50 Care of the older patient
Activities of Daily Living: Daily self-care activities, including bathing, eating, dressing, toileting, and grooming.
Cognitive Impairment: Reduction in mental functioning that results in cognitive changes, including short-term memory loss and impaired judgment and thinking.
Cultural Competence: The ability to provide culturally relevant and appropriate care to persons with diverse values, beliefs, and behaviors.
Dementia: A loss of brain function that occurs with certain a group of diseases. It affects memory, thinking, language, judgment, and behavior. The most common form of dementia is Alzheimer disease.
Geriatrics: Medical aspect of gerontology in the treatment of acute and chronic conditions in older adults (i.e., a person 65 years of age or older).
Gerontology: The scientific study of age, aging, and the aged using a lifespan, biopsychosocial approach.
Health: A state of physical, mental, and social well-being.
Instrumental Activities of Daily Living: The activities performed by people living independently, including meal preparation, money management, shopping, and taking medications.
Person-Centered Care: Focuses on individual care needs by understanding how the individual experiences his or her situation in order to most effectively address needs and desired outcomes.
Presbycusis: Age-associated hearing changes or the slow loss of hearing as people get older.
Presbyopia: Age-associated visual changes of diminished ability to focus on near objects.
The world’s population is aging at a rapid pace. The current population of adults older than 65 years constitutes 34 million people, or approximately 13% of the population. Projections suggest that by 2030, 69 million individuals will be older than 65 years, or approximately 19% of the population.1 This trend represents two important phenomena: the increase in life expectancy and the aging of the baby boomers (those born between 1946 and 1964) who began to turn 65 in 2011. Older adults are not only living longer; they are doing so free of disease and disability. According to “compression of morbidity theory,” the limit to life span may be stretched significantly with a concurrent delay in the onset of chronic conditions.2 This stretching of the lifespan would result in a population living longer and healthier than any generation to date.
The World Health Organization defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.3 In this view, older adults may then perceive themselves as healthy despite physical limitations or disease. It is essential in caring for the older patient to recognize overall health from physiologic, psychological, and social perspectives. In assessing an older adult’s health, an appropriate delineation is between an individual’s chronological age versus their functional age. Some individuals who are more judicious in using preventive health measures and who maintain more active lifestyles may have little decline or age-related comorbidities, reflecting greater functioning relative to chronologic age, whereas others may have multiple comorbidities, perhaps at an even earlier age, reflecting functional limitations relative to age. Gerontologists often use the distinctions young-old, old-old, and oldest-old to differentiate between older adults. In terms of functional capacity, gerontologists also describe aging in terms of primary, secondary, and tertiary aging.4 Primary aging represents aging free of disability and disease. Secondary aging encompasses developmental changes affected by lifestyle, disease, or factors that are not inevitable processes of biologic aging. Tertiary aging is rapid loss and decline experienced at the end of life. Differentiation of age and functional capacity is essential to focus attention on the diversity of this population and establish some markers that are helpful in meeting the individual needs of older adults.
Many different chronologic markers are used for governmental determinations and legal purposes (i.e., 40 years of age for age discrimination determination, 50 years of age for AARP membership, and 65 plus years of age for Social Security). As a result, no one definition of old-age, elderly, or older adult is accepted. Because no biomarkers exist, a definition of when old age begins is difficult because individuals age at different rates than is reflected simply by chronologic age. The growing complexity and diversity of the aging population mandates a holistic interprofessional biopsychosocial approach to care to move beyond a simplistic chronologic marker of age toward a more accurate functional assessment.
Care of the older adult patient is particularly important in the postanesthesia care unit because of the normal physiologic changes that occur with aging and may be compounded by multiple comorbid conditions. With advancing age, the potential risks of complications from surgical procedures increases, because of the potential for multiple comorbidity. Morbidity and mortality are at least fourfold more likely in older adults and twentyfold more likely in emergency procedures.5 These conditions include congestive heart failure, insufficient oxygenation of the blood, improper elimination of carbon dioxide, fluid and electrolyte imbalance, diabetes and the associated complications, and drug toxicity.
Advances in anesthetic care have resulted in a substantial reduction in perioperative morbidity and mortality in the aging population.6 Successful anesthesia care of the older adult patient is highly dependent on the knowledge of the changes associated with aging and the effects of anesthesia on the older patient. Therefore, the focus of this chapter is primarily on the normal aging changes that take place in addition to the disease states associated with aging and their translation to functional status, especially of the cardiovascular system. It is essential to keep in mind throughout this chapter that the rate at which each individual and organ system age is highly individualistic. This phenomenon is referred to as the individuation of aging.7 Individual genes, hormonal balance, diet, medications, environmental exposure, and emotional stress and burden are all factors that influence individual biological aging.
