An Overview of Chinese Multidisciplinary Expert Consensus on Perioperative Brain Health in Elderly Patients
The rapidly aging population in China presents significant challenges for anesthesiologists, particularly in the context of perioperative brain health in elderly patients. Comorbidities and functional decline in this demographic increase the risk of cerebral complications, which can lead to long-term morbidity and a reduced quality of life post-surgery. To address these challenges, a multidisciplinary team in China has developed a consensus aimed at minimizing the negative impact of pre-existing conditions, facilitating brain function recovery after surgery, and improving overall postoperative outcomes in elderly patients. This consensus focuses on the most common central nervous system comorbidities and postoperative complications in the elderly, emphasizing the importance of maintaining brain health in this population.
The consensus covers several critical areas, including the prevention of postoperative stroke, delirium, and cognitive dysfunction, as well as the perioperative management of patients with Alzheimer’s disease (AD), Parkinson’s disease (PD), and obstructive sleep apnea (OSA). Additionally, it addresses the prevention and treatment of anxiety, depression, and insomnia in elderly patients undergoing surgery.
Strategies to Prevent Perioperative Stroke
Perioperative stroke, which includes both ischemic and hemorrhagic strokes, occurs in approximately 0.1% to 1% of cases, with the majority being ischemic. Common predisposing factors include advanced age, a history of stroke, atrial fibrillation, and vascular and metabolic diseases. To reduce the risk of perioperative stroke, it is essential to optimize the patient’s medical conditions before surgery, particularly for those with chronic diseases.
Regional anesthesia may lower the incidence of perioperative stroke in patients undergoing limb surgeries. It is crucial to avoid dehydration, hypotension, hyperglycemia or hypoglycemia, and low hemoglobin levels (below 70 g/L). Maintaining blood pressure near preoperative baseline levels can also help reduce the risk. Intraoperative monitoring techniques such as transcranial Doppler sonography and regional cerebral oxygenation monitoring may be beneficial. For diabetic patients, stringent glycemic control is necessary, with a target intraoperative glucose range of 7.8 to 10.0 mmol/L.
Early diagnosis and proper management of postoperative stroke are vital. Screening for suspected stroke should be conducted promptly using the National Institutes of Health Stroke Scale, radiological examination, and neurology consultation.
Definitions and Preventions of Perioperative Neurocognitive Disorders (PND)
Perioperative neurocognitive disorders (PND) encompass a range of cognitive impairments, including postoperative delirium (POD), delayed neurocognitive recovery (up to 30 days), and postoperative neurocognitive disorders (up to 12 months). POD is characterized by acute fluctuations in mental status within one week after surgery, manifesting as disturbances in attention, cognition, and consciousness. PND is associated with increased hospital stays, higher care costs, elevated readmission rates, prolonged cognitive impairment, and higher mortality.
Preoperative neurocognitive assessment is recommended for high-risk patients. For those with pre-existing cognitive impairment, multiple therapeutic interventions such as nutritional supplements, physical exercises, and cognitive training should be implemented. Perioperative use of anticholinergics and benzodiazepines should be avoided. Regional anesthesia is preferred for patients at high risk for PND. Dexmedetomidine offers potential neuroprotective benefits over other sedatives. For general anesthesia, propofol-based total intravenous anesthesia (TIVA) is recommended. Intraoperative hemodynamic management should aim to keep blood pressure within 20% of baseline and maintain hemoglobin levels above 100 g/L in critically ill patients. Multimodal analgesia should be used to reduce opioid consumption. Postoperative neurocognitive reassessment with neuropsychological tests is useful for identifying new-onset cognitive impairment. Non-benzodiazepine sedatives such as propofol and dexmedetomidine may reduce the risk of POD in patients transferred to the intensive care unit. Intravenous haloperidol and dexmedetomidine can be used to manage delirium with severe agitation.
Management of Patients with Parkinson’s Disease (PD)
Patients with PD are prone to immobility, respiratory dysfunction, and psychiatric symptoms, necessitating comprehensive preoperative assessment. Maintaining established medication regimens for PD helps prevent symptom exacerbation. Opioids with serotonin reuptake inhibitory activity (e.g., pethidine and tramadol) and selective serotonin reuptake inhibitors should be avoided in patients taking monoamine oxidase-B inhibitors. For patients with severe dyskinesia, general anesthesia with tracheal intubation is recommended. Non-steroidal anti-inflammatory drugs are preferred over opioids for postoperative analgesia. Anti-parkinsonian medications, except monoamine oxidase B inhibitors, should be resumed as soon as possible after surgery. Serotonin receptor antagonists such as ondansetron are preferred over dopamine antagonists for preventing nausea and vomiting. For PD patients with postoperative psychiatric disturbances, clozapine and quetiapine may be used to treat hallucinations and delusions.
Management of Patients with Alzheimer’s Disease (AD)
AD is the most common form of dementia and is associated with postoperative cognitive decline. Preoperative 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 necessary, 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 postoperative complications such as delirium.
Management of Patients with Anxiety and/or Depression
Anxiety and depression are common psychiatric disorders in elderly patients and should be assessed preoperatively. Non-pharmacological interventions are recommended as initial treatment for transient preoperative depression. Psychiatric consultation should be considered for patients with moderate or severe anxiety. Drug interactions between antidepressants and anesthetics, as well as potential side effects, should be carefully evaluated. It is crucial to identify patients at increased risk of self-harm or suicide.
Perioperative Considerations for Patients with Insomnia
Insomnia is prevalent in the geriatric population. Diagnosis is based on a history of sleep disorders and objective sleep studies such as polysomnography. The severity of insomnia, comorbidities, and current medications should be assessed preoperatively. Long-acting benzodiazepines may exert additive effects on anesthetics and opioids and should be avoided preoperatively. General anesthetics should be titrated based on depth of anesthesia monitoring. Non-pharmacological approaches should be considered as initial therapy for postoperative insomnia.
Perioperative Concerns for Patients with Obstructive Sleep Apnea (OSA)
Patients with OSA are at increased risk for perioperative pulmonary and cardiovascular complications. The Stop-Bang questionnaire can be used to identify patients with OSA. Continuous positive airway pressure therapy and other preoperative interventions should be initiated for patients with severe OSA. Regional anesthesia should be considered whenever possible. General anesthesia with a secured airway is favored over deep sedation with an unsecured airway. Complete reversal of neuromuscular blockade should be verified before extubation. Implementation of a surveillance system with pulse oximetry is required in the early postoperative period. A multimodal analgesic approach is recommended after surgery to reduce the demand for opioids.
This comprehensive consensus provides detailed guidance on perioperative brain health in elderly patients, addressing various conditions and complications to improve outcomes and quality of life in this vulnerable population.
doi.org/10.1097/CM9.0000000000001213
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