Adults age 65 and older ("older adults") are the fastest growing segment of the United States population, and their number is expected to double to 89 million between 2010 and 2050. 1 Based on these evolving demographics, it is expected that there will be a concurrent rise in the demand for a variety of surgical services, including vascular surgery (with a projected growth of 31%) and general surgery (with a projected growth of 18%). 2 Older adult surgical patients often require a different level of care than younger patients during the perioperative period. Many have multiple chronic illnesses other than the one for which surgery is required, and therefore are prone to developing postoperative complications, functional decline, loss of independence, and other untoward outcomes. In order to provide optimal care for the older surgical patient, a thorough assessment of the individual's health status and a plan of care during the perioperative period designed to look for and address any identified deficits is essential. To assist clinicians with this assessment and subsequent care, in 2010, the American College of Surgeons (ACS) partnered with the American Geriatrics Society (AGS) and the John A Hartford Foundation to develop guidelines for the optimal surgical care of older adults. The first part of these guidelines, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)/American Geriatrics Society (AGS) Best Practices Guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient 3 was published in 2012. This resource defined 9 assessment categories: cognitive/behavioral disorders, cardiac evaluation, pulmonary evaluation, functional/performance status, frailty, nutritional status, medication management, patient counseling, and preoperative testing. The second part of these guidelines, presented here, targets the rest of the perioperative period, beginning in the immediate preoperative period and extending through the postoperative period and discharge transition. These guidelines build on the domains of geriatric care and proposed geriatric competencies established by previous work and are designed to provide a framework for thinking about the complex issues around perioperative care in this patient population. 4,5 GERIATRIC SURGERY EXPERT PANEL, LITERATURE REVIEW, AND GUIDELINES DEVELOPMENT Similar to the preoperative assessment guidelines, the optimal perioperative management guidelines leveraged the expertise of a 28-member, multidisciplinary panel representing the American College of Surgeons (ACS), American Society of Anesthesiologists, American Geriatrics Society (AGS), the ACS Geriatric Surgery Task Force, and the AGS Geriatrics for Specialists Initiative. This document is divided conceptually into 3 domains: the immediate preoperative, intraoperative, and postoperative periods. A literature review of MEDLINE was performed for each domain in order to identify systematic reviews, metaanalyses, practice guidelines, and clinical trials between

The postoperative delirium in older adults guideline project was initiated by selecting an interdisciplinary, multi-specialty 23 member panel. The panel was chosen by the American Geriatrics Society's Geriatrics-for-Specialists Initiative (AGS-GSI) council with additional input from the panel co-chairs, with the goal of selecting participants with special interest and expertise in postoperative delirium. Represented disciplines included the fields of geriatric medicine, general surgery, anesthesiology, emergency medicine, geriatric surgery, gynecology, hospital medicine, critical care medicine, neurology, neurosurgery, nursing, obstetrics and gynecology, orthopedic surgery, ophthalmology, otolaryngology, palliative care, pharmacy, psychiatry, physical medicine and rehabilitation, thoracic surgery, urology, and vascular surgery.Additional ex officio panel members included a representative from the National Committee for Quality Assurance (NCQA), a quality measures expert, and a caregiver representative. The following panel members served on the writing group for this best practices statement: Stacie Deiner, MD;Conflicts of interest were disclosed initially and updated three times during guideline development. Disclosures were reviewed by the entire panel and potential conflicts resolved by the co-chairs (see Appendix 1). LITERATURE REVIEWThe methods for postoperative delirium risk factors, screening (case finding), and diagnosis (Table 1, Topics I to III) were distinct from the other aims, because these topics were thoroughly addressed in recent high-quality guideline statements and systematic reviews upon which the recommendation statements in these sections were based. 4,20-22 Additionally, these topics were considered outside the scope of the main literature search, which focused on prevention and treatment of delirium in the perioperative setting. Key citations were included in the section summaries. Sections were drafted by panel groups and then refined with the committee co-chairs. Subsequently, full consensus of the panel was achieved for all recommendation statements and summary sections.The methods for the literature search for the aims addressing the pharmacologic and nonpharmacologic interventions for the prevention or treatment of postoperative delirium in older adults (Table 1, Topics IV to X) included comprehensive searches, targeted searches, and focused searches. A more detailed description of the search methods is found in the accompanying clinical guideline document. 19 Comprehensive searches (1988( to December 2013 in PubMed, Embase, and CINAHL used the search terms delirium, organic brain syndrome, and acute confusion and resulted in a total of 6,504 articles. Additional, alternative terms included for the prevention and treatment of delirium were the words prevention, management, treatment, intervention, therapy, therapeutic, and drug therapy. Two additional targeted searches using the U.S. Library of National Medicine PubMed Special Queries on Comparative EffectivenessResearch and PubMed Cli...