An Overview of Chinese Multidisciplinary Expert Consensus on Perioperative Brain Health in Elderly Patients

In today’s world, with the increasing aging population, the challenges faced by anesthesiologists in dealing with elderly patients are becoming more and more prominent. Comorbidities and functional decline in these patients can significantly increase the risks of cerebral complications, which may lead to long-term morbidity and a reduced quality of life after surgery. This makes it crucial to implement effective perioperative brain protection strategies for geriatric patients.

Goals for Developing This Consensus

The Chinese multidisciplinary team behind this consensus aimed to address these challenges. Their goals were to minimize the negative impact of pre-existing comorbidities, facilitate brain function recovery after surgery, and improve the overall post-operative outcomes in elderly patients. The consensus focuses on the most common central nervous system comorbidities and post-operative complications in the elderly, emphasizing the need for greater concern in maintaining brain health for this population. It delves into various issues such as the prevention of post-operative stroke, delirium, and cognitive dysfunction, as well as the perioperative management of patients with specific conditions like Alzheimer disease (AD), Parkinson disease (PD), obstructive sleep apnea (OSA), and the prevention and treatment of anxiety, depression, and insomnia.

Strategies to Prevent Perioperative Stroke

Perioperative stroke is a significant concern. The incidence of perioperative stroke ranges from approximately 0.1% to 1%. While it includes both ischemic and hemorrhagic strokes, the majority are ischemic. Common predisposing factors include advanced age, a previous stroke, atrial fibrillation, and vascular and metabolic diseases. For patients with chronic diseases, optimizing their medical conditions before surgery is essential. Regional anesthesia may reduce the incidence of perioperative stroke for patients undergoing limb surgeries. Dehydration, hypotension, hyper or hypoglycemia, and a low hemoglobin level (<70 g/L) should be avoided. Maintaining blood pressure near pre-operative baseline levels can help lower the risk. Intra-operative transcranial Doppler sonography and regional cerebral oxygenation monitoring may be beneficial. For diabetic surgical patients, more stringent glycemic control is needed, with the target of intraoperative glucose ranging from 7.8 to 10.0 mmol/L. Timely screening for suspected stroke using tools like the National Institutes of Health Stroke Scale, radiological examination, and neurology consultation is vital for early diagnosis and proper management of post-operative stroke.

Definitions and Preventions of Perioperative Neurocognitive Disorders (PND)

Post-operative delirium (POD) is a state of acute fluctuations in mental status within 1 week after surgery, manifested by acute disturbances in attention, cognition, and consciousness. PND encompasses cognitive impairments identified in the pre-operative period, POD, delayed neurocognitive recovery (up to 30 days), and post-operative neurocognitive disorders (up to 12 months). PND is associated with increased length of stay, elevated care expenditure, increased hospital readmission rates, prolonged cognitive impairment and dementia, and higher mortality. PNDs are the most frequent post-operative complications in elderly patients, especially those with frailty and pre-existing cognitive impairment. Pre-operative neurocognitive assessment should be performed for high-risk patients. For those with pre-existing cognitive impairment, multiple therapeutic interventions such as nutritional supplements, physical exercises, and cognitive training are recommended. Anticholinergics and benzodiazepines should be avoided perioperatively. Regional anesthesia is the preferred anesthesia technique for high-risk PND patients. Dexmedetomidine has potential neuroprotection benefits over other sedatives. For general anesthesia, propofol-based total intravenous anesthesia (TIVA) is recommended. In intraoperative hemodynamic management, keeping patients’ blood pressure within 20% from baseline and maintaining the hemoglobin level above 100 g/L in critically ill patients is suitable. Multimodal analgesia should be implemented to reduce opioids consumption. Post-operative neurocognitive reassessment with neuropsychological tests is useful to identify new-onset cognitive impairment. Non-benzodiazepine sedatives like propofol and dexmedetomidine may reduce the risk of POD for patients transferred to the intensive care unit. Intravenous haloperidol and dexmedetomidine can be used for the management of delirium with severe agitation.

Management of Patients with PD

Patients with PD are prone to developing immobility, respiratory dysfunction, and psychiatric symptoms, so comprehensive pre-operative assessment is needed. Maintaining their established PD medication regimens helps prevent symptom exacerbation. Opioids with serotonin reuptake inhibitory activity (pethidine and tramadol) and selective serotonin reuptake inhibitors should be avoided in those taking monoamine oxidase-B inhibitors. For patients with severe dyskinesia, general anesthesia with tracheal intubation is recommended. Non-steroidal anti-inflammatory drugs are preferred as an alternative to opioids for post-operative analgesia. Anti-parkinsonian medications, except monoamine oxidase B inhibitors, should be resumed as soon as possible after surgery. Serotonin receptor antagonists like ondansetron are preferred over dopamine antagonists to prevent nausea and vomiting. For PD patients with post-operative psychiatric disturbances, clozapine and quetiapine may be used to treat hallucinations and delusions.

Management of Patients with AD

AD is the most common form of dementia and is associated with post-operative cognitive decline. Pre-operative assessment of cognitive function and depression is recommended for AD patients. Regional anesthesia is preferred over general anesthesia for limb surgeries. If general anesthesia is performed, TIVA with propofol and remifentanil is recommended, and drugs that may aggravate cognitive impairment should be avoided. A multimodal approach may reduce the incidence of post-operative complications like delirium.

Management of Patients with Anxiety and/or Depression

Anxiety and depression are common psychiatric disorders in elderly patients and should be assessed pre-operatively. Non-pharmacological interventions are recommended as initial treatment for transient pre-operative depression. Psychiatric consultation should be considered for patients with moderate or severe anxiety. Drug interactions between antidepressants and anesthetics, and potential side effects should be checked. Identifying patients with an increased risk of self-harm or suicide is crucial.

Perioperative Considerations for Patients with Insomnia

Insomnia is prevalent in the geriatric population. The diagnosis is based on the history of sleep disorders and objective sleep studies like polysomnography. The severity of insomnia, comorbidities, and current medications should be assessed pre-operatively. Long-acting benzodiazepine may have additive effects on anesthetics and opioids and should be avoided pre-operatively. General anesthetics should be titrated based on depth of anesthesia monitoring. Non-pharmacological approaches should be considered as the initial therapy for post-operative insomnia.

Perioperative Concerns for Patients with OSA

Patients with OSA are at an increased risk for perioperative pulmonary and cardiovascular complications. The Stop-Bang questionnaire can be used as a concise tool to identify OSA patients. Continuous positive airway pressure therapy and other pre-operative interventions should be initiated if patients have severe OSA. The use of regional anesthesia should be considered whenever possible. General anesthesia with a secured airway is favored over deep sedation with an unsecured airway. A complete reversal of neuromuscular blockade should be verified before extubation. Implementation of a surveillance system with pulse oximetry is required in the early post-operative period. A multimodal analgesic approach is recommended after surgery to reduce the demand for opioids.

This consensus, developed by experts from renowned institutions such as the Department of Anesthesiology, Peking University Third Hospital, the Department of Anesthesiology and Operating Theater, Xuanwu Hospital, Capital Medical University, and the Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, provides valuable guidelines for anesthesiologists and healthcare providers dealing with elderly patients. It is based on scientific research and clinical experience, aiming to improve the perioperative care and outcomes of this vulnerable population. For more detailed information, the full consensus can be accessed through the provided DOI: 10.1097/CM9.0000000000001213.

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