The aging body: an overview
Cardiovascular system
Cardiovascular health is essential to the overall well-being of the older adult. Healthy cardiovascular functioning can be maintained across the lifespan, and disease can be prevented through healthy lifestyle choices and preventive care; however, heart disease remains the leading cause of death for both males and females.8 Of all of the body systems, the cardiovascular system exerts the most influence on anesthesia and general health outcomes.8 Annually, more than 1 million surgeries are complicated by adverse cardiac outcomes, such as postsurgical myocardial infarction or death from cardiac disease.9 This risk can be reduced with a thorough preoperative interview and assessment that examines functional capacity and existing comorbidities and the current treatment regime.8
Functional capacity
The assessment of functional capacity reflects the ability to perform activities of daily living that require sustained aerobic metabolism.10 Exercise tolerance in daily life is the best indicator of the quality of biologic age. It is also one of the most important predictors of perioperative outcomes in older adult patients.11,12 Poor exercise tolerance reflects low functional capacity and greater severity of disease. Functional status is usually reflected in metabolic equivalent (MET) levels. One MET corresponds to a resting oxygen consumption of 3.5 mL/kg/min. MET scores are multiples of resting metabolism, which are used as a point of reference to describe the oxygen demands of any activity.13 Box 50-1 provides examples of MET ratings of activities. Functional status can be ascertained during the preoperative screening. Questions addressing daily activities and assessing lifestyle habits, such as house cleaning, vacuuming, walking, and stair climbing, and any participation in regular exercise should provide adequate information for a subjective assessment of the patient’s functional status.14 Objective assessment can be made via exercise testing. Patients who are unable to regularly meet a 4 MET demand have an increased perioperative cardiac risk.15
Adapted from Hlatky MA, et al: A brief self-administered questionnaire to determine functional capacity, Am J Cardiol 64:651–654, 1989; Fletcher GF, et al: Exercise standards: a statement for healthcare professionals from the American Heart Association, Circulation 104:1694–1740, 2001.
Structural changes
There are several structural changes frequently seen with advancing or older age that occur within the cardiovascular system. Changes of the arteries include dilation of the large arteries accompanied by thickening of the arterial walls and changes in wall matrix. An increase in elastin and collagen tissues in the heart and arteries can cause arterial wall thickening and an increase in smooth muscle tone.16–19 Increased vascular stiffness leads to elevated systolic arterial pressure and pulse wave velocity, early reflected pulse pressure waves, and late peak systolic pressure, which trigger a series of cardiac adjustments. A resultant augmenting of aortic impedance and cardiac mechanical load may be seen.
Clinically elevated left ventricular afterload causes an increase in myocyte size and thickening of the left ventricular wall.18 When combined with augmentation of aortic impedance, elevated afterload prolongs myocardial contraction. This adaptive measure preserves cardiac function by lengthening the amount of time available for the heart to eject blood into stiffened vasculature. The resultant prolonged myocardial contraction delays ventricular relaxation time, which manifests as a decrease in early ventricular filling.19–23
Between the ages of 20 and 80 years, the rate of early diastolic filling decreases by 50%.24 This decrease may be the result of a prolonged isovolumetric relaxation time between aortic valve closure and mitral valve opening. With aging, alterations in calcium release from the myoplasm to the sarcoplasmic reticulum may contribute to the changes in early diastolic filling.16,23
For maintenance of stroke volume, end diastolic filling is increased.16 The effectiveness of this strategy is dependent on the atrial contribution to end diastolic filling; therefore left atrial size increases.20 Enlargement of the atria raises the likelihood of atrial fibrillation among elders, thus underscoring the importance of stable hemodynamics to ensure normal sinus rhythm.
