surgical positioning if needed Implement measures to maintain adequate body temperature and prevent hypothermia (eg, monitor body temperature, increase room temperature, place temperature-regulating blanket, provide warmed IV and irrigation solutions) Monitor fluid balance, hemodynamics, and oxygenation Assess and document patency and drainage of hemodynamic access lines, indwelling urinary catheter, and drains Reassess skin integrity at completion of the procedure and before transfer to the postanesthesia care unit

Postoperative Care

      

Return sensory aids to patient as soon as possible Assess the patient frequently and compare with baseline assessment values Assess the patient for presence of delirium; do not leave the patient unattended if delirium presents Administer medications as needed to relieve nausea and vomiting Implement the pain management plan Maintain fall prevention interventions Implement interventions to decrease risk for atelectasis and pneumonia; help the patient to turn, cough, and deep breathe

adult patient’s anxiety. Therefore, a calm preoperative environment should be established and maintained. Loss of muscle mass, muscle weakness, and impaired balance in older adult patients make it imperative that the preoperative nurse assess risk for fall and initiate fall prevention precautions. The preoperative nurse also should assess the patient’s cardiac and pulmonary status.

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The preoperative nurse should ascertain when the patient last consumed food or drink because preoperative fasting decreases aspiration risk during induction and emergence from anesthesia.75 Although the risk of aspiration is decreased with preoperative fasting, the older adult patient must be monitored closely for dehydration and hypoglycemia. Preoperative fasting can exacerbate malnutrition, leading to the increased risk for pressure ulcer development.

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Therefore, the preoperative nurse should complete and document a detailed skin assessment, noting any areas of dryness, lesions, or bruising. The preoperative nursing considerations must be communicated to the RN circulator for continuity of care. During the hand-over communication, the preoperative nurse should notify the RN circulator of the patient’s general baseline health status and any abnormalities in  oxygen saturation or other blood gas levels because older adult patients are less able to respond to hypoxia and hypercapnia and decompensate quickly;  cardiac rhythm because older patients are prone to cardiac arrhythmias;  hepatic and renal function tests, which could affect the patient’s ability to metabolize medications and may change medications used in the OR; and  skin integrity to mitigate the risk for pressure ulcer development.

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Special Needs Populations: Older Patients

patient as long as possible. Fall prevention is communicated to all members of the intraoperative team. Transportation devices such as a slide board might be required if the older adult patient has limited mobility. Older adult patients are sensitive to temperature extremes. The intraoperative nurse should communicate the older adult patient’s baseline body temperature to the anesthesia professional preoperatively and implement measures to maintain comfort and normothermia. Methods include maintaining adequate room temperature and providing assistive warming devices such as temperatureregulating blankets, warm blankets, head covers, and socks as needed. Positioning the older adult patient for the surgical procedure requires extra attention to bony prominences and other identified at-risk areas. Areas of compromised skin integrity may require extra protection and padding. Examples of protective materials include foam pads, gel pads, and pillows. Older adult patients may also exhibit limited limb range of motion. Caution must be exercised when positioning the

In collaboration with the anesthesia professional, the RN circulator should monitor all fluids administered and fluid output.

The preoperative nurse should also communicate any concerns of the patient to the RN circulator.

Intraoperative Nursing Considerations The intraoperative period begins when the preoperative nurse hands over the older adult patient’s care to the RN circulator and the patient is transported to the OR. During the intraoperative period, the RN circulator must implement measures to mitigate complications common to older adult patients undergoing surgery. These complications include the risk for confusion, falls, hypothermia, positioning injuries, fluid and electrolyte imbalances, cardiac or hemodynamic complications, deep vein thrombotic complications, and skin integrity injuries. When the adult older patient enters the OR, communication helps mitigate the development of confusion. The nurse should minimize background noise, speak clearly, enunciate, and speak loudly enough so that the patient understands the situation. Visual and hearing aids should remain with the

