Self-Guided Pre-Surgical Optimization of Older Adults: An Integrative Literature Review

Abstract

Background

Surgical complications pose a significant risk for older adults (60+ years old) undergoing elective surgery, highlighting the need for interventions to prevent harm. Pre-surgical optimization has been postulated as one method to promote health outcomes before elective surgeries. Creative approaches to pre-surgical optimization are necessary, especially given the shortage of health-care providers. This review examines the existing literature on critical elements of pre-surgical optimization that older adults can effectively self-manage as well as the best methods to design resources to empower older adults to self-optimize prior to surgery.

Methods

An integrative review was conducted by searching literature indexed in Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Scopus.

Results

Two themes emerged from the analysis of 22 empirical studies: 1) critical elements of pre-surgical optimization for older adults, and 2) effective strategies for educating and preparing older adults for surgery. Additionally, six subthemes were identified.

Conclusion

Evidence-informed self-guided pre-surgical optimization resources for older adults should be developed to prevent surgical complications among older adults.

Keywords

older adults pre-surgical optimization surgery prehabilitation patient education

Implications for Knowledge Translation

Pre-surgical optimization can help reduce post-operative complications in older adults.

Older adults can benefit in preparing for surgery through self-guided interventions in smoking cessation, nutritional enhancement, and physical activity.

Providing older adults with educational resources tailored to their needs can empower them to take an active role in their care and overall health.

Surgical complications have become a significant public health concern, ranking as the third leading cause of death globally (7.7%), surpassed only by ischemic heart disease and stroke (Nepogodiev et al., 2019). Specifically, 4.2 million deaths per year are caused by perioperative complications related to surgery, with the highest burden among older adults and those with underlying medical conditions (Nepogodiev et al., 2019). Older adults (60+ years) face the highest burden of surgical complications, with one in four experiencing post-operative complications following elective surgery (Watt et al., 2018).

Furthermore, of the surgical demographic, a large component of surgical volumes is attributable to the aging population and older adults (Søreide & Wijnhoven, 2016). With the number of older adults within Canada projected to double by 2037 (Statistics Canada, 2024a), addressing post-operative complications in this population has become increasingly urgent. This aging demographic shift has contributed to a significant increase in surgical volumes across Canada (Statistics Canada, 2024b), underscoring the importance of implementing effective strategies to ensure the best surgical outcomes for older adults and mitigating implications for the health-care system.

Older adults often present with comorbidities and increased physiological vulnerability, placing them at higher risks of surgical complications and mortality (McDonald et al., 2018). Pre-surgical optimization (PSO) is one proactive approach designed to improve surgical outcomes by preparing patients for surgical procedures through comprehensive assessment, risk stratification, and targeted interventions to address modifiable risk factors (Surgical Patient Optimization Collaborative, 2022).

Pre-surgical optimization involves engaging in health-promoting activities prior to surgery to reduce the likelihood of complications (McLaughlin et al., 2021). This preventive approach leverages pre-surgical wait times to improve patients’ overall health, ultimately minimizing surgical risks (Gagliardi et al., 2021). Some elements of PSO, such as anemia management, require provider-driven interventions (Shander et al., 2023). However, some aspects like nutrition, smoking cessation, and physical activity can be managed independently by patients without requiring intensive clinic oversight. A wholly provider-driven PSO approach is resource-intensive and not feasible given the ongoing health-care provider shortages (Kiran et al., 2024; Li et al., 2023).

Conversely, self-guided PSO approaches allow patients to take a more active role in optimizing modifiable risk factors such as nutrition, smoking cessation, and physical activity. These strategies have advantages in accessibility and scalability. This contrast highlights the limitations of provider-driven models and the need to know more about self-guided strategies within surgical optimization.

Evidence shows that older adults benefit from PSO programs. McDonald et al. (2018) found that older adults who participated in a PSO programs had lower readmission rates at 7 and 30 days compared to a similar group who received standard care; the PSO group experienced fewer complications, on average, highlighting the efficacy of preventive pre-operative care in this population. Furthermore, a systematic review and meta-analysis by Watt et al. (2018) found that older adults are at increased risk of harm following surgery, and that optimizable factors were often predictors of these complications. These findings suggest that PSO can be beneficial for older adults. Given the magnitude of post-operative complications in older adults, the challenges of provider-driven PSO programs, and the potential benefits of PSO for this population, it is essential to review the literature on elements that can be effectively self-managed by older adults.

