Application of a perioperative nursing strategy in the surgical treatment of elderly patients: a narrative review†
Article Category: Review
Published Online: Apr 13, 2022
Page range: 1 - 9
Received: Apr 03, 2021
Accepted: Aug 31, 2021
DOI: https://doi.org/10.2478/fon-2022-0001
Keywords
© 2022 Ding-Yang Lyu et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
With the advancement of public health, education, and social services, the average life expectancy of humans has been significantly extended, and the problem of population aging has become increasingly serious; consequently, an increasing number of elderly patients need surgical treatment. Due to the existence of aging, multiple chronic conditions (MCCs), frailty, and other factors in older adults, the risk of adverse clinical events during surgery is also significantly increased. In the United States, 31.9% of older people undergo surgery 1 year before death.1 Hence, for elderly patients who are about to undergo surgery, in addition to considering the prognosis of surgical diseases, it is also necessary to consider various factors, such as life expectancy, functional status, and quality of life, in elderly patients.2 The American Geriatrics Society (AGS) and the American College of Surgeons (ACS) jointly promulgated the Optimal Preoperative Assessment of the Geriatric Surgical Patient in 2012,3 which was updated in 2015 to the Optimal Perioperative Management of the Geriatric Patient.4 The guidelines point out the following: Due to the existence of geriatric problems/geriatric syndromes and large individual differences in older adults, it is necessary to conduct comprehensive evaluations and holistic, individualized, and continuous perioperative nursing and therapy through an interdisciplinary team (including the surgery department, geriatrics department, anesthesiology department, internal medicine department, rehabilitation medicine department, nutrition department, pharmacy department, etc.). Through a literature review and data collection, this article will discuss the perioperative nursing and therapy of elderly patients based on 3 aspects: preoperation, intraoperation, and postoperation.
The physiological reserve and ability to resist stress are decreased in older adults. Thus, the preoperative evaluation of elderly patients is indispensable. The content of evaluations of the general health status includes performance status, nutrition status, and frailty. The most important indicator is performance status.
Performance status is an indicator that can be used to determine patients’ general health status and tolerance to treatment through their physical strength. The Karnofsky performance status-based score is a frequently used scoring method worldwide. If the Karnofsky performance status-based score is <40, the treatment effect is often poor, and it is often difficult to tolerate chemotherapy. The Eastern Cooperative Oncology Group (ECOG) developed a simplified performance status rating scale. It divides patients’ performance status into 6 levels, from 0 to 5. It is generally considered that chemotherapy is not suitable for patients with a performance status level of 3 or 4.
Malnutrition in older adults often results in decreased surgical tolerance and an increase in the risk of surgery and the incidence of complications. Elderly patients should undergo a preoperative nutritional assessment according to the Geriatric Nutritional Risk Index (GNRI)5 and the Nutritional Risk Screening 2002 (NRS2002).6 Reasonable nutritional support should be given according to the evaluation results, which is helpful for elderly patients to pass the perioperative period safely, reduce the incidence of complications, shorten the length of hospital stay, and reduce medical expenses.
Frailty is a special state in which the physical function of older adults is gradually weakened. It is characterized by increased vulnerability and decreased stress capacity caused by the decline in physiological function. The meta-analysis of Lin et al.7 included 23 studies. It uses the frailty phenotype and frailty index to assess the frailty of elderly patients aged >75 years (with respect to cardiovascular disease, tumor, abdominal disease, hip fracture, and other emergency and elective surgeries). The results showed that frailty is significantly correlated with short-term and long-term adverse events such as postoperative mortality, postoperative complications, admission to nursing facilities, and disability. Therefore, frailty is an independent risk factor for postoperative adverse events.8 All elderly patients should undergo an evaluation of their frailty status according to the Fried Frailty Phenotype9 and Edmonton Frail Scale10 before surgery, and the surgical risk should be fully explained. Interdisciplinary teams should take comprehensive measures to intervene against potential problems and prevent the occurrence of adverse events.
