Life is most delightful when it is on the downward slope, but has not yet reached the abrupt decline.
We have all encountered geriatric patients amid or on the precipice of an “abrupt decline” in health. Our aim as physicians and as a health care community is to not only extend those late-life years but also the quality of those years. Postoperative delirium may certainly incite an abrupt decline in a geriatric surgical patient and deserves our prioritized focus. This is a very common and potentially devastating, yet possibly preventable, postsurgical complication in older patients. Speed and quality of convalescence in geriatric surgical patients is multifactorial, and we have the ability to positively influence key contributors, including premedication, pain management, anesthetic management, and immediate postoperative care.
Recently, evaluation of practice trends and perceptions toward postoperative delirium by anesthesiologists revealed that, despite having more information to guide us than ever before, awareness of this information is deficient, even for physicians who care for a significant geriatric cohort (Anesth Analg 2018;127:1406-13; Anesth Analg 2020;130:1572-90; Br J Anaesth 2021;126:423-32; J Am Coll Surg 2016;222:930-47). No less than 15 subthemes of unique challenges and considerations were identified by anesthesiologists when asked to describe their understanding of postoperative delirium prevention, identification, and management (Anesth Analg April 2022). Feasible implementation is a critical component of effectively delivering interventions before, during, and after surgery to improve postoperative outcomes. It is encouraging to see that simple changes for delirium prevention are becoming more common in anesthesiology, with trends of less utilization of diphenhydramine and midazolam and increased use of regional analgesia being reported (Anesth Analg April 2022). More involved interventions like preoperative consent specifically focusing on delirium risk and EEG-guided anesthetic depth titration are still not common practice.
Enhanced Recovery After Surgery (ERAS) protocols are becoming widely utilized to help patients better tolerate the stress of surgery. Recognizing the reported deficits in knowledge regarding postoperative delirium best practices, avoiding routine administration of anxiolytics, and favoring use of regional analgesia for pain control as foundational ERAS components are likely contributing to positive trends in geriatric anesthetic care, which would have much less momentum otherwise. One of the ways to conceptualize the difference between ERAS and the Perioperative Surgical Home (PSH) is that ERAS focuses on the type of surgery scheduled, where PSH focuses on the kind of patient who is having surgery (Can J Surg 2021;64:E381-90). Leveraging the infrastructure that is already in place to support ERAS programs can potentially lead to an accelerated expansion of perioperative elements focused on promoting cognitive recovery of the geriatric surgical patient. Indeed, applying ERAS-based care to geriatric surgical patients has shown benefit, but the most complex geriatric patients will likely benefit more from a PSH model of care where robust preoperative screening could be used to identify frail patients; prehabilitation could target nutrition, physical activity, behavioral stress-coping strategies, and comorbidity optimization; and patient education and shared decision-making could result in an appropriately timed discussion of postoperative delirium risk (i.e., not in the preoperative holding area immediately prior to the patient’s scheduled surgery).
It is clear that multidisciplinary, team-based care of geriatric surgical patients can improve postoperative outcomes. Unfortunately, resources to support comprehensive care models such as ERAS or PSH are not unlimited. With this in mind, occasions to make even small-scale, pragmatic changes to geriatric surgical care should be emphasized. One domain of perioperative care we have near absolute control over and that can promote healthy recovery of cognitive function after surgery in older patients is medication administration. The compendium of medications to avoid or use with caution in geriatric patients is known as the American Geriatrics Society Beers Criteria (J Am Geriatr Soc 2019;67:674-94). Drugs on this list often present an unfavorable balance of benefits and harm for older people. Several common perioperative medications are on the list and can be broadly classified as central nervous system modulators and pain relievers. Postoperative nausea and vomiting prophylaxis and treatment strategies should minimize use of first-generation antihistamines like diphenhydramine and hydroxyzine. Likewise, antidopaminergics like promethazine and prochlorperazine, in addition to anticholinergics like transdermal scopolamine, should be avoided as all have cognitive impairment risks. For periprocedural anesthesia and other clinical scenarios (i.e., seizures, significant anxiety, ethanol withdraw, etc.), short-acting benzodiazepines like midazolam may be appropriate; however, knowing the significant risks to cognitive recovery after administration, the benefit of giving benzodiazepines carte blanche to the older adult must be questioned in geriatric surgical patients.
One drug that should be avoided without exception is meperidine. Attractive as opiate-sparing pain medications, non-cyclooxygenase-selective nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, meloxicam, and ketorolac have renal, gastrointestinal, and hematologic side effects for which the need, dose, and duration must be carefully determined for older patients. Furthermore, skeletal muscles relaxants like cyclobenzaprine and methocarbamol should be avoided as they are seldom effective at the doses tolerated by geriatric patients secondary to anticholinergic side-effects and sedation. An increased risk of fracture makes very deliberate and careful use of skeletal muscle relaxants cogent. A Beer’s Criteria-aversive approach to caring for the geriatric surgical patient may include a longer preoperative discussion to minimize anxiety non-pharmacologically, a balanced propofol and opiate-based TIVA for the patient at high risk of PONV, use of a neuraxial or regional block with local anesthetic for pain control, and particular vigilance over intraoperative body temperature to avoid rigors in the recovery room.
The are many significant challenges to the delivery of accessible, high-quality perioperative care. In these times of unprecedented health care resource utilization, the demands placed on us as health care workers are leading to burnout and feelings that our challenges are insurmountable. Nothing can recalibrate one’s view of the magnitude of impact we make on others’ lives as clinicians like finding yourself or a loved one in the position of being “the patient” who is facing a major surgery. The routine, day-to-day tasks of our “work” are a completely different experience for the patient and their family. Being on the “other side” may even cause you to wonder how patients without a close support person who is a health care worker, someone to help them understand and advocate for them, could ever successfully navigate our medical system and receive the highest-quality care possible. ERAS protocols already promote improved outcomes in surgical patients and have several components that align with some key best practices for delirium prevention. A more PSH-like comprehensive, coordinated, multidisciplinary approach to postoperative delirium prevention, recognition, and treatment is a promising approach for geriatric perioperative care, though admittedly, widespread accessibility of this level of care for older patients seems challenging. Focusing on minimizing the use of Beers Criteria medications is an extremely important consideration for improving perioperative geriatric care, as this is a change that can be made right now to move us toward reducing the significant burden of postoperative delirium. How will you want your care when it is your turn?
To conclude with another quote from Seneca: “Let us cherish and love old age.” Let anesthesiologists be the protectors of health and well-being of the older adult.