management surgical elderly patient

1. Care of geriatric surgical patient
DR. Doha Rasheedy
Associate professor of Geriatric Medicine
Ain Shams University

2. Background
 The geriatric population is growing and will approach 20% of
the population by 2025.
 Geriatric surgeries have increased and are now approaching
40% of all surgeries. With surgical morbidity and mortality
increase with age.
1. Complication rate is 7.1% in all patients versus 17% in those aged
over 65.
2. Mortality is 1.2% in all patients, 2.2% in those aged 60 to 69, 6%
in those aged over 80, and 8% in those aged over 90.
 Age is not the only factor, and comorbidities play a major role.
 Healthy geriatric patients have outcomes similar to healthy
younger patients.
 Preoperative geriatric assessment is needed to recognize
individual risk factors for complications and to implement
measures to prepare the patient for surgery and to lessen this
risk.

3. Predictors of surgical outcomes
Ageing and Reserve
Medical comorbidities
Nature of
surgery
Geriatric giants:
Malnutrition
Frailty
Cognition
Social support

5. Postoperative complications in
Geriatric Patients
• Length of stay
• Deconditioning
• Delirium
• Infections
– Wound
– Urinary
– Pneumonia
• Cardiac
– Infarction/ischemia
– Congestive heart failure
– Arrhythmia/arrest
• Pulmonary
– Pneumonia
– Need for mechanical ventilation
– DVT/PE
– atelectasis

6. Patient-specific factors can increase risk
• Dementia can increase risk for delirium
postoperatively (see other risk factors).
• Diabetes and renal disease are associated with
increased risk for cardiac complications.
• Vascular disease is considered a coronary artery
disease equivalent.
• COPD, smoking, uncontrolled asthma, and obesity
are associated with higher pulmonary complications.
• Malnutrition is associated with poor outcomes and
wound healing.
• Low level of activity or functional capacity can be
associated with increased cardiac risk.
• Sarcopenia delays functional recovery.

7. The nature of the procedure may also increase risk
• High risk: Major vascular surgery, emergent surgeries.
and those with increased blood loss are high-risk
procedures for cardiac complications (>5%).
• Intermediate risk: Intra-abdominal, intrathoracic,
orthopedic, and carotid endarterectomy are
associated with 1% to 5% incidence of cardiac
complications.
• Low risk: Superficial surgeries, endoscopy, breast, and
cataract surgeries are low risk and associated with
<1% risk for cardiac complications.
• Intra-abdominal and thoracic procedures increase
risk for pulmonary complications.

8. PROPER PREOPERATIVE
ASSESSMENT

9. Checklist for the Optimal Preoperative Assessment
of the Geriatric Surgical Patient
Chow, Warren B. et al. Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practices Guideline from
the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics
SocietyJournal of the American College of Surgeons, Volume 215, Issue 4, 453 - 466

10. Preoperative Tests Recommended for All Geriatric
Surgical Patients

11. Preoperative Laboratory Tests Recommended for
Selected Geriatric Surgical Patients

12. Preoperative Imaging and Body Functional Tests
Recommended for Selected Geriatric Surgical Patients

13. Preoperative geriatric assessment
checklist
• Cognitive screening
• Decision making capacity
• Screening for Depression
• Functional status, fall risk
• Frailty
• Nutritional assessment
• Medical assessment
• Medication review
• Support system
• Advance directives

14. DECISION-MAKING CAPACITY
• Before obtaining the surgical consent, the surgeon should
determine whether or not the patient has decision-making
capacity.
The 4 legally relevant criteria for decision-making capacity are:
1. The patient can clearly indicate his or her treatment
choice.
2. The patient understands the relevant information
communicated by the physician.
3. The patient acknowledges his or her medical condition,
treatment options, and the likely outcomes.
4. The patient can engage in a rational discussion about the
treatment options.