The decrease in cognitive function in elderly patients can lead to an increase in the incidence of postoperative complications and mortality. Culley et al.11 conducted a clinical observation of 211 elderly patients aged >65 years who underwent elective hip or knee arthroplasty. The results showed that the incidence of postoperative delirium was higher and the hospital stay was longer if there was preoperative cognitive impairment in elderly patients. Therefore, more attention should be paid to the evaluation of preoperative cognitive function in elderly patients. In their guidelines on preoperative assessment of elderly patients and postoperative delirium, both ACS and AGS recommend that medical staff evaluate the cognitive function of elderly patients before surgery.3 Nonpsychiatrists can evaluate elderly patients according to the cognitive function assessment scale (Table 1). Among such scales is the Mini-Mental State Examination (MMSE); this is one of the most influential and popular cognitive impairment screening tools in the world, and it covers time, place orientation, immediate memory, attention, computing, short-term memory, language, and visual spatial structure ability.
Commonly used cognitive-function assessment scales.
| Scale | Sensitivity (%) | Specificity (%) | Assessment time (min) |
|---|---|---|---|
| MMSE12 | 63.4 | 65.4 | 5–10 |
| ACE-R13 | 91.9 | 76.3 | 10–20 |
| MoCA14 | 80–100 | 50–70 | 10–15 |
Preoperative anxiety/depression can lead to postoperative pain aggravation, cognitive impairment, increased complications, and mortality. It is also related to the decline in long-term quality of life after surgery.15 Therefore, it is necessary to evaluate the anxiety/depression of elderly patients before surgery. Nonpsychiatrists can evaluate elderly patients according to the anxiety and depression scale (Table 2). For those with problems, relevant intervention measures should be actively taken.
Commonly used anxiety and depression assessment scale.
| Scale | Features |
|---|---|
| HAMA16 | This assessment takes 15–20 min and is the most commonly used scale to assess the severity of anxiety. The total score is 56 points: scores of 14 and above indicate anxiety, and scores of ≥29 indicate severe anxiety. It is conducted by trained professionals. |
| GAD-717 | This assessment takes 5 min and is mainly used for generalized anxiety screening. The total score is 21 points: 0–4 is normal, 5–9 indicates mild anxiety, 10–14 indicates moderate anxiety, and ≥15 indicates severe anxiety. |
| GDS18 | This assessment is used for depression screening and takes 5–15 min. There are 30-, 15-, 10-, and 6-item versions. The highest score on the 30-item scale is 30: 0–10 is normal, 11–20 indicates mild depression, and 21–30 indicates moderate and severe depression. This test is suitable for older people. |
| HAMD19 | This tool assesses the severity of depression and takes 15 min. It is the gold standard of depression assessment scales and is conducted by trained professionals. The scale has 3 versions of 17, 21, and 24 items. When using the 17-item table, the highest score is 56 points: 0–7 is normal, 8–14 indicates mild depression, 15–23 indicates moderate depression, and ≥24 indicates severe depression. |
Delirium is an acute temporary brain dysfunction characterized by inattention, changes in the level of consciousness, and cognitive dysfunction, which is common in elderly patients. Delirium often leads to a series of adverse clinical outcomes, including serious postoperative complications, prolonged hospital stay, delayed rehabilitation, decreased physical and cognitive function, and even death.20 Nonpsychiatrists can evaluate elderly patients according to the delirium assessment scale (Table 3). For high-risk patients, it is recommended that they undergo cognitive training and psychological interventions, improve their general condition and sleep, and avoid the presurgical use of drugs that increase the risk of delirium.21
Commonly used delirium assessment scales.