As the population ages and surgical volumes increase, health-care providers may struggle to provide comprehensive PSO programs for all older adults (Aronson et al., 2020). Self-management strategies to empower older adults to optimize their health prior to surgery may be a potential solution to augment current optimization programs. There is a clear need to develop education resources and tools to support older adults in effectively self-managing and optimizing their health prior to elective surgery.

Aim of the Study

While there is a large body of evidence on PSO, literature on self-guided PSO for older adults needs to be synthesized. The aim of this integrative literature review was to identify critical elements of PSO that older adults could effectively manage and to examine the most effective methods for delivering self-guided educational PSO resources. This review sought to highlight evidence-based strategies to improve surgical outcomes for older adults while addressing barriers to self-management.

Methods

Review Questions

This review was guided by the following research questions, which were developed to address the overarching aim of exploring self-managed PSO in older adults:

According to the literature, what are the most important PSO components for older adult patients?

Is education effective in improving these health components before surgery?

What education interventions are being used?

What PSO methods are the most effective for this population?

Each stage of the review process was designed to systematically address these questions and synthesize evidence related to self-managed PSO among older adults.

Review Framework

An integrative review was conducted according to the framework outlined by Whittemore and Knafl (2005). This approach was selected because it allows for the inclusion of diverse research designs, providing a comprehensive understanding of the phenomenon of interest. By synthesizing findings from qualitative, quantitative, and mixed-methods studies, this methodology allows for the inclusion of diverse research designs, providing a comprehensive understanding of the phenomenon of interest. This methodology facilitates the identification of patterns, gaps, and emerging themes across different methodologies, making it particularly well-suited for complex health-care topics (Whittemore & Knafl, 2005).

This review followed Whittemore and Knafl's (2005) five-stage framework:

Identifying the Problem – The first stage involved defining the research problem and identifying a gap in the literature related to self-managed PSO in older adults.

Searching the Literature – A systematic search strategy was employed using relevant databases and search terms to identify studies that met the inclusion criteria.

Evaluating the Data – Retrieved studies were screened and critically appraised for quality and relevance using predetermined inclusion and exclusion criteria.

Analyzing the Data – Data from the included studies were synthesized to identify key themes and patterns relevant to self-managed PSO.

Presenting the Findings – The final stage involved organizing and reporting the synthesized results in a clear and structured manner.

By adhering to this structured framework, this review ensures a rigorous and systematic synthesis of the available evidence on self-managed PSO in older adults.

Identification of the Problem

While PSO has been shown to improve outcomes for older adults, existing literature primarily emphasizes provider-driven approaches. Limited evidence exists on how older adults can independently engage in PSO to improve readiness for surgery. This review therefore focuses on synthesizing available evidence on self-managed PSO and identifying strategies to support older adults in optimizing their health prior to surgery.

Inclusion and Exclusion Criteria

Inclusion Criteria. All quantitative, qualitative, and mixed methods studies and reviews were considered for inclusion. To be included in this integrative review, studies were required to meet the following:

Contained older adult populations (60+ years of age).

Examined written educational approaches for older adults, with an emphasis on pre-surgical self-guided resources.

Were peer-reviewed or grey literature.

Were published in English between September 2014 and September 2024

Exclusion Criteria. Studies were excluded if they:

Focused on provider-driven interventions without potential for self-management.

Were non-research articles (i.e., editorials, opinion pieces, conference abstracts, book chapters, or commentaries).

Search Strategy

A literature review was conducted with the assistance of a research librarian to help formulate key questions, key terms, and a search strategy. The search strategy included the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Scopus, and the Nursing and Allied Health Database; grey literature was searched using Google, Google Scholar, and Open Grey. The search strategy utilized subject headings, Medical Subject Headings (MeSH) terms, and keywords, including “pre-operative”, “pre-surgical”, “optimization”, “prehabilitation”, “enhanced recovery”, “enhanced recovery after surgery (ERAS)”, “ERAS”, “self-guided education”, “education”, “older adults”, and “seniors”. These search terms then led to the identification of overarching themes, which necessitated including the search terms “nutrition”, “nutrition support”, “physical activity”, “smoking”, and “smoking cessation”. Reference lists were also scanned for potential additional literature.

