Since the Roman times, the idea of Pietas – loosely defined as duty, loyalty, or devotion to one’s ancestors or parents – was expressed as an important virtue ( In Asian traditions, filial piety – defined as exhibiting proper love and respect towards one’s parent or elders – is also a virtue held in high regard (Aging families in Chinese society. 2022). These sentiments are sometimes generalized to relationships outside of the family unit (provider-patient dyads), whereby older patients from diverse backgrounds may be deferent to providers out of respect (Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed, 1990). Similarly, the concept of familismo is deeply rooted in the Latina/o community. As such, health care decisions are often made collectively and involving several family members (Arch Clin Neuropsychol 2023;38:408-32).

It is estimated that the number of people 65 years and older will double by the year 2060 – and that population is currently more diverse than ever. These demographics present challenges to health care in the United States and compel us to develop greater competency with cultural, racial, gender, and ethnic disparities. This is also of utmost import when caring for the older adult. Work with older adults is often at the intersection of multiple social vulnerabilities, and cultural factors may interact with social and environmental determinants of health (i.e., low health literacy, access to care), creating challenges to effective communication (Arch Clin Neuropsychol 2023;38:408-32). By adopting a cultural humility approach to care, perioperative professionals (i.e., anesthesiologists, geriatricians, and neuropsychologists) can shift narratives about mistrust, reduce disparities, and create more inclusive care environments.

Poor communication is a common cause of errors in health care (StatsPearls. 2023). In perioperative medicine, effective communication engages all members of the team to assign responsibilities, set expectations, and identify strategies to check progress and assess outcomes (AORN J 2016;104:111-20). Effective communication is especially critical with older adults, who can experience age-related changes such as reduced perceptual abilities, slower thinking speed, and diminished memory that can hinder comprehension. Recent emphasis on preoperative cognitive screening for older adults to identify baseline cognitive impairment is important to accurately assess risk for postoperative delirium and long-term cognitive decline (JAMA Intern Med 2023;183:442-50; Perioper Care Oper Room Manag 2020;20:100092; In light of the changing demographic landscape of the U.S., we propose that conducting perioperative provider-patient interactions that adopt a cultural humility paradigm is an integral component of effective communication, particularly when working with ethnoracially and linguistically diverse older adults (Arch Clin Neuropsychol 2023;38:408-32). In this article, we discuss how culture and self-identities influence provider-patient communication and perioperative care for diverse older adults.

The term “cultural humility” is defined as a long-term commitment to foster equitable and mutually beneficial partnerships via openness and self-awareness (J Health Care Poor Underserved 1998;9:117-25). Under this paradigm, communication extends beyond conveying information. It provides a unique opportunity to provide patient-centered care by promoting active listening, recognizing how dissimilarities between provider and patient can affect care, and respecting patients’ cultural backgrounds, beliefs, and values. Cultural factors may influence patients’ attitudes toward treatment, decision-making processes, and help-seeking behaviors (J Commun Healthc 2023;16:186-96). With older adults, communication is multifaceted, involving the patient and family members in the context of historical factors, culture, and values.

Preoperative communication is essential to establishing a strong working alliance, which fosters preoperative optimization, intraoperative management, and postoperative recovery. It is common for patients to be labeled as “noncompliant,” when in fact ineffective communication and lack of comprehension of instructions are the culprit. In a recent patient encounter, a 67-year-old patient with end-stage renal disease secondary to type 2 diabetes was scheduled for fistula creation. At the time of his preoperative clearance visit with the primary care provider, his glucose was well controlled with a hemoglobin A1C of 6.7% on metformin. On the day of surgery, five weeks later, his glucose levels were >300 mg/dL. Using a phone interpreter, the anesthesiologist in the pretreatment unit ascertained that the patient had stopped taking his metformin and was labeled “medication noncompliant,” and concerns about his commitment to his well-being were raised. A second anesthesiologist, with syn-language fluency, interviewed the patient and learned that his teen daughter had acted as an interpreter during the preoperative clearance visit. When comparing the provider’s notes with the patient’s understanding, the praise he received for well-controlled diabetes led to the impression that he no longer had diabetes, and preoperative instructions to hold metformin before surgery led to the understanding that he no longer needed to take the medication. Reassessment of the patient’s symptoms revealed that in the two weeks prior to the surgery, the patient had experienced dizziness, lightheadedness, and forgetfulness. Communication devoid of context and culture led to cancellation of an outpatient procedure and subsequent hospitalization.

Adopting a cultural humility paradigm may prevent errors even when language is not a barrier. Anxiety regarding a procedure, poor hearing, and deference anchored in values have been involved in near-misses when an older adult, taught to respect their health care provider, nods in agreement when the wrong side is being marked for surgery. Integrating a cultural humility paradigm into care can also facilitate the identification of postoperative delirium, particularly hypoactive symptoms, and subclinical changes in cognition.

Improving communication by adopting a cultural humility paradigm can potentially improve surgical outcomes and promote cognitive health and psychological health (see Table). Engaging patients and their families as equitable partners in health care is empowering and may motivate patients to speak genuinely, resulting in treatment plans that align with their culture, beliefs, and values. Patients involved in the process of decision-making can help shape their postoperative care plan, which promotes treatment adherence, reduces anxiety, and supports patients’ overall well-being throughout the perioperative period. Moreover, communication delivered within a cultural humility paradigm can help identify and address barriers to care. By understanding cultural factors that may influence patients’ access to health care, professionals can implement strategies to overcome barriers and ensure equitable access to perioperative optimization programs. This approach reduces disparities in care, improves outcomes, and contributes to a more just health care system.


There is greater risk with surgery and anesthesia as we age. The older patient typically is complex, has multiple comorbidities, is on multiple medications, and often is more frail. Given these additional risks, it is incumbent on the perioperative physician to take additional precautions that are patient-centered, with age-focused interventions that mitigate risk, prevent harm, and improve cognitive health for our patients. Cultural competency is a critical component of maintaining brain health after anesthesia and surgery.