| Scale | Sensitivity (%) | Specificity (%) | Characteristics and applicable groups |
|---|---|---|---|
| CAM22 | 76.0 | 100 | Based on DSM-3R; has been verified in the Chinese population; suitable for elderly patients who are hospitalized23 |
| CAM-ICU24 | 81.8–93.4 | 87.7–90.8 | Based on DSM-IV; has been verified in the Chinese population; suitable for patients with endotracheal intubation and patients who are in intensive care units or emergency departments25 |
| 3D-CAM | 95.0 | 94.0 | Based on CAM and provides the standardized evaluation method; has not been verified in the Chinese population; suitable for older people and patients with dementia26 |
Cardiovascular events are one of the most dangerous postoperative complications. Emergency surgery and large and medium-sized surgical procedures easily induce and aggravate all kinds of cardiac events. Patients with previous angina pectoris or insufficiency of the myocardial blood supply indicated by a preoperative electrocardiogram should be treated with a polarization liquid for more than a week and with vasodilators as appropriate. Patients with hypertension should keep their blood pressure close to the normal range. Patients with frequent ventricular premature beats should use antiarrhythmic drugs such as lidocaine and mexiletine and comply with treatments that improve coronary per-fusion and increase the myocardial oxygen supply. For perioperative atrial fibrillation in the older adults, measures should be taken to improve coronary circulation, reduce blood pressure, supplement potassium and magnesium in a timely manner, and control hyperthyroidism to keep the heart rate <100 bpm. Patients with atrioventricular block and bundle branch block should receive an atropine test, and those with a poor response should consider installing a temporary pacemaker. Patients with congestive heart failure should use diuretics and drugs that can reduce afterload to control heart failure before the operation, but excessive diuresis before surgery should be avoided to prevent hypotension caused by an insufficient blood volume during the operation. For patients with symptomatic aortic valve stenosis, aortic valve replacement should be performed before elective noncardiac surgery; patients with mitral stenosis are generally not recommended to undergo mitral valve replacement before noncardiac surgery. If mitral stenosis is severe, percutaneous balloon mitral valvuloplasty or thoracotomy valvuloplasty can be performed before high-risk surgery.
Elderly patients with physical weakness are prone to ischemia during surgery, so it is particularly important to avoid hypotension and hypovolemia before surgery. Some studies have shown that shortening the time of preoperative fasting can reduce not only patients’ reactions, such as thirst, hunger, and tension, but also postoperative insulin resistance, and improve protein metabolism.27 The enhanced recovery after surgery (ERAS) model advocates that the fasting time should be adjusted to 2 h before the operation. Usually, patients can drink 12.5% carbohydrate drinks in the amount of 800 mL 10 h before surgery and drink ≤400 mL 2 h before the operation.28 The guidelines for perioperative management of elderly patients jointly issued by AGS and ACS also recommend that adults undergoing non-emergency surgery abstain from transparent fluid at least 2 h before elective surgery requiring general anesthesia, regional anesthesia, or sedation/analgesia. Examples of clear liquids include water, pulp-free fruit juices, carbonated drinks, green tea, and black coffee.4
There are increasing numbers of elderly patients with respiratory diseases. Smoking should be banned for at least 2 weeks before the operation, and acute and chronic pulmonary infections must be thoroughly controlled. Patients should be treated with effective antibiotics and undergo postural drainage 3–5 d before the operation to limit the amount of sputum to a minimum, and they should practice deep breathing and coughing and undergo chest therapy to improve pulmonary ventilation. Patients with obstructive pulmonary dysfunction or spastic bronchial asthma should be treated with nebulized inhalation of bronchodilators such as ephedrine, aminophylline, epinephrine, or isoproterenol, and the forced expiratory volume in 1 s (FEV1) test can be used to evaluate the effect of medications. Steam inhalation or oral ammonium chloride or potassium iodide can be used to dilute the sputum if it is sticky. Generally, for respiratory diseases with pulmonary dysfunction, unless there are extrapulmonary factors, the pulmonary function can be significantly improved using the above-described comprehensive treatment.
Risk factors for cerebral apoplexy include peripheral vascular disease, hypertension, atrial fibrillation, elderly patients aged >70 years, and type of operation (the incidence of cerebral apoplexy after carotid endarterectomy is the highest). Patients with a history of cerebral apoplexy or transient ischemic attack (TIA) should undergo cerebral computed tomography (CT), carotid artery Doppler ultrasound, and angiography to ensure that the cause can be determined and intracranial hemorrhage or subdural hematoma can be ruled out. Patients with carotid artery stenosis >70% confirmed by carotid arteriography should undergo prophylactic carotid endarterectomy. Patients with inconspicuous carotid stenosis or possible noncardiogenic thrombi should use aspirin for prophylactic anticoagulation therapy.