To enhance reproducibility, Boolean operators were used to combine terms as follows:

(“preoperative” OR “pre-surgical” OR “prehabilitation” OR “enhanced recovery” OR ERAS) AND (“self-management” OR “self-guided education” OR “patient education”) AND (“older adults” OR seniors OR elderly) AND (“nutrition” OR “physical activity” OR “smoking cessation”).

Article Selection Process

The review process was staged and methodical. Initial reviews consisted of screening of titles for potential inclusion. Abstracts of included studies were examined to determine if the study warranted full-text screening. Full-text articles were reviewed to determine whether the studies met the inclusion criteria.

A search across all databases yielded 463 articles. After removing duplicates and screening titles and abstracts, full texts of 44 articles were screened. Reference lists were also scanned. A total of 22 research-based studies were selected for inclusion in the review. Most studies on PSO components were empirical, whereas studies on educational interventions were a mix of qualitative and quantitative research.

Article screening, data extraction, and critical appraisal were conducted by the first author. Titles and abstracts were screened for relevance based on inclusion and exclusion criteria. Full-text articles meeting these criteria were reviewed in detail, and data were extracted into a structured matrix for analysis.

Figure 1 shows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram used to illustrate the study selection process.

Figure 1.

PRISMA Flow Diagram.

Data Management and Extraction

Data was collected on individual characteristics of the studies and organized within Endnote 20. Additionally, information regarding the author(s), research design, research question(s), methods, key results, and critical appraisal was tabulated in table format for ease of comparing findings across studies and to analyze and synthesize findings.

Quality Appraisal

The review process involved critically appraising the 22 included studies. All quantitative studies (N = 11) and reviews (N = 6) were evaluated using the Public Health Agency of Canada (PHAC) Critical Appraisal Toolkit (Public Health Agency of Canada, 2014) to assess the quality of studies. Quantitative studies were evaluated for strength of research design, sampling methods, internal and external validity, control of confounding variables, ethical considerations, analytical approach, and applicability. All qualitative studies (N = 5) were appraised using the Joanna Briggs Institute (JBI) Checklist for Qualitative Research (Joanna Briggs Institute, 2017). This tool evaluates clarity of philosophical perspective, study methodology, data collection, representation and analysis, influence of researcher, ethical considerations, and interpretation of results.

Data Synthesis

The analysis involved identifying key themes across the literature that highlighted critical elements for PSO that could be self-managed by older adults, followed by synthesis. Additionally, the review compiled evidence-based strategies for educating and preparing older adults for surgery. Patterns in the literature were identified and categorized according to their respective themes, with the objectives of the review in mind and careful consideration of findings in each individual study.

The quality ratings from the critical appraisal process were considered during synthesis. Studies appraised as higher quality or those employing more rigorous research designs were given greater weight when identifying themes and drawing conclusions. Lower-quality studies were used to provide contextual insight or highlight gaps in the literature requiring further investigation. This approach ensured that the synthesis reflected both the wide range of available evidence and the relative strength of the included studies.

Data Display

Data from the literature review was transferred into a literature summary table to provide an organized and concise overview of each study, including publication details, study design, key findings, and overall quality rating, with key elements of critical appraisal. A detailed literature summary table is provided for review; please see Supplemental File 1. The results were sorted and organized into two themes, with six subthemes, highlighting pertinent details, critical appraisals, and potential resources to support the development of self-guided PSO resources for older adults. The findings of the literature review are presented according to these themes and subthemes in the Results section (Whittemore & Knafl, 2005).

Results

Characteristics of Retrieved Studies

Of the included 22 research studies, 11 were quantitative (e.g., Agrawal et al., 2021; Lee et al., 2019; McDonald et al., 2018), six were reviews (e.g., Hughes et al., 2019; Ricker et al., 2024; Thomsen et al., 2014; Watt et al., 2018), four were qualitative (e.g., Barnes et al., 2023; Gillis et al., 2019; McLaughlin et al., 2021), and one used a mixed methods approach (Edmonds et al., 2017). Among the quantitative studies, one had strong design while eight had moderate design and two had weak design. The overall quality of quantitative studies included six high and five medium quality studies; five reviews were rated as high quality, and one was medium. Each of the qualitative studies was of high enough quality for inclusion in the review. The included studies provided valuable insights into key content and considerations for developing self-guided PSO resources for older adults.

The included non-review research studies were conducted in four different countries. Among the included studies, two were from Australia, four from Canada, one from the Netherlands, and the remaining nine were from the United States. The reviews included research from the United States. Since the study settings were all based in countries similar to Canada, the findings are considered generalizable to the target population.

