Delirium and cognitive decline are common complications of anaesthesia and surgery in older adults. Evidence-based recommendations on strategies to reduce the risk of postoperative neurocognitive disorders have now been presented in a new practice advisory.
Many older adults develop delirium after surgery, with symptoms such as confusion, lethargy, or agitation. Although most patients 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.
“Cognitive and functional changes after surgery are a serious problem in older patients, sometimes leading to loss of independence,” said lead author Frederick Sieber of Johns Hopkins Hospital, Baltimore.
“We provide new recommendations on proposed steps to reduce these risks, based on an updated review of the current evidence.”
Based on their findings, the multidisciplinary expert panel developed the following recommendations.
One recommendation is to consider expanded preoperative evaluation in older adults scheduled for inpatient procedures to reduce the risk of postoperative delirium.
The researchers state that if patients are identified with cognitive impairment and/or frailty, changes in patient care can be initiated. These changes include, but are not limited to, involvement of a multidisciplinary care team and geriatrician or geriatric nurse visits, and patient and family education on postoperative delirium risk.
Secondly, they suggest choosing either neuraxial or general anaesthesia for older adults when either is clinically appropriate, based on shared decision-making. The evidence suggests no superiority with either technique in reducing postoperative delirium. Either total intravenous or inhaled anaesthesia is acceptable for general anaesthesia in the older population.
Further, they recommend considering dexmedetomidine to reduce risk, noting that, 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).
Finally, the research team recommends minimising the use of other medications, noting to 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 limitations remain in the available evidence reviewed and further details the critical issues identified by the task force that remain in the key areas considered, that require further research.
“It is critically important for anaesthesiologists to be aware of the risks of postoperative delirium and other neurocognitive disorders in older adults,” Dr. Sieber said.
“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.”
Further information and resources are available from the ASA Perioperative Brain Health Initiative.
