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Preserving Cognition and Attaining Ideal Anesthesia and Surgical Outcomes in Older Adults

  • Kenneth Boockvar
    Affiliations
    James J. Peters VA Medical Center, Geriatrics Research, Education, and Clinical Center, Bronx, New York
    The New Jewish Home, Research Institute on Aging, New York, New York
    Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, New York, New York
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      Older adults are frequent candidates for surgery, yet information on the risks and benefits from surgical procedures and anesthesia in this population is limited. Such information is critical to making informed decisions, and older patients often face high risks whether opting for surgery (ie, from complications of the procedure and anesthesia) or not (ie, from complications of the underlying condition). In particular, frail older adults, who have less physiologic reserve and reduced life expectancy, should receive surgical and perioperative care that adheres to the following core geriatrics principles: (1) lowering initial treatment intensity to minimize harm; (2) ascertaining all care outcomes that may be important, including function and quality of life
      • Chee J.
      • Tan K.Y.
      Outcome studies on older patients undergoing surgery are missing the mark.
      ; and (3) tailoring treatments to the patient’s goals, especially when there may be tradeoffs (eg, length versus quality of life).
      • Boockvar K.S.
      • Meier D.E.
      Palliative care for frail older adults: “there are things I can’t do anymore that I wish I could … ”.
      Some recent advances have produced surgical and anesthesia approaches that are concordant with these geriatrics principles. First, the advance of noninvasive surgical techniques has increasingly made surgical approaches possible in older adults with serious conditions who in the past could not have undergone invasive procedures (eg, transcatheter aortic valve replacement
      • Adams D.H.
      • Popma J.J.
      • Reardon M.J.
      • et al.
      Transcatheter aortic-valve replacement with a self-expanding prosthesis.
      ). Second, attention is growing to surgical and anesthesia complications that are particularly common and dangerous in older adults such as delirium and cognitive loss.
      • Behrends M.
      • DePalma G.
      • Sands L.
      • Leung J.
      Association between intraoperative blood transfusions and early postoperative delirium in older adults.
      • Robinson T.N.
      • Dunn C.L.
      • Adams J.C.
      • et al.
      Tryptophan supplementation and postoperative delirium--a randomized controlled trial.
      Third, recognition has increased among surgeons and anesthesiologists of the importance of frailty as a predictive factor, which may help patients and providers identify tradeoffs and tailor decision making.
      • Buigues C.
      • Juarros-Folgado P.
      • Fernandez-Garrido J.
      • et al.
      Frailty syndrome and pre-operative risk evaluation: a systematic review.
      • Chikwe J.
      • Adams D.H.
      Frailty: the missing element in predicting operative mortality.
      Fourth, there is consensus that managing older patients medically before, during, and after surgery is important to attaining ideal surgical outcomes. This is because the most common complications of surgery in older adults are not surgical-site problems but medical conditions such as thromboembolism, exacerbations of chronic heart and lung diseases, delirium, falls, and function decline from prolonged immobility.
      • Boockvar K.S.
      • Halm E.A.
      • Litke A.
      • et al.
      Hospital readmissions after hospital discharge for hip fracture: surgical and nonsurgical causes and effect on outcomes.
      This finding has led to health services and quality improvement efforts to ensure uniform delivery of recommended nonsurgical care to older adults before, during, and after surgery, sometimes via medical (or geriatrics) co-management, standardized physician orders, and rehabilitation after hospitalization. These approaches have been implemented successfully with improved outcomes in older patients undergoing hip fracture repair and other orthopedic procedures.
      • Della Rocca G.J.
      • Moylan K.C.
      • Crist B.D.
      • et al.
      Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study.
      • Morrison R.S.
      • Chassin M.R.
      • Siu A.L.
      The medical consultant’s role in caring for patients with hip fracture.
      More needs to be done to align anesthesia and surgical care with geriatrics principles. Over the past 2 years only 3 articles were been published in this journal about anesthetic agents,
      • Byon H.J.
      • Choi B.M.
      • Bang J.Y.
      • et al.
      An open-label comparison of a new generic sevoflurane formulation with original sevoflurane in patients scheduled for elective surgery under general anesthesia.
      • Golembiewski J.
      • Dasta J.
      Evolving role of local anesthetics in managing postsurgical analgesia.
      • Zhang C.