Themes and Subthemes

Theme 1: Critical Elements of Pre-Surgical Optimization for Older Adults

The review identified numerous critical elements of PSO. Many studies included surgical patients in general where older adults were a part of these studies but were not specifically addressed. A recognizable gap in the literature is limited research focused specifically on PSO for older adults, despite their known unique physiological needs and increased surgical risks of this population (Yang et al., 2011). Additionally, there was limited research examining self-management of PSO in this population. This gap highlights a valuable opportunity for future research. However, the major components of PSO that can be effectively self-managed by older adults were consistently identified across studies included smoking cessation, nutrition and increased physical activity.

Subtheme: Smoking Cessation

The literature indicates a correlation between smoking and post-operative complications in older adults. Smoking is consistently identified as a risk factor that exacerbates the likelihood of adverse surgical outcomes, particularly in the older adult population (Grønkjær et al., 2014).

In the general surgical population, pre-operative smoking has been linked to an increased post-operative surgical complications, including site infections (Agrawal et al., 2021; Ely et al., 2020; Johnson et al., 2021; Karamanos et al., 2016), wound dehiscence (Johnson et al., 2021; Karamanos et al., 2016; Kashanchi et al., 2021), implant failures (Johnson et al., 2021), and unexpected returns to the operating room (Kashanchi et al., 2021; Thomas & Leitman, 2018). Likewise, pre-operative smoking has also been associated with many medical post-operative complications such as cardiac issues (Agrawal et al., 2021; Johnson et al., 2021), and delirium (Kim et al., 2020; Zhang et al., 2024). Notably, Haeuser et al. (2021) found that the negative effects of smoking on post-operative complications are exacerbated in older adults. Their large (N = 10,528) retrospective cohort study found that for older adults undergoing surgery, smoking significantly increased the risk of some post-operative complications including pulmonary complications, wound complications, need for transfusion and reintervention rates. Their findings also indicated that advancing age was significantly associated with a higher probability of developing complications, with a stronger association observed with each additional year. Likewise, Zhang et al. (2024) found that smoking was associated with the development of post-operative delirium in older adults which increases the risk of mortality. These findings underscore the importance of smoking cessation in PSO for older adults, highlighting the necessity of incorporating smoking cessation support into self-guided PSO resources.

The literature highlights several approaches to delivering smoking cessation interventions to the general population in the pre-operative period. However, no studies specifically examined the unique needs of older adults in delivering smoking cessation interventions pre-operatively. Smoking cessation interventions have been found to be efficacious when applied to the general population pre-operatively (Prestwich et al., 2017; Thomsen et al., 2014). A meta-analysis of randomized controlled trials by Prestwich et al. (2017) found that preoperative smoking cessation interventions significantly increased abstinence rates, with 46.2% of participants quitting smoking compared to 24.5% in control groups. These findings highlight the importance of integrating pre-surgical smoking cessation education into PSO resources, ensuring older adults have the necessary support to quit smoking before surgery.

Methods for providing successful pre-operative smoking cessation support have been examined extensively in the literature. A systematic review and meta-analysis by Prestwich et al. (2017) examined methods of pre-operative smoking cessation supports and found that intensive multi-component interventions, including counselling and nicotine replacement therapy (NRT) demonstrated higher abstinence rates (25–36.4%) compared to brief interventions (13%). Similarly, Thomsen et al. (2014) found in their Cochrane Review that a combination of counselling and NRT was the most effective approach for smoking cessation. However, the optimal timing and intensity of these interventions remain unclear (Ricker et al., 2024).

Additionally, providing patients with the rationale behind smoking cessation before surgery is particularly impactful. An older, but particularly interesting study by Shannon-Cain et al. (2002) found that smoking rates decreased from 15% to 4% when patients were informed regarding the risks of smoking in relation to surgical risks. This knowledge coincides with findings from the cross-sectional study by Webb et al. (2020) where fewer than 40% of people who smoked in the study answered correctly pertaining to knowledge of post-operative complications resulting from smoking. Furthermore, a randomized control trial by Webb et al. (2020) found that offering free NRT appeared to promote engagement in smoking cessation attempts in comparison to those who were not offered free NRT in patients awaiting surgery. Given these findings, comprehensive PSO resources for older adults would benefit from including key information, including the risks of smoking pre-operatively, as well as offering evidence-based smoking cessation supports such as counselling, and information on how to obtain cost-free NRT.