15. Advance directives
• It is strongly recommended that the surgeon
ensure that the patient has an advance
directive and a designated a health care proxy
or surrogate decision makers. These
documents should be placed in the medical
chart

16. NUTRITIONAL STATUS
All patients should be evaluated for their nutritional status:
1. Document height and weight and calculate body mass index (BMI).
2. Measure baseline serum albumin and prealbumin levels.
3. Inquire about unintentional weight loss in the last year.
Document patients with severe nutritional risk if they exhibit any of the following:
• BMI < 18.5 kg/m2
• Serum albumin < 3.0 g/dL (with no evidence of hepatic or renal dysfunction)
• Unintentional weight loss > 10% to 15% within 6 months.
Patients at severe nutritional risk should, if feasible, undergo a full nutritional
assessment by a dietician to design a perioperative nutritional plan to address
deficits, and should be considered for preoperative nutritional support.
• Poor nutritional status is associated with increased risk of postoperative
adverse events, mostly infectious complications (eg, surgical site infections,
pneumonia, urinary tract infections, etc) and wound complications (eg,
dehiscence and anastomotic leaks), and increased length of stay for patients
undergoing elective gastrointestinal surgery

17. Cardiac testing (see Figure)
• Those requiring emergent surgery will need to undergo
surgery with management of complications and
consultation with cardiologists and/or other specialists.
• Those with unstable, active cardiac issues such as
decompensated congestive heart failure, arrhythmias,
severe valvular disease, or recent MI/ischemia will
need cardiology consultation and delay of surgery, if
possible, for assessment, treatment, and stabilization.
• In general, all low-risk surgical procedures can proceed
without cardiac testing unless otherwise indicated.
• Stress testing should be considered for all high-risk
surgery patients

18. Cardiac evaluation for noncardiac surgery

19. Pulmonary testing (see Figure)
• There are no definitive predictors of who with
lung disease should proceed with surgery other
than lung resection.
• Testing is directed to defining disease states and
optimizing status prior to proceeding with
surgery.
• Consider baseline arterial blood gases and CXR.
• Consider pulmonary function tests before and
after treatment to optimize function.
• In overweight patients suspected of obstructive
sleep apnea, sleep studies may be warranted.

20. Pulmonary evaluation for surgery

21. Risk Factors for Postoperative
Pulmonary Complications

22. Preoperative Strategies for Preventing Postoperative
Pulmonary Complications
1. Epidural use whenever possible
2. Avoid intermediate-(for example, cisatracurium, rocuronium, vecuronium) and
long-acting neuromuscular blocking agents (i.e., pancuronium) where possible
3. When neuromuscular blockade is used, ensure adequate recovery of
neuromuscular function prior to extubation
4. Use of laparoscopic approaches whenever possible, especially during bariatric
surgery
Intraoperative Strategies for Preventing Postoperative Pulmonary Complications
1. Preoperative optimization of pulmonary function in patients with COPD and asthma
that is not well controlled
2. Smoking cessation(4-8 weeks before surgery)
3. Preoperative intensive inspiratory muscle training
4. Selective chest radiograph and pulmonary function tests (not routine for all patients)

23. Medication Management
• The patient’s complete medication list, including over the counter
medications, supplements, vitamins, and herbal agents, should be
reviewed and documented.
• 1. Discontinuation of nonessential medications.
– General considerations may include:
• a. The potential for withdrawal
• b. The progression of disease with interruption of drug therapy
• c. The potential for interactions with anesthetic agents
• 2. Continuation of essential medications.
• 3. Planning for the resumption of all other baseline outpatient
medications in the postoperative period with consideration for
minimizing polypharmacy risk
Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline
from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J. Am. Coll.
Surg. Oct 2012;215(4):453-466.

25. Perioperative β-blockers
• Initiating β-blockers in the perioperative period is controversial as the
published data have been inconsistent.
• β-blockers should be continued for patients who are already taking
them.
• Furthermore, starting β-blocker therapy should be considered
perioperatively for patients at high risk of coronary events who are
scheduled for elevated-risk noncardiac surgery, provided
contraindications do not exist. It is clear that large doses of these agents
should not be started on the day of surgery due to an increased risk of
stroke and overall mortality.
• Caution is also advised as β-blockers increase the risk for hypotension
and bradycardia, side effects that can be particularly dangerous in older
patients. If initiated, β-blocker therapy should be prescribed several
days to weeks prior to surgery at a starting dose with subsequent
gradual dose adjustments to achieve a resting heart rate of 55 to 65
beats/min while avoiding hypotension.
• When prescribed, β-blocker therapy should be continued throughout
the perioperative period and up to 30 days postoperatively.

26. Statin

27. • Aspirin, clopidogrel, nonsteroidals, and other
antiplatelet drugs increase the risk of
perioperative bleeding and, if not essential,
should be held for a recommended 5 to 7 days.
• Drugs with anticholinergic properties, such as
diphenhydramine or meclizine, can increase the
risk of perioperative delirium and should be held
or discontinued.
• Holding diuretics for 24 hours prior to surgery
should be considered if these are not needed to
treat excessive volume or symptoms of
pulmonary congestion in patients with HF.

