The American Society of Anesthesiologists (ASA) has published a practice advisory for perioperative care of adults aged 65 and older undergoing inpatient surgery in the January 2025 issue of Anesthesiology.

According to demographic projections cited in the advisory, the U.S. population of adults aged 65 and older will increase from 46 to 98 million over 30 years. This age group currently undergoes more than 30% of inpatient surgeries while representing 15% of the total population.

The advisory committee reviewed literature published between January 2000 and October 2023 to develop four recommendations:

• The first recommendation suggests expanded preoperative evaluation including cognitive and frailty screening for older adults scheduled for inpatient procedures. When screening identifies cognitive impairment or frailty, the advisory indicates implementing multidisciplinary care teams and geriatric specialist involvement.
• The second recommendation, supported by moderate-strength evidence, states either neuraxial or general anesthesia can be selected when clinically appropriate, as research showed no difference in postoperative delirium rates between techniques.
• The third recommendation indicates either total intravenous or inhaled anesthesia is acceptable for general anesthesia in older patients.
• The fourth recommendation states dexmedetomidine may reduce postoperative delirium risk while noting its effects on bradycardia and hypotension. This recommendation stems from 31 randomized trials showing lower delirium rates with dexmedetomidine versus placebo.

The advisory includes a best practice statement regarding medications with central nervous system effects and their potential to increase postoperative delirium risk.

The committee excluded recommendations on anesthesia depth monitoring and postoperative pain management, citing insufficient or conflicting evidence in older adults.

Research cited in the advisory found 19% of patients aged 80-89 years and 26% of those 90 years or older showed functional decline 30 days after surgery. Additionally, 35% of older adults who developed new disabilities showed no recovery after 6 months.

The advisory committee identified areas needing additional research, including prehabilitation programs and interventions following preoperative screening.

The practice advisory development involved anesthesiologists specializing in geriatric care, a geriatrician, a geriatric surgeon, a patient representative, and epidemiology-trained methodologists. All task force members disclosed potential conflicts of interest.