Subtheme: Nutritional Support

The literature highlights the importance of optimizing nutrition for older adults undergoing surgery, particularly addressing undernourishment. It is understood that undernourishment causes decreased levels of serum albumin, a substance necessary for wound healing and overall recovery after surgery (Johnson et al., 2021; Thomas & Leitman, 2018; Zhang et al., 2024).

Providing nutritional education support for older adults before surgery is critical for this population. Three studies reviewed emphasized the importance of including nutritional support in PSO programs for older adults. A retrospective cohort study by Johnson et al. (2021) found that older patients with low serum albumin levels had 3.7-fold higher odds of developing a post-operative infection and, more concerning, 7.2-fold higher odds of 30-day mortality. Similarly, Thomas and Leitman (2018) found that 30-day mortality was significantly correlated with low serum albumin levels and increased age. Controlled trial evidence further supports the notion of malnutrition as a critical PSO component for older adults. A meta-analysis of 15 studies found a statistically significant decrease in the incidence of both infectious and non-infectious complications after pre-surgical nutritional support (Jing-Xia et al., 2015).

Zhang et al. (2024) found in their systematic review and meta-analysis that low pre-operative albumin levels were significantly associated with an increased risk of post-operative delirium following total joint arthroplasty in older adults. Given the increased risk of post-operative infections, 30-day mortality and post-operative delirium related to undernourishment in older adults, the literature strongly supports the inclusion of nutritional support within PSO resources.

Encouraging adequate protein intake in PSO materials designed for older adults is critical. Patients with illness or surgical injury have elevated protein requirements (Gillis et al., 2015). Older adults often suffer from anabolic resistance, which means that larger amounts of protein are necessary to avoid body tissue catabolism that puts older adults at increased risk of complications if nutritional needs are not satisfied (Moore et al., 2015). A prospective cohort study of older adults found that half of the participants consumed less than one gram of protein per kilogram per day (Phillips et al., 2016); evidence-based dietary protein requirements range from 1.2 to 1.6 grams per kilogram per day to offset age-related muscle regression and tissue health for older adults (Phillips et al., 2016). Therefore, a balanced diet rich in protein, spread throughout the day, is recommended before surgery.

Studies indicated that older adults face some significant challenges in adhering to and understanding nutritional information (Beelen et al., 2017; Gillis et al., 2019). Two qualitative studies described these challenges and revealed how the provision of pre-surgical nutrition education could potentially be improved. Patients described that they found it difficult to adhere to nutritional recommendations (Beelen et al., 2017; Gillis et al., 2019) and participate in PSO of their nutritional status (Gillis et al., 2019). Many older adults were often unaware of the risks of undernutrition and lacked knowledge regarding the health consequences of such (Beelen et al., 2017; Gillis et al., 2019). However, both studies found that participants were more likely to follow recommendations if they perceived clear benefits to their health and wellbeing. Specifically, Gillis et al. (2019) described that patients believed food was healing but reported that they would have preferred to have more specific information on what to eat and how much, particularly in preparation for surgery. These findings indicate that providing clear, actionable nutrition education tailored to older adults’ needs and preferences could improve their engagement and adherence to pre-surgical nutritional optimization.

Subtheme: Physical Activity

Increasing physical fitness emerged as another key subtheme within the literature regarding important PSO elements for older adults. The relationship between physical activity and surgical complications in older adults was the subject of a prospective cohort study (Lee et al., 2019) and a systematic review and meta-analysis of RCT (Hughes et al., 2019). Lee et al. (2019) investigated the impact of baseline physical activity on the incidence of post-operative delirium. The findings indicated that regular physical activity was associated with 74% lower odds of developing post-operative delirium, concluding that physical activity increases physiological reserves and reduces the incidence of post-operative complications such as delirium. Likewise, the systematic review and meta-analysis by Hughes et al. (2019), highlighted the benefits of pre-operative physical conditioning before surgery, and emphasized its role in improving post-operative outcomes in older adults including reduced morbidity. As previously noted, protein synthesis, necessary for healing and physiological reserves is influenced by both nutrition and physical activity improving patient outcomes (Gillis et al., 2015). Therefore, physical activity is another important component to PSO resources for older adults.