28. • Patients on antiepileptic, cardiovascular, and
antihypertensive medications typically should take their
medications on the morning of surgery.
• Medications for seizure disorders, Parkinson disease, and
agents for myasthenia gravis should be continued
throughout the perioperative period to minimize the risk
of worsening neurologic symptoms
• Abrupt discontinuation of β-blockers and clonidine is
associated with significant cardiovascular complications.
Patients using these medications can be managed with
intravenous metoprolol, or transdermal clonidine patches
if unable to resume oral intake postoperatively.
• Angiotensin-converting enzyme inhibitors and
angiotensin receptor blockers are commonly held on the
morning of surgery to avoid the known risk of
hypotension upon induction of anesthesia.

29. Anti Diabetic treatment
• Oral hypoglycemics are generally held the night prior to
surgery, to reduce the risk of perioperative hypoglycemia.
• Patients who require insulin typically receive 50% to 80% of
their usual dose of basal insulin on the morning of surgery.
• Rapid-acting or mealtime insulin is held on the day of surgery
as patients are NPO.
• Postoperative glucose levels above 250 mg/dL can be safely
managed with short-acting subcutaneous insulin while
intravenous infusions of insulin is preferred if hemodynamic
instability is present (a cause of variable absorption of
subcutaneous insulin).
• Metformin should be suspended the day before a procedure
with iv contrast and for 48h afterward.
• SGLT-2 inhibitors and GLP-1 agonists should be omitted for the
day of surgery, irrespective of the timing of the operation.

30. • Steroids should be maintained through the surgical
period and doses doubled if taking >7.5mg
prednisolone equivalent per day to avoid
hypoadrenal crises.
• Although acute adrenal crisis is an uncommon
condition, it is reasonable to administer
perioperative stress dose steroids for patients with
adrenal suppression from chronic steroid exposure.
• A typical regimen consists of 25 to 50 mg of
intravenous hydrocortisone every 8 hours depending
on the magnitude of the procedure, and tapering
over 2 to 3 days as permitted based on the
postoperative course.
• For patients who develop postoperative adrenal
insufficiency, replacement of both glucocorticoids
and mineralocorticoids is necessary

31. The management of anticoagulants prior to surgery
• For patients on chronic warfarin with an international normalized ratio (INR) goal of 2.0 to 3.0,
four scheduled doses should be withheld to allow the INR to normalize to less than 1.5 before
surgery.
• If the INR is typically kept above 3.0, then longer periods without a warfarin dose may be
required. The INR should be measured on the day of surgery to ensure that it has reached an
acceptable range.
• If the INR is excessive, a small dose of vitamin K (eg, 1 mg intravenously or 2.5 mg orally) may be
given, which will further reverse the INR within 24 hours. If rapid reversal of the INR is required,
fresh frozen plasma can be administered.
• When the INR is less than 2.0, other prophylactic antithrombotic interventions should be
considered.
• Elective surgery is best avoided for at least 3 months following a DVT or pulmonary embolism (PE)
event to ensure adequate duration of anticoagulation treatment. If this is not possible, then
anticoagulation bridging with LMWH should be given before and after the procedure for patients
on warfarin while the INR is less than 2.0.
• ‘Bridging therapy’ is indicated in special circumstances: metallic heart valves (especially mitral or
non-bileaflet aortic), VTE episode within 3 months, cardiac thrombus, and stroke/TIA due to AF
• LMWH should be stopped 24 hours before surgery; restarting LMWH can be considered 24 to 48
hours after surgery, depending on the type of surgery, bleeding risk, and thrombotic risk of the
patient.
• Patients receiving one of the newer oral anticoagulants (eg, dabigatran, rivaroxaban, or apixaban)
do not require perioperative bridging therapy given the relatively short half-life of these agents.
These medications can be discontinued 1 to 4 days prior to surgery depending on the patient’s
risk of thrombosis, surgical bleeding risk, and renal function.