Gender differences may be found in certain age-related changes in cardiac function.16 Men seem to have different compensatory mechanisms than women. To maintain stroke volume in the presence of the age-associated decrease in heart rate, men have an increase in left ventricle end-systolic volume and left ventricle end-diastolic volume. This mechanism preserves cardiac output in aging men, whereas a 15% decrease is seen in cardiac output in women. Table 50-1 summarizes cardiac changes in response to exercise that occur with age.25
Table 50-1 Changes in Cardiovascular Response to Exercise with Comparison of 20 and 80 Years of Age
| CARDIOVASCULAR PHYSIOLOGY | PEAK RESPONSE AT AGE 20 YEARS | CHANGE IN PEAK RESPONSE BETWEEN 20 AND 80 YEARS |
|---|---|---|
| LV end-diastolic volume | ↔,↓ | ↑30% males; ↔ females |
| LV end-systolic volume | ↓ | ↓100% |
| Ejection fraction | ↑ | ↓15% |
| Stroke volume | ↑ | ↔ |
| Heart rate | ↑ | ↓25% |
| Cardiac output | ↑ | ↓25% |
| Stroke work | ↑ | ↑15% males; ↔ females |
| SVR | ↓ | ↑30% |
| Oxygen consumption | ↑ | ↑50% |
| Plasma catecholamines | ↑ | ↑ |
| Myocardial contractility | ↑ | ↓60% |
| Beta-adrenergic stimulation | Fully functional | ↓ |
LV, Left ventricular; ↔, no change; ↑, increase; ↓, decrease; SVR, systemic vascular resistance.
Adapted from Eagle KA: Perioperative cardiac assessment for noncardiac surgery: eight steps to the best possible outcome, Circulation 107:2771–2774, 2003.
The most clinically relevant age-related changes in cardiovascular function are increased myocardial stiffness and all of the subsequent compensatory actions and blunted beta-adrenergic responses. During increased oxygen demand, the most relevant changes in the older patient are autonomic reflex dysfunction and beta-adrenoreceptor responsiveness. See Table 50-1 for cardiovascular age-related changes to upright peak exercise.
Cardiovascular risk assessment
Preoperative risk assessment is an important component in minimizing perioperative morbidity and mortality. This assessment is best achieved through the work of an interdisciplinary team that consists of the patient, the primary care physician, the surgeon, and the anesthesia professional. In addition, training and expertise are essential to the quality care of older adult patients. This assessment relies on the evaluation of the interaction of clinical markers, functional capacity, type of surgical procedure, and age. When risks are identified, measures should be used to minimize the risks before surgery and to improve immediate periprocedural outcomes and long-term clinical outcomes. Some clinical markers act as predictors of perioperative cardiovascular risk. These markers can be categorized by the perioperative risk associated with them (Box 50-2) as major, intermediate, and minor perioperative risk.11
In addition, the type of surgery coupled with the degree of hemodynamic stress incurred during the surgery are the major determining factors of perioperative risk.11,12 Emergency surgeries are particularly high risk, especially in older patients. Other high-risk surgeries include vascular, cardiac, abdominal, and thoracic surgeries.26 Box 50-3 categorizes surgery-specific risk according to the incidence rate of cardiac death and nonfatal myocardial infarction for noncardiac surgical procedures.
BOX 50-3 Cardiac Risk Stratification for Noncardiac Surgical Procedures*
Low (reported risk, <1%)
*Combined incidence rate of cardiac death and nonfatal myocardial infarction.
Adapted from Mukherjee D, Eagle KA: Perioperative cardiac assessment for noncardiac surgery: eight steps to the best possible outcome, Circulation 107:2771–2774, 2003.
Heart
It is difficult to determine which changes in the cardiovascular and circulatory systems represent normal aging and which are disease states. Current research suggests that overall heart size in healthy older adults does not change significantly with age.27 However, there are many cellular and biochemical changes associated with older age.16,24,28 These changes include altered growth-controlling factors, impaired excitation-contraction coupling, impaired calcium homeostasis, increased myocyte apoptosis, and an increase in atrial natriuretic peptide secretion.
As a result of these age-related biochemical and molecular changes, a number of morphologic changes manifest as changes in cardiac function (Table 50-2). It is important to note that cardiac senescence can result in a number of functional impairments. These impairments can include decreased mechanical and contractile efficiency, prolongation of the contraction phase, stiffening of myocardial cells, stiffening of valves and mural connective tissue, decreased number of myocytes, increased myocyte size, increased rate of myocyte apoptosis, and a blunted beta-adrenoceptor–mediated inotropic response.29–31
Table 50-2 Changes in Cardiovascular Physiology in Healthy Individuals Between Ages 20 and 80 Years*
| LV end-diastolic volume | ↑20% males; ↔ females |
| LV end-systolic volume | ↑20% males; ↔ females |
| Ejection fraction | ↔ |
| Stroke volume | ↑20% males; ↔ females |
| Heart rate | ↓10% |
| Cardiac output | ↔ males; ↓ 15% females |
| Stroke work | ↑15% |
| Early diastolic filling rate | ↓50% |
| Systolic arterial pressure | ↑15% |
| Systemic vascular resistance | ↔ males; ↓ 45% females |
LV, Left ventricular; ↔, no change; ↑, increase; ↓, decrease.
