2026/05/21 by Odmara L. Barreto Chang, Cecilia Canales, Robert A. Whittington +1 · 1 voice
Medicine · Psychology · Social Sciences · #Dementia and Cognitive Impairment Research #Elder Abuse and Neglect #Healthcare Decision-Making and Restraints
paper · doi:10.1097/01.asm.0001194180.35763.ea
openalex publication_date 2026/05/21 · openalex created_date 2026/05/22 · openalex updated_date 2026/07/23
“I wish someone had told me about the risk of postoperative delirium. I didn't know to ask, and now I struggle with memory issues I wasn't prepared for.” Anesthesiologists are not just perioperative physicians, we are guardians of a patient's safety, dignity, and long-term well-being. Our responsibility is to help patients become active partners in their care and to understand how their vulnerabilities and treatments shape perioperative risk. For older adults, this charge goes far beyond stabilizing vital signs or managing pain. It demands that we do everything possible to support a full recovery, one that preserves physical function, emotional resilience, and, critically, cognitive health. Perioperative neurocognitive disorders (PNDs), including postoperative delirium and long-term cognitive decline, are among the most frequent and consequential complications older adults face following surgery. For example, postoperative delirium affects up to 62% of older adults undergoing surgery, and up to 40% of cases are preventable with targeted interventions (Br J Anaesth 2009;103:i41-6; N Engl J Med 1999;340:669-76; J Am Geriatr Soc 2001;49:516-22; J Am Geriatr Soc 2009;57:2029-36). Despite their impact, these conditions are too often strikingly absent from preoperative conversations (N Engl J Med 1999;340:669-76). This silence leaves patients unprepared and misses a crucial opportunity to protect the aging brain when it is most vulnerable (Br J Anaesth 2009;103:i41-6; N Engl J Med 1999;340:669-76). This article aims to provide concrete strategies that clinicians can implement to protect brain health in older adults. When anesthesiologists integrate cognitive screening, tailor anesthetic care, and engage patients and caregivers in preparation and recovery, we can meaningfully reduce PND and improve the trajectories of postoperative aging. What does the older adult want to know regarding their brain after anesthesia and surgery? Older adults undergoing surgery often have concerns about how anesthesia and surgery might affect their cognitive function. Common questions are included in the Figure.Figure: Frequently asked questions about perioperative brain concerns. Photo reprinted with permission from UCSF.Many patients express regret postoperatively, wishing they had been informed about their risk of postoperative delirium or long-term cognitive decline. As anesthesiologists, we are uniquely positioned to address these concerns and guide patients and families. Recommendations for anesthesiologists 1. Incorporate cognitive and frailty screening Cognitive screening is a vital step in identifying older adults at high risk for postoperative delirium. Brief cognitive assessments can be conducted quickly in preoperative clinics to evaluate baseline cognitive function. The Mini-Cog and Montreal Cognitive Assessment (MoCA) are practical, validated tools for this purpose. The benefits of cognitive screening are significant, as it allows for targeted interventions that can prevent up to 40% of postoperative delirium (N Engl J Med 1999;340:669-76; J Am Geriatr Soc 2001;49:516-22; J Am Geriatr Soc 2009;57:2029-36). Similar to cognitive screening, preoperative frailty screening can help identify those at higher risk for postoperative delirium (Anesth Analg 2021;133:314-23; J Am Geriatr Soc 2024;72:1781-92). Frailty screening uses multidimensional tools that assess physical, cognitive, and social/psychological domains (Anesthesiology 2020;133:78-95). Examples of frailty screens include the Risk Analysis Index, Clinical Frailty Scale, Fried Frailty Phenotype, Frailty Index, or Edmonton Frail Scale. This comprehensive approach allows for optimization that focuses on specific deficits before surgery. 2. Discuss perioperative brain risk Older adults and their families often rely on anesthesiologists to provide guidance about the risks associated with anesthesia and surgery. It is essential to discuss key aspects of perioperative brain health. Begin by addressing risk factors such as age and baseline cognitive status, which are strong predictors of postoperative delirium (Anesthesiology 2017;127:765-74; J Am Geriatr Soc 2023;71:227-34). Patients should also be informed about the possibility of experiencing temporary or long-term cognitive changes following surgery. Additionally, concerns about specific medications, such as midazolam, should be addressed, and alternatives like dexmedetomidine can be discussed when appropriate. 3. Develop practical pathways Developing practical pathways to manage perioperative brain health is crucial. Preoperative preparation should include providing patients and families with actionable steps to reduce risks, such as optimizing sleep, hydration, and nutrition. During surgery, anesthetic plans should be tailored to minimize cognitive impact, including avoidance of AGS Beers Criteria® potentially inappropriate medications in older adults and preventing deeper anesthesia states (J Am Geriatr Soc 2023;71:2052-81; Eur J Anaesthesiol 2024;41:81-108). Postoperatively, anesthesiologists should collaborate with surgical teams, geriatricians, and caregivers to monitor and manage cognitive changes, ensuring comprehensive geriatric support for the patient that includes nonpharmacological interventions such as reversing sensory loss with glasses and hearing aids, early mobility encouragement, sleep restoration, and regular reorientation, whenever possible (N Engl J Med 1999;340:669-76). 