32. Antibiotic prophylaxis
• The relationship between appropriately dosed preoperative antibiotics and
reduced risk of surgical site infections (SSIs) is well established.
• Studies have also suggested a mortality benefit at 60 days for older patients
who receive preoperative antibiotics within at least two hours of incision.
• Procedures at particularly high risk of infection include abdominal operations,
operations requiring bowel anastomosis, contaminated or dirty procedures,
procedures for cancer, and prolonged, complex, or emergent procedures.
• Preoperative antibiotics should be given based on procedure, risk factors, and
the hospital’s unique pathogen profile within 60 minutes before surgical
incision
• Older patients may have compromised renal function and, as such, may
require particular attention to dosing.
• No prophylaxis for clean procedures unless prosthetic device or higher
risk/consequences (e.g., cardiac or neurosurgical)
• Often single dose or re-dosing for no more than 24 hours
• Initial dose 60 minutes before surgery, except vancomycin and
fluoroquinolones (120 minutes) due to longer infusion times

34. PREDICT POSTOPERATIVE DELIRIUM RISK

35. Prevention and management of postoperative
delirium
• Health care professionals caring for surgical patients
should perform a preoperative assessment of delirium
risk factors and continue risk stratification during
intraoperative and postoperative periods.
• Health care professionals caring for postsurgical
patients should be trained to recognize and document
signs and symptoms associated with delirium,
including hypoactive presentations. Clinical suspicion
must be high in order to detect delirium in patients
after surgery.
• Health care professionals should assess and clearly
document preoperative cognitive function in older
adults at risk of postoperative delirium. (CAM
method- DSM V criteria)

36. Perioperative Risk Factors for Delirium

38. Medications increasing the risk of
postoperative delirium
• Anticholinergic medications
• sedative-hypnotics
• Meperidine
• The use of multiple medications (5 or more) has
been associated with an increased risk of
delirium.
• if a patient has a history of alcohol abuse or
benzodiazepine dependence, then treatment
with benzodiazepines is warranted even though
the medication would typically be avoided.

39. INTRAOPERATIVE MEASURES TO
PREVENT DELIRIUM
• The anesthesia practitioner may use processed
electroencephalographic monitors of anesthetic
depth during intravenous sedation or general
anesthesia of older patients to reduce
postoperative delirium (thereby administering
fewer or lower doses of anesthesia medications).

40. Delirium precautions
I. Determine level of risk
II. Appropriate environmental cues for day/night
III. Utilize eyeglasses or hearing aids as appropriate.
IV. Maintain hydration and nutrition.
V. Engage patient to be as active as possible, in conversation, providing orientation.
VI. Encourage time with familiar faces and use of familiar items.
VII. Allow for sleep without disturbances as much as possible.
VIII. Monitor elimination of bowels and bladder.
IX. Avoid restraints or use of foley catheters, if possible.
X. Minimize medication use.
XI. Treat pain adequately (regional analgesia, non opioid analgesia).
XII. Treat underlying conditions.
XIII. Consider low-dose antipsychotic medication in high-risk patients (no sufficient evidence to support
use)
Prophylactic administration of newly prescribed cholinesterase
inhibitors are not effective in reducing postoperative delirium and
may cause increased harm (including mortality)

41. Symptoms Associated with Delirium
• Change in level of arousal: drowsiness or decreased arousal*or increased arousal with
hypervigilance
• Delayed awakening from anesthesia*
• Abrupt change in cognitive function (worsening confusion over hours or days), including
problems with attention, difficulty concentrating,
• new memory problems, new disorientation
• Difficulty tracking conversations and following instructions
• Thinking and speech that is more disorganized, difficult to follow, slow,* or rapid
• Quick-changing emotions, easy irritability, tearfulness, uncharacteristic refusals to
engage with postoperative care
• Expression of new paranoid thoughts or delusions (ie, fixed false beliefs)
• New perceptual disturbances (eg, illusions, hallucinations)
• Motor changes such as slowed or decreased movements,* purposeless fidgeting or
restlessness, new difficulties in maintaining posture such as sitting or standing*
• Sleep/wake cycle changes such as sleeping during the day* and/or awake and active at
night
• Decreased appetite*
• New incontinence of urine or stool*
• Fluctuating symptoms and/or level of arousal over the course of minutes to hours

43. Assessment of postoperative delirium

44. Other causes of delirium
– myocardial infarction
– pulmonary embolus
– Renal, hepatic coma
– Respiratory failure
– Myxoedema
– Hypo, hyperglycemic state
Neuroimaging is typically limited to patients with
recent falls or head trauma, use of
anticoagulation, focal neurologic signs, or fever
without other explanation