The risk of thromboembolism, bleeding, and infection should be assessed in all elderly patients undergoing a surgical operation, and corresponding measures should be taken to prevent these conditions. Physicians should ensure that patients with severe anemia have their anemia corrected before surgery.
Patients with diabetes should work closely with endocrinologists and surgeons to self-test their blood glucose regularly 1 week before surgery, adjust their hypoglycemic drugs in a timely manner, and stabilize their blood glucose at a mildly high level, between 6.7 mmol/L and 10.0 mmol/L.29 Compared with foreign guidelines, the range of blood glucose regulation in Chinese guidelines is relatively conservative. According to Chinese guidelines, the recommended target for blood glucose is 7.8–10.0 mmol/L, while most foreign guidelines recommend that blood glucose be controlled within the upper limit of the normal range (6.0 mmol/L).
Elderly patients often take multiple drugs at the same time. These drugs should be verified and reasonably adjusted before the operation. For cardio-cerebrovascular drugs that are taken regularly, if there are no special circumstances, there is generally no need to stop using any of them except for anticoagulant and antiplatelet drugs during the perioperative period. Oral drugs can still be used with a small amount of water on the day of the operation.
To ensure the safety of surgical patients, some patients with poor general condition or diseases complicated with important organ dysfunction, physicians will need to postpone or cancel the operation, which also shows the importance of adequate preparation and communication before surgery.
If the auxiliary examination shows that the tumor has been widely metastasized, the operation should be canceled.
If angina pectoris is not effectively controlled, the operation should be postponed. For patients with definite coronary heart disease, if it is a life-saving operation, it must be carried out in a timely manner, and cardiac risk factors should not be excessively considered. For elective surgery, the operation should be postponed to 6 months after a myocardial infarction, during which the cardiovascular risk factors should be adjusted to the baseline state.
If there is no effective control of hypertension, diabetes, hyperthyroidism, or hypothyroidism, it is advisable to postpone the operation.
For patients with disturbance of water, electrolyte, and acid–base balance, the operation should be postponed, and the cause should be determined for adjustment.
If the heart, lung, liver, and kidney function are decompensated, the operation should be postponed.
For patients with low adrenal function, the surgery should be postponed, and hormone replacement therapy is needed before and after the operation.
For patients with hemocytopenia, abnormal blood coagulation, or preoperative anticoagulant treatment, the operation should be postponed.
ASA grade III requires careful surgery, and any operation above grade IV is prohibited.
For imperfect preoperative preparation (including medical measures, personnel, instruments, etc.), the operation should be postponed.
The tolerance and demand for drugs in older adults is reduced, and such individuals are especially sensitive to central depressants such as general anesthetics, sedative hypnotics, and opioid analgesics. In addition, the stress ability of older adults is poor, and the regulatory ability of the autonomic nervous system is not strong. Older adults cannot withstand the strong stimulation caused by surgical trauma. The operation may lead to blood pressure instability, and even accidents or coexisting diseases that suddenly progress in the malignant direction. Therefore, drugs and methods with less physiological interference and fast recovery should be selected for anesthesia, and the body should be kept in or close to physiological state (including the stability of respiration, circulation, and the internal environment) as far as possible during anesthesia and surgery. Although previous studies have shown that there is no difference in the effect of general anesthesia and regional anesthesia on the outcome of patients,30,31 considering that the brain function of elderly patients is relatively fragile, it is recommended to give priority to regional anesthesia (including intraspinal anesthesia, peripheral nerve block, etc.). The concept of ERAS emphasizes the optimization of anesthetic methods and advocates fast-track anesthetic techniques (including epidural anesthesia, regional and peripheral nerve block, and the application of short-acting anesthetics) to achieve accurate anesthesia and rapid recovery.28
Laparoscopic surgery, robot-assisted surgery, or open surgery can be selected according to the patients’ own condition, the degree of disease progression, and the operator's technology. Operators should choose the most appropriate surgical method according to their own technical level and based on the principle of reducing surgical trauma, decreasing intraoperative bleeding, shortening the operation time, and avoiding postoperative complications. Compared with open surgery, laparoscopic surgery has the advantages of a small incision, less postoperative adhesion, and rapid recovery. However, when certain confounding situations are encountered in laparoscopic surgery, such as difficulty in hemostasis, patients’ inability to tolerate pneumoperitoneum, poor exposure of lesion sites, or excessive difficulty in dissecting key parts, physicians can consider switching to open surgery. Trauma is the most important stress factor for patients. Therefore, the operation should be completed in adherence with the concept of precision and minimal invasiveness to reduce traumatic stress.
