Older Adults
Elizabeth Briand
Each year, adults aged 65 and older undergo more than 30% of all inpatient and outpatient surgeries in the United States, despite accounting for only 15% of the country’s population. With the number of older adults expected to double to nearly 100 million in the next 30 years, the need to improve perioperative care for this age group is a significant priority—especially for the anesthesiologists who play such an important role in those surgeries.
The American Society of Anesthesiologists issued a practice advisory in early 2025 for the perioperative care of older adults scheduled for inpatient surgery. The advisory provides evidence-based recommendations to manage care for this age group, a population traditionally at much greater risk for adverse postoperative outcomes compared with their younger counterparts.
Risks for older adults
For older patients facing surgery, frailty is associated with a two- to fivefold greater risk of complications, mortality, non-home discharge, and development of a new disability, according to the practice advisory.
Frailty is a common issue for older adults, consisting of a physiological decline that causes an increased vulnerability to adverse health outcomes. Key features of frailty include decreased walking speed, reduced muscle strength, reduced endurance, fatigue, unintentional weight loss, and decreased physical reserve.
Preoperative frailty is also one of the strongest predictors of postoperative delirium, which causes a sudden change in mental status, causing confusion and disorientation, said authors of the practice advisory.
“Post-op delirium is associated with many poor outcomes after surgery, including longer hospital stays and higher medical costs,” said Karen Domino, MD, professor of anesthesiology and pain medicine at the University of Washington. “Patients with post-op delirium are less likely to be able to go home after surgery and more often need care in a nursing home or rehab facility.”
Delirium is more likely in older patients with mild cognitive impairment or frailty.
“The delirium is thought to occur due to an inflammatory response to the surgery,” Domino said. “This causes some damage to the blood brain barrier.”
She said the brain inflammation may further damage the brain and lead to a decline in cognitive functioning in some patients.
“It is unclear if the delirium further damages the brain or is just a marker of brain inflammation, as sometimes it is associated with further cognitive decline,” Domino said.
Approaches to reducing postoperative vulnerabilities
While every patient is different, there are certain approaches to surgical care that may result in improved outcomes for older patients. This includes enhanced preoperative evaluations that can pinpoint potential problem areas during and after procedures.
“Preoperative identification and proactive treatment of frailty, malnutrition, mild cognitive impairment, and anemia improves surgical outcomes,” said Domino. “[With these assessments], patients and families can be warned in advance about post-op cognitive problems and plan accordingly with more help at home for their loved one.”
Preparing in advance for a surgery—almost like prepping for an athletic event—may also be an option for patients.
“Prehabilitation is an excellent way to improve surgical outcomes and has been mostly studied in patients undergoing cancer surgery and orthopedic surgery,” said Domino. The process involves working toward improvements in fitness and nutrition before a procedure. Recent research even suggests that brain prehabilitation may reduce cognitive issues post-surgery.
As part of multidisciplinary care teams, hospital-based pharmacists can play a significant role in helping to alleviate risks for surgical patients. In particular, issues related to polypharmacy can put patients at greater risk of reduced outcomes, with the potential of different medications and adverse effects interacting to cause adverse results.
“Polypharmacy of unnecessary medications is associated with post-op delirium and other problems in older patients,” Domino said. “These medications are often prescribed by multiple providers, may not be necessary, and may interact with post-op medications. Examples include benzodiazepines such as Xanax and Valium.”
With so many older Americans approaching an age when surgical care may become necessary, more research into the perioperative needs of older patients could improve overall outcomes. This includes looking at the root causes of post-op delirium and cognitive decline as well as how preventative care such as prehabilitation can help patients recover more quickly and fully. ■