      • Li J.
      • Zhao D.
      • Wang Y.
      Prophylactic midazolam and clonidine for emergence from agitation in children after emergence from sevoflurane anesthesia: a meta-analysis.
      and none focused on older adults, suggesting limited pharmaceutical development this area. Yet the potential is significant to improve perioperative care of older adults in the absence of new agents. In this Geriatrics Special Issue we bring together review articles, a case report, and original research articles written by anesthesiologist leaders who are advancing perioperative care of older adults. Two articles in this issue address preoperative identification of patients at high risk of cognitive loss and other complications of surgery.
      • Axley M.
      • Schenning K.J.
      Preoperative cognitive and frailty screening in the geriatric surgical patient: a narrative review.
      • Brown C.H.
      • Faigle R.
      • Klinker L.
      • et al.
      The association of brain MRI characteristics and postoperative delirium in cardiac surgery patients.
      One of these articles suggests tools for assessing frailty,
      • Axley M.
      • Schenning K.J.
      Preoperative cognitive and frailty screening in the geriatric surgical patient: a narrative review.
      a key adverse risk factor, which are feasible for use in routine preoperative practice. The second finds a link between greater brain ventricular size and delirium after cardiac surgery,
      • Brown C.H.
      • Faigle R.
      • Klinker L.
      • et al.
      The association of brain MRI characteristics and postoperative delirium in cardiac surgery patients.
      suggesting that brain atrophy is a risk factor for delirium, even after controlling for preoperative cognitive function and other confounding factors. Risk identification is important to be able to inform older patients of their risk and to target risk-reducing interventions to the right patients.
      A third article describes a randomized controlled trial that examines the impact of computerized cognitive exercise (1 hour daily for 10 days) before surgery on postoperative delirium, a potential risk-reducing intervention with low chance to harm.
      • Humeidan M.
      • Otey A.
      • Zuleta-Alarcon A.
      • et al.
      Perioperative cognitive protection - cognitive exercise and cognitive reserve (The Neurobics Trial): a single-blinded randomized trial.
      Two articles describe cohort studies that illustrate ways that current anesthesia practice might be modified to improve outcomes for older adults.
      • Philips A.T.
      • Deiner S.
      • Lin H.-M.
      • et al.
      Propofol use in the elderly population: prevalence of overdose and association with 30-day mortality.
      • Deiner S.
      • Luo X.
      • Silverstein J.H.
      • Sano M.
      Can intraoperative processed EEG predict postoperative cognitive dysfunction in the elderly?.
      The first shows that older adults often receive greater than recommended doses of induction propofol and that higher doses are associated with hypotension but not mortality at 30 days.
      • Philips A.T.
      • Deiner S.
      • Lin H.-M.
      • et al.
      Propofol use in the elderly population: prevalence of overdose and association with 30-day mortality.
      The second shows an association between deeper anesthesia, as measured by intraoperative processed electroencephalogram, and protection against postoperative cognitive dysfunction at 3 months.
      • Deiner S.
      • Luo X.
      • Silverstein J.H.
      • Sano M.
      Can intraoperative processed EEG predict postoperative cognitive dysfunction in the elderly?.
      These studies provide data to support definitive tests (ie, randomized controlled trials) of different components of anesthesia practice that have the potential to change practice and to improve operative outcomes for older adults.
      A case-based review highlights the multitude of neuropsychiatric medications that can be prescribed to an individual older adult during and after surgery and their potential adverse effects singly or in combination.
      • Whalin M.K.
      • Kreuzer M.
      • Kevin H.M.
      • Garcia P.S.
      Missed opportunities for intervention in a patient with prolonged postoperative delirium.
      This review illustrates the challenge of providing centrally acting nervous system agents for sedation and anesthesia to older adults who are at high risk of adverse cognitive effects. Finally, a review of postanesthesia care for older adults provides sound care suggestions that are based on current clinical knowledge.
      • Garcia P.S.
      • Duggan E.W.
      • McCullough I.L.
      • et al.
      Post-anesthesia care for the elderly patient.
      Together, the 7 articles in this issue provide context for a hopeful next phase of surgical and anesthesia care, in collaboration with aging experts, that is designed to preserve and optimize cognition, mobility, function, and quality of life; to extend life, and to reduce adverse events in older adults considering surgery and anesthesia.

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