Perioperative Brain Health in the Older Adult: A Patient Safety Imperative

Abstract

While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.

Cognitive impairment and its adverse outcomes in older surgical patients: an under-recognized problem!

“…Cortical atrophy predominately occurs in the prefrontal cortex and the hippocampus, which are regions associated with higher-order cognitive abilities. This may reflect the aging-associated decline in processing speed, memory, reasoning, attention, and executive function 3,8. These cognitive domains are regarded as fluid abilities, which are critical for performing daily activities independently 8,9.…”

“…7 Notably, the aging brain undergoes extensive structural alterations, such as atrophy, neurotransmitter imbalances, and deterioration of the blood-brain barrier. 3 Cortical atrophy predominately occurs in the prefrontal cortex and the hippocampus, which are regions associated with higher-order cognitive abilities. This may reflect the aging-associated decline in processing speed, memory, reasoning, attention, and executive function.…”

“…This may reflect the aging-associated decline in processing speed, memory, reasoning, attention, and executive function. 3,8 These cognitive domains are regarded as fluid abilities, which are critical for performing daily activities independently. 8,9 Conversely, crystallized abilities, which are cumulative skills and knowledge acquired in life such as verbal ability and general knowledge, are more resistant to decline with age.…”

“…27 Despite guideline recommendations, preoperative cognitive assessments are not routinely implemented due to multiple barriers alluded to previously. 3 Current preoperative evaluations typically focus on examinations of end-organ functions, such as the cardiac, pulmonary, hepatic, and renal systems with limited attention given to brain health. 32 The lack of documentation of baseline cognitive status may lead to under-detection of CI and missed opportunities for early intervention.…”

“…The susceptibility of older individuals to develop CI partly derives from the complexity of the aging process. Aging involves inflammatory and physiological changes across multiple organ systems including the brain, rendering the older population more vulnerable and less resilient to future inflammatory insults 3…”