The purpose of intraoperative fluid therapy is to maintain an effective circulating blood volume and water-electrolyte balance. Due to the significant decrease in the ratio of body fluid to body weight, vascular sclerosis, poor regulation of body fluid balance, and pre-operative fasting and drinking, most patients have an absolutely or relatively insufficient blood volume before surgery. Experts suggest that the blood volume status of patients should be correctly evaluated to avoid cardiac insufficiency, pulmonary edema, and abnormal blood coagulation after hemodilution caused by excessive infusion, and also to avoid insufficient perfusion caused by an inadequate level of infusion, leading to acute renal injury.32 It is generally recommended to treat such patients with goal-directed fluid therapy (GDFT). The principle of treatment is to optimize the cardiac preload, which not only maintains an effective circulatory blood volume and ensures microcirculation perfusion and tissue oxygen supply but also avoids tissue edema.33 GDFT plays an important role in reducing the complications of heart, lung, kidney, and intestinal function and improving the prognosis of patients. Research has shown that GDFT can reduce the incidence of complications after a large surgery.34 In addition, a study has shown that intraoperative restrictive fluid therapy may reduce short-term postoperative complication rates, facilitate fast recovery, shorten length of stay, and improve 5-year survival rate.35
The balance of oxygen supply and demand in the perioperative period directly affects the prognosis and survival of patients. In older adults, hypoxemia often occurs due to various factors during surgery, and it not only prolongs the recovery time from anesthesia but also easily induces myocardial ischemia, arrhythmia, neurological dysfunction, postoperative infection, and other adverse consequences. Therefore, oxygen therapy should be used, and the blood oxygen saturation should be monitored throughout the operation; heat preservation measures should be strengthened; volume therapy should be emphasized; and hemodynamic stability should be maintained to avoid an increase in oxygen consumption.
Intraoperative heat preservation is very important. Elderly patients have a thin skin and a poor ability to self-regulate their body temperature. They are often in a critical state of low temperature before the operation. Intraoperative hypothermia can cause abnormal blood coagulation function and increase the risk of wound bleeding and metabolic acidosis. In addition, hypothermia can also cause anesthetic drug metabolism disorders and weakened immune function, which can lead to an increased wound infection rate and stress reaction risk. In severe cases, cardiovascular adverse events may occur.36 Research has found that preventing peri-operative hypothermia during large abdominal surgery can reduce postoperative wound infection rates and cardiovascular events, reduce intraoperative blood loss and fluid infusion, and shorten the anesthesia recovery time.37 Therefore, the body temperature should be routinely monitored during the operation, and some heat preservation measures should be taken. Commonly used heat preservation measures are as follows: increasing the ambient temperature of the operating room (24–25 °C); inhaling heated and humidified gas; warming the blood and fluid to be transfused; flushing the body cavity with warm saline; and covering the exposed serosal surface with hot saline gauze pads during the operation to keep the area warm. It should be realized that maintaining a constant body temperature during anesthesia surgery is as necessary as maintaining the stability of the blood pressure, heart rate, and other vital signs, which is important for improving the quality of anesthesia and the perioperative quality of life.