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patient’s limbs to accommodate limitations. The RN circulator should complete a limb range-of-motion assessment before surgery to determine positioning equipment needs and modifications. Maintaining fluid and electrolyte balance intraoperatively can be challenging. Fluid shifts in older adult patients can lead to impaired respiratory function, heart failure, and swelling of the extremities.25 Therefore, in collaboration with the anesthesia professional, the RN circulator should monitor all fluids administered and fluid output. Proper positioning during surgery can minimize cardiac problems by minimizing pressure on or obstruction of a vessel.76 Continual monitoring of hemodynamics by the RN circulator, in collaboration with the anesthesia professional, minimizes the risk for cardiovascular complications. Ongoing oxygen saturation monitoring by pulse oximetry is important during the intraoperative phase. Older adult patients can be sensitive to changes in oxygenation status and may have

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AMBULATORY TAKEAWAYS Perioperative Care of the Geriatric Patient Population Ambulatory surgery centers (ASCs) have strict surgery scheduling criteria that can limit the care of the older adult patient. Although many ASCs have age limitations that determine which patients need special approval from an anesthesia professional before scheduling can occur, age alone is not a criterion for exclusion. When a patient is scheduled for an ASC procedure, the surgery center schedulers review the patient’s history and physical examination results for past medical, surgical, or cardiac issues and current medications that may determine whether the patient is appropriate for undergoing a procedure in an ASC. Although some older adults have multiple

comorbidities that would exclude them from undergoing surgery in an ASC, many older adult patients are healthy and an ASC setting is not only appropriate for their procedures, it may be the best place to accommodate this surgical patient population. Often older adult patients have fewer health issues and are on fewer medications than the middle-aged people who are scheduled in an ASC. Thus, just like for any other surgical patient, ASC clinicians should carefully review the older adult patient’s history and determine whether they are eligible candidates based on the physical health of the patient, rather than his or her age.

Benefits of an ASC Setting for Older Adult Patients Oster and Oster1 explain how aging affects an individual’s organ systems, and these effects warrant special attention in older adult patients (eg, a thorough review of current health issues, positioning issues, medications) when they require surgery. One of the most convenient aspects of an ASC for older adult patients is the small size of the facility. At most ASCs, patient access to the facility and registration are easy (eg, a single drive-up patient entrance/exit registration and surgical suites on the same level). Large hospital settings may have huge parking garages and multiple surgery suites on different floors throughout the hospital. A smaller setting can be much more convenient and less disorienting for aging patients and their family members. Although older adult patients may require more time to prepare for surgery, an ASC’s small setting allows the office and nursing personnel to attend to one patient at a time. This care allows more time to explain what is happening, both during admission and during perioperative care. Ambulatory surgery centers, like hospitals, report postoperative infection rates to the state, and compared with hospitals and hospital outpatient surgery departments, ASCs have some of the lowest postoperative infection rates.2 In addition, ASCs do not have emergency departments where

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seriously ill patients are cared for, and ASCs do not care for patients who have communicable diseases, such as tuberculosis. If older patients are relatively healthy, undergoing a procedure at an ASC may be the best choice for the patient. Finally, and perhaps most importantly, postoperative care for the older adult patient may be ideal at an ASC in contrast to a hospital setting. In the ASC setting, the postanesthesia care unit (PACU) nurse provides postoperative education to the patient and any family members or caregivers who will be responsible for the patient’s care in the first 24 hours after surgery. Because nurses in many ASCs are cross-trained to the preoperative, intraoperative, and postoperative areas, they can begin this teaching in the preoperative area, and the patient and family’s questions can be addressed there and in the OR, as well as in the PACU. As in all settings, the PACU nurse should ensure that the patient understands the postoperative instructions, and to achieve this, the PACU nurse should include appropriate, patient-selected family members who will be assisting in the patient’s postoperative care when discussing the postoperative care of incisions, medication reconciliation, signs of infection, and pain control. The nurse should ask for repetition of the instructions to help ensure that the

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patient’s caretaker understands them and can provide the necessary care. The qualities of an ASC provide a comfortable, clean, safe environment for the older adult patient and ultimately can be an optimal experience for the patient and his or her family members. References 1. Oster KA, Oster CA. Special needs population: care of the geriatric patient population in the perioperative setting. AORN J. 2015;101(4): 443-459.

