To reduce the risk of postoperative delirium in older adults scheduled for inpatient procedures, surgery teams should rethink how they prepare patients ahead of time.
This will enhance recovery, cut complications, and improve the quality of care for a growing ageing population.
This is according to the American Society of Anesthesiologists (ASA), which recently produced an updated list of strategies to reduce the risk of postoperative neurocognitive disorders for patients over 65 undergoing surgery.
The recommendations are based on a review of the current evidence.
As the global population ages, the risk of postoperative neurocognitive disorders, including delirium, is proving a growing concern.
For patients over 65, the path to recovery is often complicated by these cognitive challenges.
However, with careful preoperative evaluation, tailored anaesthesia choices and strategic medication management, hospital teams can significantly reduce this risk, improving outcomes and quality of life after surgery.
Lead author Frederick Sieber of Johns Hopkins Hospital, Baltimore, said: ‘Cognitive and functional changes after surgery are a serious problem in older patients, sometimes leading to loss of independence. We provide new recommendations on proposed steps to reduce these risks based on an updated review of the current evidence.’
Many older adults develop delirium after surgery, with symptoms such as confusion, lethargy or agitation. Although most recover, delirium has been associated with persistent neurocognitive impairment.
Following a structured process, an ASA advisory task force reviewed the research evidence on measures to minimise cognitive and other complications of anaesthesia common in patients aged 65 years or older scheduled for inpatient surgery. Based on their findings, the multidisciplinary expert panel developed the following recommendations:
• Expand preoperative evaluation: To reduce the risk of postoperative delirium in older adults scheduled for inpatient procedures, consider expanding preoperative evaluation. If patients are identified with cognitive impairment and/or frailty, changes in patient care can be initiated. These changes include the involvement of a multidisciplinary care team, visits by a geriatrician or geriatric nurse, and patient and family education on postoperative delirium risk.
• Choose the type of anaesthesia with an anaesthesiologist: When either neuraxial or general anaesthesia is clinically appropriate for older adults, the decision is based on shared decision-making. The evidence suggests that neither technique is superior in reducing postoperative delirium. Either total intravenous or inhaled anaesthesia is acceptable for general anaesthesia in the older population.
• Consider dexmedetomidine to reduce risk: Among older patients scheduled for inpatient procedures, it is reasonable to consider dexmedetomidine to lower the risk of postoperative delirium while also considering its effects on bradycardia (slowed heart rate) and/or hypotension (low blood pressure).
• Minimise use of other medications: Consider the risks and benefits of medications with potential central nervous system effects in older adults, as these drugs may increase the risk of postoperative delirium.
The report emphasises that the available evidence reviewed remains limited and further details the critical issues identified by the task force in the key areas that require further research.
Dr Sieber said: ‘It is critically important for anaesthesiologists to be aware of the risks of postoperative delirium and other neurocognitive disorders in older adults," We hope our practice advisory will promote an evidence-based approach to efforts to assess and reduce those risks, which guide next steps in research to improve cognitive outcomes and prevent functional decline for this vulnerable and growing population.’