Adapted from Eagle KA: Perioperative cardiac assessment for noncardiac surgery: eight steps to the best possible outcome, Circulation 107:2771–2774, 2003.
There is tremendous variability in both the level and intensity of age-related changes to the heart. In nonstressful conditions, the normal aging heart functions appropriately. Under stress or with damage from disease, the effects of age become more profound and can lead to functional limitations and reduced quality of life for the patient.
Respiratory system
The structural and age-related changes that can occur in the respiratory system are clinically influential to the perioperative care of the older adult patient. Structurally, an increase in chest wall rigidity increases the work of breathing. By the time an individual is 70 years of age, an approximately 20% decrease in respiratory muscle strength and endurance and a 15% decrease in alveolar surface area are seen. Older patients have an attenuated response to hypoxemia and hypercapnia. Changes in lung volume include a 20 to 40 mL/yr decrease in vital capacity, a 30% increase in residual volume by the age of 70 years, increased closing volume, and a 0.05% annual decrease in gas exchange.32
These changes in the older adult patient may hinder the ability of the patient to meet additional postoperative workloads, thus increasing the risk for acute respiratory failure. The older adult patient is more likely to develop apnea in response to opioids and benzodiazepines. The blunted response to hypoxia and lower baseline arterial oxygen tension increases the risk of postoperative hypoxemia, which can contribute to myocardial ischemia and infarction.25
Renal system
The kidneys have a crucial role in fluid and electrolyte balance. As with other body systems, the aging process affects the efficiency of the kidneys and the urinary and renal systems. Age-related changes in renal function can elevate cardiovascular risk in older adults and make them more prone to hypervolemia and hypovolemia, hypertension or hypotension, and heart failure. By the age of 70 years, glomerular filtration rate decreases at least 30% and as much as 50%; cortical nephrons are decreased; decreases are seen in renal blood flow, ability to concentrate urine, ability to conserve sodium, and tubular secretion; thirst perception is lowered; and a 10% to 15% reduction in total body water is seen.33
Hepatic function
By the time an individual is 80 years old, an approximate 40% reduction in hepatic mass and a 40% decrease in hepatic and splanchnic blood flow are seen. Decrease in the activity of hepatic cholinesterase and microsomal demethylation pathway may also accompany increasing age.34,35 These changes lead to an impaired ability to meet the increased demands of metabolism, biotransformation, and protein synthesis after surgery. Drugs that rely on hepatic metabolism have a prolonged effect for older adults. For prevention of hepatic injury from medication, hypoxia, or transfusion, careful attention to appropriate drug dosage and adequate oxygenation should be made.
Thermoregulation
Temperature regulation is slower with advanced age, with the shivering and sweating responses showing marked reductions.17 As a result, advanced age is considered a predisposing factor for perioperative hypothermia,36–39 which can impose increased demands on the cardiovascular system. Specifically, perioperative hypothermia exerts a number of adverse effects, including prolonged drug action,40 negative postoperative oxygen balance,41 immune dysfunction,42 and subsequent increased incidence of wound infection.43 Cardiac changes include a leftward shift of the hemoglobin-oxygen saturation curve, increased vascular resistance, cardiac arrhythmias, and up to a fourfold increase in cardiac output and oxygen consumption associated with rewarming and shivering.42 Special care to maintain normothermia can minimize the risk of postoperative ischemia and angina in older patients.
Sensory system
Communication with a person with age-associated hearing loss, or presbycusis, can be improved by:
• Assuming the person understands everything you are saying. Include the patient in the conversation unless they tell you otherwise.
• Addressing the person by last name unless asked to do otherwise. Avoid pet names such as “honey” and “sweetie.”
• Always approaching the patient from the front. Face the patient when you speak. This action enhances the patient’s ability to hear you and demonstrates interest and respect.
• Using good eye contact. Use a positive friendly facial expression. Elders are much better at interpreting social cues and notice on negative messages much easier than younger people.