Special Needs Populations: Older Patients 2. Hospital or ASC . . . what’s the difference? Surgery Center Network. https:// www.surgerycenternetwork.com/hospitals-vs-ascs. Accessed November 17, 2014.

Brandi Cunningham, MBA, MHA, RN, BSN, is the administrator and director of nursing of a singlespecialty ASC in Winston-Salem, NC. Ms Cunningham has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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pre-existing conditions that increase the patient’s need for supplemental oxygenation. Deep vein thrombosis is another risk associated with the geriatric population. The use of compression hose or sequential compression devices with pumps reduces the pooling of blood in the lower extremities and mitigates the risk for developing deep vein thrombosis.73 At surgical case completion, the RN circulator should assess any hemodynamic access lines, the indwelling urinary catheter bag, and drains for patency and adequate drainage. The RN circulator also should complete a skin integrity assessment before leaving the OR and report any skin changes to the surgeon.

Postoperative Nursing Considerations The postoperative period begins after the anesthesia professional and RN circulator transfer the patient to the postanesthesia care unit (PACU). The RN circulator and anesthesia professional provide the PACU RN with a handover communication. Preoperative and intraoperative nursing considerations, the surgical procedure, and additional changes in the older adult patient’s status should be included in the intraoperative to postoperative hand-over communication. The PACU RN should assess the older adult patient frequently during the postoperative period and compare findings to baseline. The geriatric patient population is at particular risk for postoperative delirium or confusion; aspiration, atelectasis, and pneumonia; hemodynamic changes; postoperative nausea and vomiting; falling; and under- or overtreated pain. It is important for the PACU RN to assess older adult patients for delirium or confusion, which can affect the patient’s ability to follow postoperative instructions. Patients who are delirious can become harmful to themselves or others and should not be

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left unattended. Visual and hearing aids should be returned to the older adult patient as soon as possible during the postoperative period to mitigate confusion and facilitate patient teaching. The PACU RN caring for the older adult patient must remember that the older adult patient has an increased risk for aspiration because of decreased laryngeal reflexes. In addition, the older adult has a greater risk for postoperative atelectasis and pneumonia because of decreased muscle strength, decreased cough reflex, and weakening or loss of the protective swallowing reflex.77 The PACU RN must implement interventions to address these potential problems. In addition, the PACU RN should encourage the older adult patient to cough and breathe deeply to maintain proper lung function. The PACU RN must assess and monitor the older adult patient carefully for signs of changes in hemodynamics and cardiac rhythm. Dehydration and medications used intraoperatively can increase the incidence of postoperative nausea and vomiting.78 The PACU RN should administer necessary medications to relieve these symptoms and encourage fluids when appropriate. Fall prevention precautions must remain in place to decrease the patient’s risk for injury. The PACU RN should assess the patient’s pain level and treat it appropriately because older adult patients may be more vulnerable to the detrimental effects of under- or overtreated pain.64 The PACU RN should assess medical, psychosocial, cognitive, and behavioral factors and compare them to the hand-over communication.79 The older adult patient may not be able to self-report or communicate pain because of cognitive impairment. The PACU RN must search for potential causes of pain, observe patient behaviors, and use

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Online Resources The following is a list of resources available to patients and health care providers but is not inclusive of all resources about aging that are available online.  Healthy aging. Centers for Disease and Control Prevention. http://www.cdc.gov/aging.  National Institute on Aging. http://www.nia.nih.gov.  Seniors’ health. MedlinePlus. http://www.nlm.nih.gov/ medlineplus/seniorshealth.html.  Healthy aging. MedlinePlus. http://www.nlm.nih.gov/ medlineplus/healthyaging.html Web site access verified November 20, 2014. pain assessment tools. The nurse should estimate the intensity of pain based on prior assessment and select an appropriate analgesic.80 Vigilant pain medication dose titration is necessary to relieve pain while avoiding adverse effects in the vulnerable geriatric population.64 The postoperative period ends when the patient is either transferred to a postsurgical floor or discharged home with support.

