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.

Figure 1.

Risk Factors for Perioperative Neurocognitive Disorders. There are three types of factors to consider. 1. Predisposing Factors which encompass the baseline medical condition of the patient. 2. Surgery and Anesthesia Factors which are associated with the type of surgery and anesthetic factors. 3. Postoperative Factors include additional characteristics that occur during the course of hospitalization.

Figure 2.

A suggested template to consider when developing a perioperative care pathway for the older adult at risk for Perioperative Neurocognitive Disorders.

Figure 3.

Three-dimensional representation of lymphatic transport and drainage concept highlighting the periarterial and the perivenous space, and the astrocytic end-feet with aquaporin 4 (AQP4) water channels and forming a sheath around the blood vessels. Cerebrospinal fluid is driven by convection through the periarterial space and is propelled across the astroglia end-feet to mix with interstitial fluid and waste products. From there, the waste and excess fluids are driven towards the perivenous space to ultimately be directed towards the lymphatic vessels and general circulation for breakdown and clearance. The black particles represent “waste” particles in the interstitial fluid (e.g., amyloid beta). SubA = subarachnoid space; Oli = oligodendrocyte. Reproduced with permission.