Recommendations by ASA may help reduce delirium in older patients having surgery

Delirium and cognitive decline are common complications of anesthesia and surgery in older adults. Evidence-based recommendations on strategies to reduce the risk of postoperative neurocognitive disorders are presented in a new practice advisory in the Online First edition of Anesthesiology, the peer-reviewed journal of the American Society of Anesthesiologists (ASA).

"Cognitive and functional changes after surgery are a serious problem in older patients, sometimes leading to loss of independence," said lead author Frederick Sieber, M.D., 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."

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 minimize cognitive and other complications of anesthesia 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: Consider expanded preoperative evaluation in older adults scheduled for inpatient procedures to reduce the risk of postoperative delirium. 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.
• Choose Type of Anesthesia with an Anesthesiologist: Choosing either neuraxial or general anesthesia 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 anesthesia is acceptable for general anesthesia 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).
• Minimize 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 emphasizes 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 anesthesiologists 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."

Reference:

Frederick Sieber et al, 2025 American Society of Anesthesiologists Practice Advisory for Perioperative Care of Older Adults Scheduled for Inpatient Surgery, Anesthesiology (2024). DOI: 10.1097/ALN.0000000000005172