4. Increase awareness among personnel Many anesthesiologists lack formal education on perioperative brain health, which creates a gap in practice. It is important to advocate for the inclusion of brain health topics in continuing medical education (CME) programs. Resources from the ASA Brain Health Initiative can be utilized to integrate brain health assessments into routine practice, helping anesthesiologists better address the needs of older adults undergoing surgery (Anesthesiology 2025;142:22-51; asahq.org/brainhealthinitiative). Practical tips for anesthesiologists (Table) Start the conversation: Proactively discuss brain health risks with older adults during preoperative evaluations. Use simple, clear language to explain the potential for memory loss, confusion, or difficulty thinking after surgery. Identify patients with baseline cognitive impairment or other risk factors for delirium. Tailor anesthetic plans: Avoid medications known to increase delirium risk, such as AGS Beers Criteria® potentially inappropriate medications. When appropriate, it is reasonable to consider dexmedetomidine to lower risk of postoperative delirium, while also considering its effects on bradycardia and/or hypotension (Anesthesiology 2025;142:22-51). Educate families and caregivers: Provide guidance on how they can support the patient before and after surgery. Incorporate nonpharmacological interventions and encourage caregivers to monitor for signs of delirium and report concerns promptly. Leverage available resources: Use tools and guidelines from the ASA Brain Health Initiative and the Anesthesia Patient Safety Foundation to enhance perioperative care for older adults. Table - Summary of key recommendations for perioperative brain health. Organization Key Recommendations American Society of Anesthesiologists (ASA) Preoperative Cognitive Screening: Use tools like Mini-Cog or MoCA to assess baseline cognitive function. Risk Communication: Educate patients and families about risks of postoperative delirium and cognitive decline. Tailored Anesthetic Plans: Avoid high-risk medications (e.g., benzodiazepines) and consider alternatives like dexmedetomidine. Postoperative Monitoring: Implement strategies to detect and manage delirium early. American Geriatrics Society (AGS) ( Anesthesiology 2017; 127:765-74; Perioper Med 2025;14:104) Comprehensive Geriatric Assessment: Evaluate frailty, cognitive function, and comorbidities preoperatively. Shared Decision-Making: Engage patients and families in discussions about risks, benefits, and alternatives to surgery. Delirium Prevention: Use evidence-based strategies such as hydration, sleep optimization, and avoiding polypharmacy. Interdisciplinary Collaboration: Work with anesthesiologists, surgeons, and geriatricians to optimize care. Surgical Guidance ( J Am Geriatr Soc 2001; 49:516-22; Anesthesiol Clin 2015;33:439-45) Preoperative Risk Assessment: Collaborate with anesthesiologists to identify high-risk patients based on age, frailty, and cognitive status. Minimally Invasive Techniques: Opt for surgical approaches that reduce physiological stress and inflammation. Postoperative Care Coordination: Ensure early mobilization, adequate pain control, and delirium monitoring. Anesthesia Patient Safety Foundation (APSF) ( J Am Geriatr Soc 2009; 57:2029-36) Preoperative Screening: Identify patients at risk for delirium and cognitive decline using validated tools. Medication Management: Avoid benzodiazepines and use alternatives like dexmedetomidine when appropriate. Intraoperative Monitoring: Optimize hemodynamic stability and oxygenation to reduce neurocognitive complications. Postoperative Support: Implement delirium prevention protocols, such as maintaining a quiet environment and promoting sleep hygiene. Informing older adults and caregivers preoperatively about the risks and benefits of surgery provides an opportunity to optimize and plan before surgery. Every patient has a unique risk profile based on their baseline health status, which can influence postoperative outcomes. As guardians of a patient's safety, we should identify those at higher risk preoperatively and develop multidisciplinary targeted pathways that allow us to work in collaboration with surgeons, geriatricians, and caregivers to provide the highest level of care to this vulnerable population. Disclosures: Dr. Barreto Chang is a consultant and Brain Health Advisory Board member for Medtronic USA, Inc., and a grant recipient of the Robert Wood Johnson Foundation. Dr. Whittington is a member of the board of directors for the Foundation for Anesthesia Education and Research and an executive section editor for the Geriatric Anesthesia section of Anesthesia & Analgesia.Odmara L. Barreto Chang, MD, PhD, Chair, ASA Perioperative Brain Health Initiative, Member, ASA Committee on Geriatric Anesthesia, and Associate Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California. @OdmaraBarretoCecilia Canales, MD, MPH, Assistant Professor, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.Robert A. Whittington, MD, Senior Associate Dean for Faculty Development, Mentorship, and Recognition, and Professor of Clinical Anesthesiology, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.Daniel J. Cole, MD, FASA, ASA Committee on Geriatric Anesthesia, Professor of Clinical Anesthesiology, and Vice Chair for Professional and Business Development, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.