Perioperative Considerations in the Management of Elderly Patients

There are several considerations that the ophthalmologist should take into account in the preoperative evaluation and perioperative management of elderly patients; loss of vision alone may not be an appropriate sole indication for surgical intervention (eg, cataract surgery). Functional assessment includes determining how vision loss affects instrumental activities of daily living (IADLs) such as reading, driving, taking medications properly, and using the telephone independently; IADLs should be documented preoperatively. All prescription medications should also be documented to ensure that they do not interact with perioperative medications. An elderly patient may have multiple medical conditions that require use of numerous prescription medications. Some of these medications can even have ocular side effects. Please see Chapter 16 for further discussion. The management of informed consent should be considered; this process may be different in patients with mild dementia and in those who have legal guardians or caregivers who will need to participate in the process.

Elderly patients undergoing surgery may be prone to confusion or delirium perioperatively. Delirium is estimated to occur in approximately 4%–5% of patients after cataract surgery. Many causes for confusion are preventable. Minimization of preoperative sedation or psychotropic medications, appropriate patient and family orientation by nursing or ancillary staff, and careful supervision and reassurance in the postoperative period can diminish confusion. Often, a confused older patient simply needs a familiar face or reassurance to regain calm. The use of restraints should be minimized.

Confusion may be exacerbated in patients with vision loss or in those who require vision rehabilitation. In a monocular older patient, patching of the eye after surgery may aggravate confusion and disorientation. Having a family member in the recovery room can be very helpful. The patch should be removed as soon as possible, and the patient should be provided with appropriate eye protection. Topical anesthetic may not be indicated because of comorbidities such as cognitive impairment and inability to cooperate during surgery. In addition, patients with decreased vision following intraocular surgery may experience limited mobility or be at increased risk for falls. Bed rest and immobilization can lead to disuse of extremities, development of pressure ulcers, and other problems. For these patients, active rehabilitation should be encouraged as soon as possible.

Though rare in outpatient ophthalmic surgery, surgical or anesthesia complications may result in life-threatening conditions. The surgeon must pay careful attention to any preexisting directives (eg, do-not-resuscitate order or living will) prior to any surgical intervention (including laser treatments and periocular injections or anesthetics). By discussing possible treatment decisions with the patient and family members early—preferably before any serious illness arises or, if a serious illness is present, early in its course—the surgeon can avoid emergency decisions.

Some potential issues for discussion include limits of treatment, antibiotics, and changes in the patient’s living situation. Candidly and openly discussing these important issues with the patient and the family (especially in cases of dementia) in the preoperative period allows them to consider these matters in the context of their belief systems and without the disorientation and confusion created by an emergency. The content, context, time, and date of such discussions should be well documented in the medical record and communicated to the patient, the family, and the primary care physician or geriatrician.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.