CONCLUSION Older adult patients undergoing surgical procedures are a vulnerable population. This patient population is at risk for perioperative complications as a result of age-related physiological changes and comorbid conditions. Nurses caring for older adult patients across the perioperative continuumdthe preoperative, intraoperative, and postoperative phasesdmust accurately assess and manage the unique needs of this growing patient population. Perioperative nurses should seek educational opportunities to learn how to provide the best nursing care to ensure that optimal patient outcomes are achieved.



References 1. Vincent GK, Velkoff VA. The next four decades: the older population in the United States: 2010 to 2050 population estimates and projections. United States Census Bureau. http://www.census.gov/ prod/2010pubs/p25-1138.pdf. Published May 2010. Accessed October 31, 2015. 2. Number of all-listed procedures for discharges from short-stay hospitals, by procedure category and age: United States, 2010. Centers for Disease Control and Prevention. http://www.cdc.gov/ nchs/data/nhds/4procedures/2010pro4_numberprocedureage .pdf. Published 2010. Accessed October 31, 2015. 3. Werner CA. The older population: 2010d2010 census brief. United States Census Bureau. http://www.census.gov/prod/ cen2010/briefs/c2010br-09.pdf. Published November 2011. Accessed October 31, 2015.

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April 2015, Volume 101, No. 4 4. Wier L, Pfuntner A, Steiner C. Statistical brief #103: hospital utilization among oldest adults, 2008. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/ statbriefs/sb103.pdf. Published December 2010. Accessed October 31, 2015. 5. Howden LM, Meyer JA. Age and sex composition: 2010d2010 census brief. United States Census Bureau. http://www.census. gov/prod/cen2010/briefs/c2010br-03.pdf. Published May 2011. Accessed October 31, 2015. 6. Meiner SE. Theories of aging. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:15-27. 7. Jackson MJ. Skeletal muscle aging: role of reactive oxygen species. Crit Care Med. 2009;37(10 Suppl):S368-S371. 8. Woo J, Leung J, Kwok T. BMI, body composition, and physical functioning in older adults. Obesity (Silver Spring). 2007;15(7):1886-1894. 9. Eliopoulos C. Common aging signs. In: Eliopoulos C, ed. Gerontological Nursing. 7th ed. New York, NY: Lippincott Williams & Wilkins; 2010:49-65. 10. Mick DJ, Ackerman MH. Critical care nursing for older adults: pathophysiological and functional considerations. Nurs Clin North Am. 2004;39(3):473-493. 11. Rabbitt P, Scott M, Lunn M, et al. White matter lesions account for all age-related declines in speed but not in intelligence. Neuropsychology. 2007;21(3):363-370. 12. Mamaril ME. Nursing considerations in the geriatric surgical patient: the perioperative continuum of care. Nurs Clin North Am. 2006;41(2):313-328. vii. 13. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007;29(1-2):125-132. 14. Kazer MW. Cognitive and neurologic function. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:564-595. 15. Munch M, Knoblauch V, Blatter K, Wirz-Justice A, Cajochen C. Is homeostatic sleep regulation under low sleep pressure modified by age? Sleep. 2007;30(6):781-792. 16. Friedman S. Sensory function. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:628-645. 17. Richardson J, Bresland K. The management of postsurgical pain in the elderly population. Drugs Aging. 1998;13(1):17-31. 18. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statisticsd2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292. 19. Menaker J, Scalea TM. Geriatric care in the surgical intensive care unit. Crit Care Med. 2010;38(9 Suppl):S452-S459. 20. Morley JE, Reese SS. Clinical implications of the aging heart. Am J Med. 1989;86(1):77-86. 21. Marik PE. Management of the critically ill geriatric patient. Crit Care Med. 2006;34(9 Suppl):S176-S182. 22. Rosenthal RA, Kavic SM. Assessment and management of the geriatric patient. Crit Care Med. 2004;32(4 Suppl):S92-S105. 23. Pisani MA. Considerations in caring for the critically ill older adult. J Intensive Care Med. 2009;24(2):83-95. 24. Walker M, Spivak M, Sebastian M. The impact of aging physiology in critical care. Crit Care Nurs Clin North Am. 2014;26(1): 7-14.