Adherence to exercise regimes for clinical improvement is generally low in older adult populations (Picorelli et al., 2014). It is therefore important to consider potential barriers and drivers to participation in exercise programs for PSO. A descriptive qualitative study by Barnes et al. (2023) explored some of the challenges and motivators for older adults participating in exercise programs before cancer surgery. The study found that manageable, home-based programs with support from others and a sense of enjoyment in the program both facilitated participation. On the other hand, barriers to participation included health conditions, fatigue, weather, and feelings of guilt when physically incapable of participating in the exercises provided. Therefore, exercise programming should incorporate home-based exercises with modifications for those who need it, suggest activities that may be enjoyable with weather-related modifications, and suggest ways in which they can obtain peer and psychosocial support in their journey, if desired.

Theme 2: Effective Strategies for Educating and Preparing Older Adults for Surgery

It is important to consider the needs and techniques specific to older adults to ensure that resources effectively address potential barriers and leverage facilitators to ensure engagement with the material (Harrison & Graham, 2021). When the older adult audience is engaged with the material, they are more likely to participate in making necessary changes (Harrison & Graham, 2021), thereby reducing the likelihood of surgical complications.

Subtheme: Providing Rationale for Change

Change theory provides a framework for understanding how to motivate and facilitate changes in health behaviours. The rationale for change in health behaviours is supported by various models that emphasize the importance of understanding what determines the behaviours, how to change behaviour, and potential processes in changing behaviour, as well as contextual elements that influence behaviour change. The Health Belief Model (HBM) (Becker, 1974) is a prominent theory related to health behaviour change. The HBM suggests that individuals are more likely to engage in health-promoting behaviours if they perceive a risk to their health, perceive that risk to have serious consequences, and believe that if they take action it will reduce their risk (Becker, 1974). To effectively motivate older adults, it is crucial to include clear rationale for PSO within the PSO resources. Understanding the reasons behind recommendations can significantly enhance engagement and willingness to take action (Harrison & Graham, 2021).

Subtheme: Created for Those with Low Digital Health Literacy

The World Health Organization (WHO) defines digital health literacy as the ability to find, understand, and use health information online to improve one's health (World Health Organization, 2021). Digital health literacy is increasingly recognized as a critical skill for older adults, enabling them to access, understand, and utilize health information available online. However, in the 2023 Canadian Digital Health Survey, 40.3% of older adult respondents did not feel confident in using information on the Internet to help them make health decisions, and 21.1% did not know how to use the Internet to answer their health questions (Canada Health Infoway, 2023). These findings have implications for creating effective health education materials for this demographic. A descriptive qualitative study by Saadati et al. (2023) sought to explore the challenges, opportunities, and support needs related to digital health literacy amongst older adults. A significant finding was that older adults face barriers in utilizing technology for health purposes, and that educational materials should be designed to address these barriers.

Additionally, the literature suggested that inequities in digital health literacy should also be carefully considered. A cross-sectional study by Gordon and Hornbrook (2018) explored the digital divide among seniors from diverse racial and ethnic backgrounds. The findings revealed that older adults tended to have less access to digital devices, less online experience, and felt less capable of seeking health information online. Additionally, Black Latino and Filipino older adults reported feeling less capable of seeking health information online compared to their White peers. Given these limitations, access options such as print supports should be considered when creating self-guided PSO resources.

Subtheme: Designed for Older Adults with Age-Related Changes in Mind

Considering the visual preferences and age-related visual changes of older adults will be important in designing self-guided PSO resources. Various studies have examined the visual preferences of older adults in print health education materials. In a large (N = 3138) longitudinal study by Playdon et al. (2016), the researchers assessed older adults’ preferred sources for health education. They found that the majority (60.9%) of older adults preferred reading books, magazines, or printed publications for health information, with headings to easily navigate the information, and underlining, bolding, and headings in a larger text size and in colour. Research shows that older adults also have preferences for sans-serif fonts with a minimum size of 14 (Wilson & Read, 2016). They also preferred shorter sentences, words, and paragraphs with spacing of either 1.5 or 2.0 (Playdon et al., 2016). The use of visual aids was preferred, but the visual aid needed to support the materials and make it easier to understand (Edmonds et al., 2017). Older adults also described a preference for photographs over graphics, and for visual aids that represent diversity in race, sex, age, and body size (Edmonds et al., 2017; Playdon et al., 2016). Following these preferences described in the literature will help make the PSO resources easier to follow and more visually appealing to older adults.