Elderly patients are more sensitive to opioids, which can easily lead to cognitive dysfunction and hemodynamic disorders and can easily inhibit the respiratory system. In addition, excessive postoperative sedation in elderly patients can induce delirium, delay recovery, and cause pulmonary complications. Therefore, the starting dose should be reduced, the increment should be titrated, the lowest effective dose should be used to control pain, and the use of barbiturates, benzodiazepines, hypnotic drugs, and muscle relaxants should be avoided; moreover, in suitable patients, the use of topical medication can avoid systemic adverse reactions.38 The concept of ERAS recommends the use of multimodal analgesia, which can effectively control exercise pain, reduce the incidence of analgesic-related adverse reactions, accelerate the recovery of intestinal function in the early postoperative period, and ensure an early postoperative transintestinal diet and the early ability to get out of bed.39
Postoperative cognitive dysfunction (POCD) refers to memory impairment, abstract thinking disorder, and disorientation disorder after anesthesia surgery, accompanied by a decline in social activity. POCD is caused by surgery and anesthesia on the basis of the degeneration of the central nervous system in elderly patients. The main factors that cause POCD during the perioperative period are age, surgery, and anesthesia. Cognitive function screening or neuropsychological tests should be performed again after surgery, which would be helpful to identify new cognitive dysfunction.
Risk factors for postoperative nausea and vomiting (PONV) include age (<50 years), female sex, nonsmoking status, history of motion sickness, history of PONV, and postoperative administration of opioids. The concept of ERAS advocates the use of two antiemetics to reduce the incidence of PONV.
Respiratory insufficiency and hypoxemia are important causes of early postoperative death in elderly patients. Measures for postoperative respiratory system nursing include the following: (1) It is not advisable to remove the endotracheal tube prematurely after the operation. Extubation should be performed when the patient is naturally and fully awake, can respond to being called, and shows no abnormality after stopping oxygen for 5–10 min. Patients should receive mask oxygen after extubation. (2) After the operation, when the patient's consciousness is clear and his/her blood pressure is stable, a semirecumbent position is adopted, which is conducive to lung gas exchange and sputum discharge and prevents the occurrence of penetrating pneumonia and pulmonary edema. (3) It is advisable to turn the patient over regularly, slap his/her back, and assist him/her with cough and expectoration.
Elderly patients often cannot eat normally after surgery and need enteral or parenteral nutrition. The concept of ERAS emphasizes the early postoperative recovery of the diet and the consumption of easily digestible and fiber-rich foods to prevent constipation.
Caregivers should encourage patients to get out of bed early, which is helpful for recovering multiple systemic functions such as breathing, exercise, and digestion. Early rising from bed also has a positive effect on preventing lung infections, pressure ulcers, and deep vein thrombosis of the lower extremities.40 If it is difficult to get out of bed early, the patient should perform physical exercises in bed to maintain physical function as much as possible.
The functional status of elderly patients after surgery is worse than that before surgery, and elderly patients are relatively unfamiliar with the hospital environment. Therefore, they are very prone to falls. Therefore, to prevent falls, medical staff should pay close attention when elderly patients get out of bed early.
Post-discharge nursing reflects the continuity of holistic medical care.41 Elderly patients are in a fragile state for a long time after surgery, and this condition is also called post-discharge syndrome. Various adverse clinical events are prone to occur at this stage, such as falls, infections, acute exacerbations of chronic diseases, malnutrition, decline in function, etc. Therefore, comprehensive and continuous nursing and therapy, such as rehabilitation, nutrition, etc., is needed to restore the best postoperative function and avoid hospitalization. When the patients are discharged from the hospital, they should be instructed to keep a detailed discharge summary and communicate with the responsible medical staff in time if there is any problem. Medical staff should provide relevant education to the patient and caregivers.
The purpose of surgical treatment in elderly patients would not only be fulfilled merely by providing surgical treatment for a certain disease on condition, but also by considering their functional status and life expectancy from both holistic and individualized perspectives and formulating a perioperative nursing strategy that benefits a given patient the most. Through interdisciplinary teamwork with a clear division of labor, comprehensive preoperative assessment and perioperative nursing and therapy are carried out to minimize the risk of surgery, reduce the occurrence of complications, promote the rapid recovery of elderly patients, and improve the quality and efficiency of medical care, which is the ultimate goal of perioperative multidisciplinary management. This paper briefly summarizes the perioperative nursing of elderly patients, but more specific strategies are still needed for the perioperative nursing mode of each systemic disease.