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

Kenneth Boockvar, MD, MS 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; and (3) tailoring treatments to the patient’s goals, especially when there may be tradeoffs (eg, length versus quality of life). 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). Second, attention is growing to surgical and anesthesia complications that are particularly common and dangerous in older adults such as delirium and cognitive loss. 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. 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. 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. 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, 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