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April 2015, Volume 101, No. 4 25. Hendrix TJ. Respiratory function. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:432-461. 26. Nagappan R, Parkin G. Geriatric critical care. Crit Care Clin. 2003; 19(2):253-270. 27. Salles N. Basic mechanisms of the aging gastrointestinal tract. Dig Dis. 2007;25(2):112-117. 28. Stamm LA, Wiersema-Bryant LA, Ward C. Gastrointestinal function. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:482-516. 29. Grassi M, Petraccia L, Mennuni G, et al. Changes, functional disorders, and diseases in the gastrointestinal tract of elderly. Nutr Hosp. 2011;26(4):659-668. 30. Moss C, Dhillo WS, Frost G, Hickson M. Gastrointestinal hormones: the regulation of appetite and the anorexia of ageing. J Hum Nutr Diet. 2012;25(1):3-15. 31. Saber A. Perioperative care of elderly surgical patients. Am Med J. 2013;4(1):63-77. 32. Schmucker DL. Age-related changes in liver structure and function: implications for disease? Exp Gerontol. 2005;40(8-9): 650-659. 33. Gong Z, Muzumdar RH. Pancreatic function, type 2 diabetes and metabolism in aging. Int J Endocrinol. 2012;2012:320482. 34. Beck LH. The aging kidney. Defending a delicate balance of fluid and electrolytes. Geriatrics. 2000;55(4):26-28, 31-32. 35. Narici MV, Maganaris CN. Adaptability of elderly human muscles and tendons to increased loading. J Anat. 2006;208(4):433-443. 36. Wu M, Fannin J, Rice KM, Wang B, Blough ER. Effect of aging on cellular mechanotransduction. Ageing Res Rev. 2011;10(1):1-15. 37. Upadhyaya RC. Musculoskeletal function. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:517-544. 38. Friedman S. Integumentary function. In: Meiner SE, ed. Gerontologic Nursing. 4th ed. St Louis, MO: Elsevier; 2011:596-627. 39. Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3(2):383-389. 40. Takane AK, Balignasy MD, Nigg CR. Polypharmacy reviews among elderly populations project: assessing needs in patient-provider communication. Hawaii J Med Public Health. 2013;72(1):15-22. 41. Baranzini F, Diumi M, Ceccon F, et al. Fall-related injuries in a nursing home setting: is polypharmacy a risk factor? BMC Health Serv Res. 2009;9:228-237. 42. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345-351. 43. Health, United States, 2013 with special feature on prescription drugs. National Center for Health Statistics. http://www.cdc.gov/ nchs/data/hus/hus13.pdf. Accessed November 4, 2014. 44. Randall RL, Bruno SM. Can polypharmacy reduction efforts in an ambulatory setting be successful? Clin Geriatr. 2006;14(7):33-35. 45. Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516-1523. 46. Fulton MM, Allen ER. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract. 2005;17(4):123-132. 47. Haque R. ARMOR: a tool to evaluate polypharmacy in elderly person. Ann Longterm Care. 2009;17(6):26-30.