• Using expanded speech and speaking in a lower pitch, rather than raising the voice. This action is helpful because presbycusis is marked by loss of high pitches, and raising your voice also raises your pitch. Also, a lower pitch is more calming.
• Using proper enunciation. Loss of hearing “S” and “F” sounds is most frequent.
• Encouraging the patient to wear a hearing aid, if the patient uses one.
• Being certain that the environment is “elder friendly” or is a low-distraction and low-noise environment. Presbycusis specifically affects a person’s ability to filter ambient sound.
• Using written instructions if hearing loss is significant.
Communication with a person with age-associated vision loss, or presbyopia, can be improved by:
• Approaching the person face to face.
• Identifying yourself when you approach and avoiding startling the patient.
• Telling the person your intentions before you begin.
• Using large-print (sans serif, high-contrast print is best) or recorded material when available.
• Encouraging the patient to wear glasses and keep them clean, if he or she uses glasses.
• Being certain that older patients have sufficient time to adjust to light changes and that stairs and walkways are clutter free and clearly marked. Presbyopia specifically affects the ability to adjust between light and dark surroundings and depth perception.
The aging mind: an overview
Dementia and delirium
Differentiating dementia, cognitive impairment, and delirium is essential for the anesthesia provider. Whereas true dementias are inherently irreversible, delirium and cognitive decline are potentially reversible if properly diagnosed and treated.
The dementias are characterized by a global decline in cognitive function resulting in significant social or functional impairment.44 Dementia seriously affects a person’s ability to perform activities of daily living, including feeding, bathing, and dressing. Initial involvement is in parts of the brain that control thought, memory, and language. Although the exact cause of AD is unknown, autopsies reveal three different types of lesions on patients’ brains: senile plaques, neurofibrillary tangles, and vascular lesions. Senile plaques and vascular lesions contain high levels of beta-amyloid protein. The important consideration from an anesthesia perspective is that the presence of dementia also indicates that the patient has increased metabolic risk and comorbidities that need to be addressed during preanesthesia and perianesthesia phases.
Cognitive impairment refers to cognitive changes including short-term memory loss, confusion, and decreased performance on neuropsychological tests. Symptoms of cognitive impairment are greater than changes caused by normal aging, but are insufficient to meet the criteria for a dementia diagnosis. Delirium is a disorder that disrupts brain functionality. Delirium clinically presents with major behavioral changes not explained by a preexisting dementia.27
Postoperative cognitive decline and delirium are adverse events that occur frequently in older adults.45 One study of delirium in older adult patients found a prevalence of 31.4% at initial assessment and an incidence of 31.1% during the course of hospitalization.44 Postoperative deliriums can be particularly prevalent and problematic for older patients. Preexisting patient factors, medications, and various intraoperative and postoperative causes have been implicated in the development of postoperative delirium.45
There are a number of tools available for assessing and screening for delirium, including the confusion assessment method (CAM), and the delirium rating scale (DRS).46,47 A physical examination, history assessment, and laboratory study are all important tools for identifying possible causes of delirium.
Working with the aging population: essential concepts
Geropharmacology
Older adults living in the community take an average of 2.7 to 4.2 prescription and nonprescription medications.48 Nonprescription medications include both over-the-counter (OTC) drugs as well as dietary supplements. Among prescription medication users, approximately 46% concurrently use OTC drugs and 52% concurrently use dietary supplements.49 Concurrent use of prescription medications, OTCs, and dietary supplements can lead to medication-related adverse events. Medication-related problems have many forms, often as a result of polypharmacy: overuse of medications, inappropriate prescribing, and drug interactions. Hanlon and colleagues48 found that 55% of outpatients were taking drugs with no indication, 33% were taking ineffective drugs, and 17% were taking drugs with therapeutic duplications.50,51 Thirty percent of hospital admissions are linked to medication-related problems; furthermore, medication-related problems are the fifth leading cause of death in the United States.52
Almost one quarter of community-dwelling older adults use medications that should be avoided. The Beers criteria, a list of medications that are usually considered inappropriate when given to elderly people, were created to measure inappropriate prescribing and highlight common drug interactions.53 These criteria are updated regularly and should be a companion when working with older adult patients. For example, long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were the most frequently inappropriately prescribed medications.51 Table 50-3 illustrates some possible adverse effects or drug interactions that can take place in older patients during the perioperative period. Age-related changes to organ systems affect a drug’s pharmacokinetic and pharmacodynamic properties.