Discussion

The aim of this integrative review was to synthesize evidence to gain a deeper understanding of self-guided PSO for older adults by identifying critical PSO elements that can be effectively self-managed and exploring the most effective methods for delivering this education through self-guided resources. The findings indicate that smoking cessation, nutritional optimization, and increased physical activity are key areas for self-management in PSO, yet there is limited research specifically addressing how older adults can independently engage in these interventions. Additionally, this review highlighted that the design and delivery of self-guided PSO resources plays a critical role in accessibility and effectiveness for older adults.

This review highlights a gap in the literature in that the benefits of PSO are well established for older adults (McDonald et al., 2018; Watt et al., 2018), many interventions remain provider-driven, with little emphasis on patient self-management and empowerment. Self-guided PSO could potentially serve as an important tool to enhance patient empowerment and reduce the burden on health-care systems to help reduce surgical complications.

The findings indicated that smoking cessation, nutritional support, and physical activity were recognized as important PSO elements for all older adults (Grønkjær et al., 2014; Hughes et al., 2019), but successful implementation with older adults may require unique considerations. Many older adults were unaware of the risks associated with smoking (Webb et al., 2020) and malnutrition (Beelen et al., 2017; Gillis et al., 2019), which suggested that self-guided PSO resources needed to focus on not only behaviour change but also improving health literacy. This review also highlighted the importance of designing PSO materials that were visually accessible, considerate of digital health literacy levels, and culturally inclusive, which contributed to the literature on patient education and engagement in PSO.

The results of this integrative review aligned with existing research demonstrating the effectiveness of PSO in reducing post-operative complications (Gillis & Wischmeyer, 2019; Hughes et al., 2019). However, while previous studies examined the role of structured, supervised PSO programs, this review suggests that self-guided approaches may offer a feasible alternative, especially for older adults who lack access to prehabilitation services or had barriers.

The association between smoking and surgical complications was well documented (Grønkjær et al., 2014; Prestwich et al., 2017). Previous research supports the use of NRT and behavioural counseling as effective pre-surgical interventions (Thomsen et al., 2014). This review highlighted a gap in how these interventions are delivered to older adults. The literature suggested that patients remained unaware of the benefits of smoking cessation before surgery (Shannon-Cain et al., 2002; Webb et al., 2020), which might explain the reasons why self-guided smoking cessation is underutilized. Additionally, previous research has focused on younger populations (Prestwich et al., 2017), whereas older adults might require differing approaches, such as print-based resources or clinician engagement to facilitate behaviour changes.

Nutritional optimization was highlighted as important within the PSO literature for reducing surgical risks (Johnson et al., 2021; Thomas & Leitman, 2018). Older adults faced barriers to understanding and adhering to pre-surgical dietary recommendations (Beelen et al., 2017; Gillis et al., 2019). Previous studies highlighted that adequate pre-operative protein intake can improve surgical outcomes (Gillis & Wischmeyer, 2019), but there is minimal evidence on adherence in older adults. These findings added that self-guided PSO resources must provide clear, actionable dietary guidance tailored to older adults’ needs.

This review is also consistent with previous research in that pre-operative physical activity improves surgical outcomes (Hughes et al., 2019; Lee et al., 2019). However, while existing studies emphasize structured exercise programs, the findings suggest that adherence is a challenge for older adults (Picorelli et al., 2014). This review highlighted that health conditions, motivation, and environmental barriers can impact participation (Barnes et al., 2023), indicating that self-guided PSO programs must include strategies to enhance motivation and engagement, such as home-based or social supportive components.

While the benefits of PSO are well-established, the emphasis on self-guided interventions in this review differed from much of the existing research, which focused on provider-driven models. This discrepancy may be due to reliance on health-care professionals to guide patients through prehabilitation, particularly in high-resource areas with increased access. This represents a traditionalist approach to health care in which there are power imbalances between providers and patients which may not be desirable for patients or feasible in the long-term. As health-care systems face resource constraints and workforce shortages (Kiran et al., 2024), there is a need for patient-driven models of care.

This review emphasized the unique needs of older adults. While previous studies on patient education have often treated older adults as a homogeneous group, this review suggested that factors like digital literacy (Canada Health Infoway, 2023), socioeconomic status (Gordon & Hornbrook, 2018), and individual learning preferences (Wilson & Read, 2016) may play a critical role in the effectiveness of self-guided interventions.