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Special Needs Populations: Older Patients 48. Zarowitz BJ, Stebelsky LA, Muma BK, Romain TM, Peterson EL. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25(11): 1636-1645. 49. Kaufman G. Polypharmacy in older adults. Nurs Stand. 2001; 25(38):49-55. 50. Shepler SA, Grogan TA, Pater KS. Keep your older patients out of medication trouble. Nursing. 2006;36(9):44-47. 51. Prybys KM, Melville KA, Hanna JR, Gee A, Chyka PA. Polypharmacy in the elderly: clinical challenges in emergency practice: part I: overview, etiology, and drug interactions. Emerg Med Rep. 2002;23(11):145-153. 52. Milton JC, Hill-Smith I, Jackson SHD. Prescribing for older people. BMJ. 2008;366(7644):606-609. 53. Wyles H, Rehman HU. Inappropriate polypharmacy in the elderly. Eur J Intern Med. 2005;16(5):311-313. 54. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-2012. 55. MeReC Bulletin. Prescribing for the older person. National Prescribing Centre. http://www.npc.nhs.uk/merec/other_non_clinical/ resources/merec_bulletin_vol11_no10.pdf. Published 2000; 11(10). Accessed November 3, 2014. 56. Kagansky N, Berner Y, Koren-Morag N, Perelman L, Knobler H, Levy S. Poor nutritional habits are predictors of poor outcome in very old hospitalized patients. Am J Clin Nutr. 2005;82(4):784-791. 57. Kaiser MJ, Bauer JM, R€amsch C, et al; Mini Nutritional Assessment International Group. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-1738. 58. Compan B, di Castri A, Plaze JM, Arnaud-Battandier F. Epidemiological study of malnutrition in elderly patients in acute, sub-acute and long-term care using MNA. J Nutr Health Aging. 1999;3(3): 146-151. 59. Liu L, Bopp MM, Roberson PK, Sullivan DH. Undernutrition and risk of mortality in elderly patients within 1 year of hospital discharge. J Gerontol A Biol Sci Med Sci. 2002;57(11):M741-M746. 60. Orsitto G, Fulvio F, Tria D, Turi V, Venezia A, Manca C. Nutritional status in hospitalized elderly patients with mild cognitive impairment. Clin Nutr. 2009;28(1):100-102. 61. Hiesmayr M, Schindler K, Pernicka E, et al; NutritionDay Audit Team. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. Clin Nutr. 2009;28(5):484-491. 62. Heuberger RA, Caudell K. Polypharmacy and nutritional status in older adults: a cross-sectional study. Drugs Aging. 2011;28(4): 315-323. 63. Ashburn MA, Lipman AG, Carr D, Rubingh C. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. Glenview, IL: American Pain Society; 2003. 64. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100(6):1573-1581.

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OsterdOster 65. McCaffery M. Pain Management: Assessment & Overview of Analgesics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. 66. Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain. 2013; 154(12):2649-2657. 67. Eliopoulos C. Comfort and pain management. In: Eliopoulos C, ed. Gerontological Nursing. 7th ed. New York, NY: Lippincott Williams & Wilkins; 2010:182-190. 68. Gagliese L, Katz J. Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain. 2003;103(1-3): 11-20. 69. Lariviere M, Goffaux P, Marchand S, Julien N. Changes in pain perception and descending inhibitory controls start at middle age in healthy adults. Clin J Pain. 2007;23(6):506-510. 70. Pickering G, Jourdan D, Eschalier A, Dubray C. Impact of age, gender and cognitive functioning on pain perception. Gerontology. 2002;48(2):112-118. 71. Milisen K, Braes T, Foreman MD. Assessing cognitive function. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. 4th ed. New York, NY: Springer Publishing Company; 2012:122-134. 72. Richardson V. Patient comprehension of informed consent. J Periop Pract. 2013;23(1/2):26-30. 73. Doerflinger DM. Older adult surgical patients: presentation and challenges. AORN J. 2009;90(2):223-244. 74. Bashaw M, Scott DN. Surgical risk factors in geriatric perioperative patients. AORN J. 2012;96(1):58-74. 75. Ekstein M, Gavish D, Ezri T, Weinbroum AA. Monitored anaesthesia care in the elderly: guidelines and recommendations. Drugs Aging. 2008;25(6):477-500.

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April 2015, Volume 101, No. 4 76. Millsaps CC. Pay attention to patient positioning. RN. 2006;69(1): 59-63. 77. Bergman SA, Coletti D. Perioperative management of the geriatric patient. Part I: respiratory system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(3):e1-e6. 78. Millar E. Reducing the impact of preoperative fasting on patients. Nurs N Z. 2009;15(5):16-18. 79. Hadjistavropoulos T, Herr K, Turk DC, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain. 2007;23(1 Suppl):S1-S43. 80. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs. 2011; 12(4):230-250.