Table 50-3 Adverse Effects or Drug Interactions Associated with the Older Adult Patient
| DRUG | ADVERSE EFFECT OR DRUG INTERACTION |
|---|---|
| Antibiotic | Prolongation of muscle relaxants |
| Antidysrhythmic | Prolongation of muscle relaxants |
| Benzodiazepine | |
| Diazepam | Decreased metabolism |
| Chlordiazepoxide | Increased CNS effects |
| Flurazepam | Prolonged drowsiness |
| Digoxin | Decreased renal excretion with increased CNS disorientation, anorexia, nausea, and cardiotoxicity; blood levels twofold to threefold higher in older adult with any given dose |
| Diuretic | Hypokalemia, hypovolemia |
| Halothane | Decreased anesthetic requirement |
| Lithium | Clearance decreased by 65% and effective dose by 30% in comparison with patients at 25 years of age; increased side effects of tremor, diarrhea, and edema |
| Meperidine | Markedly elevated plasma levels and decreased red blood cell and plasma binding of drug; increased incidence rate of nausea, respiratory distress, and hypotension |
| Methyldopa | Enhanced hypotensive effects |
| Pancuronium | Decreased clearance from plasma |
| Propranolol | Plasma level approximately threefold to fourfold higher in elderly because of decreased metabolism; bradycardia, congestive heart failure, bronchospasm, mental confusion, and attenuation of autonomic nervous system activity |
| Tricyclic antidepressant | Increased anticholinergic effects: confusion, agitation, and disorientation; cardiac conduction disturbances; increased anesthetic requirements |
| Warfarin | Enhanced sensitivity |
CNS, Central nervous system.
Adapted from Krechel S, editor: Anesthesia and the geriatric patient, New York, 1984, Grune & Stratton; Miller R, editor: Anesthesia, ed 5, New York, 2000, Churchill Livingstone.
Pharmacokinetics refers to the time it takes for the drug to be liberated, absorbed, distributed, metabolized, and excreted. Drug distribution is altered by the age-related decrease in total body water and lean mass, increase in total body fat, decrease in serum albumin, decrease in cardiac output, reduction in blood volume, and increase in α1-acid glycoprotein.54 Injection of medication into a contracted blood volume produces a higher plasma concentration of drug. High protein–bound drugs may have an exaggerated clinical effect (e.g., lidocaine, propranolol, thiopental, etomidate, profol, alfentanil) because of a higher level of unbound (free) drug. Decreased distribution of water-soluble drugs can cause an adverse reaction because of the initial high plasma concentrations. Conversely, increased distribution of fat-soluble drugs can prolong the action of that medication (e.g., diazepam, midazolam).54
Pharmacodynamics is the ability of the drug to react with a specific receptor and to translate that effect on the receptor into a physiologic response. This reaction can render older adults more sensitive to a given concentration of most drugs; however, the opposite is true in regard to beta-adrenoreceptor antagonist and agonist and to digoxin. A higher incidence rate of hyperkalemia, renal failure, and death from gastrointestinal bleeding is associated with the use of nonsteroidal antiinflammatory drugs.18,54
In the assessment of the older adult patient, the informed clinician must consider changes in cardiovascular, renal, hepatic, and respiratory function; the compensatory mechanisms; and coexisting comorbid conditions. As a result of marked heterogeneity of drug response in older adult patients, no strict age rules can be applied across the entire older adult population.25
Person-centered care and cultural competence
Person-centered care necessitates taking the time to know the patient’s personal preferences, goals, and priorities to provide the highest quality care. A person-centered approach views the patient as the center of defining what is most important to effective delivery of his or her care and care outcomes. An individuals’ life experience affects their personal health beliefs, which results in a wide variety of understanding, preferences, and knowledge regarding care provision and medical practice. Assurance of understanding is essential to quality patient care and is at the foundation of person-centered care. Contrary to popular belief, older adults are among the most compliant in regard to care planning. Most frequently, poor compliance is the result of external barriers (e.g., income restrictions) and lack of understanding from poor communication.
Summary
Perianesthesia nursing care of older patients requires a thorough understand of physiologic and psychological changes that occur with aging. An accurate assessment of the individual is necessary based on personal functioning, the presence of comorbidities, medication regimen, and psychological outlook of the older adult patient. When caring for older adults, keep in mind that age is just a marker of years lived and does not accurately represent the totality of the older patient.
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