Implications for Practice, Policy, and Research

The findings of this integrative review have several important implications for practice, policy, and research regarding the PSO of older adults. When applied in these areas, the findings have the potential to decrease postoperative complications in this population.

This review highlighted the need to ensure that older adults are screened for smoking, nutritional status, and physical activity before surgery so that the appropriate support can be provided. Nurses and allied health professionals are ideally positioned to lead these efforts through early assessment, education, and ongoing support. Their expertise in in health coaching, patient education, and behaviour change positions them as facilitators of self-guided PSO strategies. Furthermore, it is essential that self-education materials to prepare older adults for surgery are developed with the unique needs and preferences of older adults in mind. Key considerations include providing a rationale for change, incorporating text and visual elements that align with older adults’ learning preferences, and addressing barriers related to digital literacy. These elements will ensure that materials are accessible, engaging, and effective in supporting self-management.

From a policy perspective, this review advocates for greater recognition of the leadership role of nurses and allied health professionals in implementing and sustaining PSO initiatives. Dedicated funding and institutional support should be directed toward developing nurse-led optimization programs that integrate self-guided education within routine preoperative care. Clinical practice guidelines and quality indicators should emphasize PSO for older adults and explicitly acknowledge the contribution of interdisciplinary teams in driving these efforts, improving surgical outcomes and system efficiency.

This review highlighted gaps in research specific to self-guided PSO for older adults, specifically regarding the physiological challenges older adults experience with surgery and the optimizable factors that can be targeted through self-management. Additionally, stronger and more specific evidence is needed around the role of nurses and allied health professionals in supporting and sustaining self-guided PSO education.

Limitations of Study

This integrative review had several limitations. First, specific research on PSO and self-guided PSO education for older adults is limited. Most studies examine adult populations without conducting age-specific analysis. The evidence base for self-guided PSO remains limited, with most studies focusing on provider-driven models of care. Additionally, many of the studies included focused solely on one element of PSO rather than examining a multimodal approach.

The review process was conducted by a single reviewer, which may have introduced potential selection or interpretive bias during screening, data extraction and appraisal. However, methodological transparency and the use of standardized appraisal tools were utilized to enhance consistency and rigour.

Finally, the variety of study designs, outcome measures, and populations in the review made it challenging to draw definitive conclusions. Despite these limitations, this review provides a valuable synthesis of the current evidence on PSO for older adults and highlights important key areas for future research and practice.

Conclusion

PSO is a critical component of the surgical trajectory in preventing post-operative complications. However, resources to address this important pre-surgical need remain limited. This integrative review synthesizes the literature and evidence on the critical elements of PSO that older adults can effectively self-manage, as well as the methods and resources available to provide optimization resources for this population. The key self-management elements identified were smoking cessation, nutritional optimization, and physical activity enhancement. Effective education and resource accessibility were also identified as key considerations. While substantial evidence supports the benefits of PSO in adult populations, there is a significant gap in the literature in examining the specific needs and preferences of older adults undergoing elective surgery. This review underscores the need for self-guided educational resources on PSO targeted towards the older adult population, aiming to reduce surgical complications and improve overall health.

Supplemental Material

sj-docx-1-cng-10.1177_10784535261456800 - Supplemental material for Self-Guided Pre-Surgical Optimization of Older Adults: An Integrative Literature Review

Supplemental material, sj-docx-1-cng-10.1177_10784535261456800 for Self-Guided Pre-Surgical Optimization of Older Adults: An Integrative Literature Review by Cherisse C. McMain and Esther Monari in Creative Nursing

Footnotes

Acknowledgements

The first author, Cherisse McMain, would like to express gratitude to Dr. Esther Monari for her mentorship and support throughout the practicum experience, as well as for encouragement in pursing publication of this work. The first author would also like to thank Michelle Swab for assistance with the development of the search strategy for this article.

ORCID iDs

Cherisse C. McMain

Esther Monari

Ethical Considerations and Informed Consent

Not applicable – this article is an integrative literature review.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Not applicable – no datasets were generated or analyzed during this study.

Supplemental Material

Supplemental material for this article is available online.

Author biographies

Cherisse C. McMain, RN, MScN, (she/her), is a Surgical Quality Consultant at Island Health.

Dr. Esther Monari, RN, PhD, (she/her), is an Assistant Professor in the Faculty of Nursing at Memorial University of Newfoundland in St. John's, Newfoundland, Canada.

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