Kristen A. Oster, MS, APRN, ACNS-BC, CNOR is an assistant nurse manager of the skull base, head/neck, and neuro surgical service line in the main OR at Porter Adventist Hospital, Denver, CO. Ms Oster has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Cynthia A. Oster, PhD, MBA, APRN, CNS-BC, ANP is nurse scientist, clinical nurse specialist for critical care and cardiovascular services at Porter Adventist Hospital, Denver, CO. Dr Oster has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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EXAMINATION

Continuing Education: Special Needs Population: Care of the Geriatric Patient Population in the Perioperative Setting 2.6 www.aorn.org/CE

PURPOSE/GOAL To provide the learner with knowledge specific to perioperative care of the geriatric patient population.

OBJECTIVES 1. 2. 3. 4.

Discuss the epidemiology of aging in the US population. Explain the pathophysiology of aging. Identify special considerations directly tied to age-related changes and conditions in the geriatric patient population. Describe perioperative care of the older adult patient undergoing surgery.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.

QUESTIONS 1. It is estimated that the population 75 years of age and older will increase by 77% between 2010 and 2030 a. true b. false 2. Neurological changes associated with aging include decreased 1. cerebral perfusion. 2. intelligence. 3. motor function, hearing, vision, and memory. 4. nerve fiber conduction velocity. 5. number of neurons. 6. size of the brain. a. 1, 2, and 5 b. 2, 3, 4, and 6 c. 1, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6

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3. The number, elasticity, and surface area of alveoli increase, thereby increasing the area that the lungs must perfuse. a. true b. false 4. A musculoskeletal phenomenon associated with aging in which muscle weakness occurs, muscle mass is lost, and locomotor activity is reduced is called senile a. osteoporosis. b. cachexia c. sarcopenia. d. motor neuron disease. 5. Polypharmacy is recognized by 1. use of multiple medications or too many forms of medications. 2. multiple prescribers. 3. use of several filling pharmacies. 4. use of over-the-counter medications.

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5. multiple dosing schedules. 6. drug-seeking behaviors. a. 1, 3, and 5 b. 2, 4, 5, and 6 c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6 6. The prevalence of malnutrition in older adult hospitalized patients is estimated to be as high as a. 39% b. 42% c. 45% d. 49%. 7. The role of age in pain perception is not clear, with some evidence suggesting increased sensitivity to thermal and mechanical pain in older adults. a. true b. false 8. The preoperative RN’s assessment should include assessing the patient’s 1. cognitive and sensory function. 2. general baseline health status. 3. muscle mass, muscle weakness, impaired balance, and fall risk. 4. nutritional status and preoperative fasting status. 5. visual and hearing acuity. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

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9. During the intraoperative period, the RN circulator must implement measures to mitigate complications common to older adult patients undergoing surgery, including the risk for 1. confusion. 2. hypothermia. 3. cardiac or hemodynamic complications. 4. falls or positioning injuries. 5. fluid and electrolyte imbalances. 6. skin integrity injuries a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 10. The PACU RN should assess the older adult patient frequently during the postoperative period to monitor for increased risks for 1. aspiration, atelectasis, and pneumonia. 2. falling. 3. hemodynamic changes. 4. postoperative delirium or confusion. 5. postoperative nausea and vomiting. 6. under- or overtreated pain. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

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LEARNER EVALUATION

Continuing Education: Special Needs Population: Care of the Geriatric Patient Population in the Perioperative Setting 2.6 www.aorn.org/CE

T

his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.

7.

Will you be able to use the information from this article in your work setting? 1. Yes 2. No

8.

Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.)

8A.

How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________

8B.

If you will not change your practice as a result of reading this article, why not? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________

9.

Our accrediting body requires that we verify the time you needed to complete the 2.6 continuing education contact hour (156-minute) program: ___________________________________

OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss the epidemiology of aging in the US population. Low 1. 2. 3. 4. 5. High 2.

Explain the pathophysiology of aging. Low 1. 2. 3. 4. 5. High

3.

Identify special considerations directly tied to age-related changes and conditions in the geriatric patient population. Low 1. 2. 3. 4. 5. High

4.

Describe perioperative care of the older adult patient undergoing surgery. Low 1. 2. 3. 4. 5. High

CONTENT 5.

6.

To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

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