45. PHARMACOLOGIC TREATMENT OF
POSTOPERATIVE DELIRIUM
• The prescribing practitioner may use antipsychotics at the lowest effective
dose for the shortest possible duration to treat patients who are severely
agitated or distressed, and are threatening substantial harm to self and/or
others.
• The prescribing practitioner should not prescribe antipsychotic or
benzodiazepine medications for the treatment of older adults with
postoperative delirium who are not agitated and threatening substantial harm
to self or others.
• The prescribing practitioner should not use benzodiazepines as a first-line
treatment of the agitated postoperative delirious patient who is threatening
substantial harm to self and/or others to treat postoperativedelirium except
when benzodiazepines are specifically indicated (including, but not limited to,
treatment of alcohol or benzodiazepine withdrawal). Treatment with
benzodiazepines should be at the lowest effective dose for the shortest
possible duration, and should be used only if behavioral measures have failed
or are not possible and ongoing use should be evaluated daily with in-person
examination of the patient

46. INTRAOPERATIVE CARE

47. Preoperative fasting
• Dehydration is less well-tolerated in advancing age.
• Excessive preoperative fasting increases discomfort and
agitation and promotes the onset of Postoperative
delirium
• A fasting period of 6 h is adequate in terms of the
prevention of aspiration .
• Clear fluids should not be avoided for longer than 2 h
preoperatively, since these are not associated with an
increased risk of aspiration or other complications
• The preoperative consumption of carbohydrate-
containing drinks up to 2 h prior to surgery is beneficial
and, as a form of non-drug-based anxiolysis, has a
positive effect on the well-being of the patient

48. Intraoperative Management Checklist
• Anesthetic approach Consideration of regional
techniques to avoid postoperative
complications and improve pain control
– Perioperative analgesic plan Directed pain history
Multi-modal or opioid-sparing techniques
Consideration of regional techniques
– Postoperative nausea risk stratification and
prevention strategies

49. • If muscle relaxants are to be used, short-acting substances
should be selected where possible; metabolism that is
independent of liver and kidney function is beneficial
(e.g., cis-atracurium). Relaxometry should be performed
concomitantly.
• The duration of benzodiazepine action increases in a
strongly age-dependent manner; furthermore, these
substances are associated with the development of POD .
Therefore, benzodiazepines should be used with the
utmost restraint in elderly patients. In the case of active
benzodiazepine abuse, which applies to no small number
of elderly patients (prevalence of around 1.2 million),
abrupt discontinuation in the perioperative phase is
naturally not recommended.
• Opioids as well as postoperative pain increase the risk of
POD (opioids: OR: 2.5 [1.2; 5.2], pain: OR: 3.7 [1.5; 8.9]) .
Therefore, adequate opioid-reduced analgesia is of great
importance.

50. • Patient safety Strategies to pressure ulcers
and avoid nerve damage
• Prevention of postoperative pulmonary
complications and hypothermia
• Fluid management and physiologic
management:
– Appropriate use of intravenous fluids
– Appropriate hemodynamic management
– Continuation of indicated cardiac medications

51. ALTERATIONS TO PHYSIOLOGY AND CLINICAL
IMPLICATIONS FOR ANESTHESIA

52. Intraoperative Hypothermia
• temperature of less than 36.0°C.
• the elderly in particular are predisposed to hypothermia
due to altered thermoregulation from decreased muscle
mass, metabolic rate, and vascular reactivity.
• Hypothermia is associated with adverse events in the
surgical patient, including surgical site infections, cardiac
events, coagulopathy leading to surgical bleeding, and
increased oxygen consumption due to shivering.
• Core temperature should be monitored in surgeries lasting
more than 30 minutes.
• Patient warming with forced air warmers and/or warmed IV
fluids should be used in older patients who are undergoing
procedures longer than 30 minutes to avoid hypothermia

53. POSTOPERATIVE CARE

55. Postoperative care
• Pain management
• Delirium monitoring
• Early ambulation
• Bowel management
• Falls prevention
• Pressure ulcer prevention
• Prevention of pulmonary complications
• Transition of Care Following the Perioperative
Period

56. Pain management
• Use opioid-sparing techniques, which may include
preoperative, intraoperative, and/or scheduled postoperative
acetaminophen or the addition of regional techniques such as
neuraxial blockade or peripheral nerve blocks.
• Avoid potentially inappropriate medications as defined by the
American Geriatrics Society Beers criteria. Common
analgesics and anxiolytics to avoid include:
– Barbiturates
– Benzodiazepines
– Nonbenzodiazepine hypnotics (eszopiclone, zolpidem, zaleplon)
– Pentazocine
– Meperidine
– Skeletal muscle relaxants (carisoprodol, chlorzoxazone,
metaxalone, methocarbamol, orphenadrine)
– Non-Cox NSAIDs

57. Prevent postoperative constipation
• Gentle handling and minimal manipulation of the intestines
• Pain management — Opioids should be used sparingly and
supplemented with NSAIDS and other nonopioid pain relievers
• Maintenance and replacement fluid therapy, correct
electrolytes imbalance.
• early oral feeding, and early mobilization, achieved
normalization of gastrointestinal function within 48 hours in
most patients
• Chewing gum postoperatively
• Include a prophylactic pharmacologic bowel regimen such as a
stool softener (for example, docusate) and stimulant laxative
(for example, bisacodyl) e.g. Minalax (bisacodyl+ docusate
sodium)
• Oral mineral oil should be avoided (Beers criteria)

58. Perioperative Nausea and Vomiting
• RISK FACTORS
– Female gender
– Nonsmoking status
– History of PONV or motion sickness
– Younger age (age<50 years)
– Use of volatile anesthetics and nitrous oxide
– General versus regional anesthesia
– Use of intraoperative and postoperative opioids
– Longer duration of surgery
• Older adults at moderate or high risk for PONV should receive prophylactic interventions and risk mitigation
strategies based on their baseline risk factors.
• Better using regional anesthesia whenever possible. If general anesthesia is required, we prefer TIVA
with propofol.
• antiemetics:
– Ondansetron 4 mg IV at the end of surgery
– Scopolamine patch – We have the patient apply a scopolamine patch at least two hours prior to the induction of
anesthesia, with instructions to remove the patch within 24 hours of application.
– Dexamethasone 4 mg intravenously (IV) after induction.
• Unfortunately, the best medications in the arsenal for fighting perioperative nausea and vomiting also can precipitate delirium in
older patients.
• Postoperative pain control – We use a multimodal approach to postoperative pain control, which may
include acetaminophen (1 g IV), ketorolac (15 to 30 mg IV) after consultation with the surgeon, regional
anesthesia techniques, and local anesthetic wound infiltration.
• Rescue antiemetics – If nausea and vomiting occur in the postanesthesia care unit (PACU), we administer
an antiemetic from a different class of drug from those used for prophylaxis. Our usual options include:
– Prochlorperazine 5 to 10 mg IV
– Droperidol 0.625 mg IV

59. Perioperative Nausea and Vomiting
prophylaxis

60. Venus thromboembolism prevention
DVT risk assessment models:
e.g. Caprini risk assessment model for venous thromboembolism

61. Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Clinical assessment of venous thromboembolic risk in surgical
patients. Semin Thromb Hemost. 1991;17 Suppl 3:304–312

63. POSTOPERATIVE STRATEGIES TO PREVENT
PULMONARY COMPLICATIONS

64. AHRQ UNIVERSAL FALL PRECAUTIONS
• Familiarize patient with environment
• Demonstrate call light use
• Maintain call light within reach
• Keep personal possessions within reach
• Sturdy handrails in bathrooms, room, and hallway
• Hospital bed in low position when patient resting; raised to
comfortable height when patient transferring
• Hospital bed brakes locked
• Wheelchair wheels locked when stationary
• Nonslip, comfortable, well-fitting footwear
• Night light or supplemental lighting use
• Keep floor surfaces clean and dry; clean spills promptly
• Keep patient care areas uncluttered
• Follow safe patient handling practices

65. Postoperative nutrition
• Minimize the duration of ‘nil by mouth’ by allowing solids up to 6h before
anaesthesia and, in some cases, clear fluids up to 2h. Provision of high-
energy liquid supplements on the day of surgery may help and post-
operatively, in all cases, initiate enteral feeding as soon as possible
• Older adult patients should undergo daily evaluation of their ability to
intake adequate nutrition, and this includes risk of aspiration. There should
be an initiation of dietary consultation and/or formal swallowing
assessment if indicated.
• Older adult patients who use dentures should have them easily available
and accessible.
• The following aspiration precautions should be instituted in all older adult
patients who undergo inpatient surgery:
– Head of bed elevation at all times with repositioning
– Sitting upright while eating and one hour after completion of eating
• Older adult patients should undergo daily evaluation of fluid status for at
least first five postoperative days, such as daily recording of input/output or
daily weights

69. UTI prevention

71. Prevention of functional decline

72. PRESSURE ULCER PREVENTION AND TREATMENT

73. THANK YOU