#298 New APSF Brain Health Guidance For Older Adults

Postoperative delirium is one of the most common adverse events after surgery for older adults, and it can change a patient’s recovery, independence, and quality of life. We take a practical, evidence-focused look at what anesthesia teams can actually do to support perioperative brain health, using the latest recommendations from the APSF Brain Health Patient Safety Advisory Group.

We walk through the four questions clinicians keep asking at the bedside. First, does intraoperative hypotension drive delirium? We break down why the data is mixed, what mechanisms make hypotension plausible, and why individualized hemodynamic goals with rapid correction still belong in a modern patient safety strategy. Next, we tackle benzodiazepines and the Beers Criteria: newer trials and practice advisories suggest short-acting agents like midazolam and ultra-short-acting options like remimazolam do not need to be avoided solely to prevent postoperative delirium, while medication review, deprescribing, and cognitive screening remain essential.

From there, we get into anesthetic depth and intraoperative EEG monitoring. EEG guidance can reduce burst suppression and may help tailor dosing as part of precision anesthesia, but the evidence is still inconclusive on whether it prevents delirium in older adults. We close with the long-debated choice between general anesthesia and regional anesthesia, highlighting recent meta-analyses and trials showing no significant difference in delirium incidence once confounders are controlled, with a key nuance around avoiding excessive sedation.

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For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/298-new-apsf-brain-health-guidance-for-older-adults/

© 2026, The Anesthesia Patient Safety Foundation

Transcript

Key Takeaways Up Front

Alli 0:00

Do you want to make sure that your anesthesia practice is in line with the latest in perioperative patient safety? Here are a few key takeaways from the APSF Brain Health Patient Safety Advisory Group from 2025. You can adopt these strategies to help keep patients safe during anesthesia care. Number one, it is important to maintain optimal interoperative blood pressure with proactive and individualized management strategies to minimize the occurrence, severity, and duration of hypotension and its associated complications in older adults. Number two, preoperative doses of short acting, like midazolam, or ultra-short acting, like remimazolam, do not need to be avoided for the specific purpose of trying to minimize postoperative delirium. Number three, interoperative EEG monitoring is a useful adjunct to tailor anesthetic depth and support precision anesthesia by individualizing care where it may help minimize drug exposure. And finally, selection of anesthesia techniques, general anesthesia or regional anesthesia, does not significantly affect the incidence of postoperative delirium in older adults. Stay tuned as we discuss these important considerations and more on the show today. Hello and welcome back to the Anesthesia Patient Safety Podcast. I'm your host, Allie Bechtel. When I'm not podcasting about patient safety, I provide patient care as an anesthesiologist. Here's what we will be talking about today: postoperative delirium as a leading perioperative brain health risk. Before we dive further into the episode, we'd like to recognize PPM, a major corporate supporter of APSF. PPM has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, PPM. We wouldn't be able to do all that we do without you. Our featured article is from the October 2025 APSF newsletter. It is Perioperative Brain Health and Postoperative Delirium Prevention. Recommendations from the APSF Brain Health Patient Safety Priority Advisory Group by Ryan Field and colleagues. To follow along with us, head over to APSF.org and click on the newsletter heading. The fourth one down is Newsletter Archives. Then click on October 2025 and scroll down until you get to our featured article today. And I will include a link in the show notes as well. Let's start with some background about perioperative delirium, which is the most common adverse event after surgery for older adults. The incidence is as high as 65%. Post-op delirium is associated with longer hospital stay, increased morbidity and mortality, and distress for patients and their families. Brain health is one of the APSF patient safety priorities, and we've talked about it before on the podcast. If you get a chance, check out episodes number 164 and number 165, where we talked about the 2023 APSF article, Perioperative Brain Health, a patient safety priority all anesthesia professionals must address. This article included a guide to help create brain health implementation protocols. There are several evidence-based interventions that may help to reduce the risk for postoperative delirium, including preoperative cognitive screening, early mobilization, maintaining orientation, promoting sleep hygiene, ensuring the timely return of personal items such as glasses, hearing aids, and dentures after surgery, interoperative dexmedatominine use, and providing delirium education for healthcare professionals. Have you implemented these strategies at your hospital? Today, we are going to switch our focus to the impact of interoperative anesthetic management on brain health for older patients. There are new studies, conflicting results, and questions that anesthesia professionals may be struggling to answer. The APSF Perioperative Brain Health Patient Safety Advisory Group is here to help present the new findings and updated recommendations. We love talking about recommendations on the podcast, so this is really exciting to help improve patient safety and outcomes. Let's look at the impact of intraoperative hypotension, which is a possible modifiable risk factor for postoperative delirium in elderly or high-risk patients. We need to pay close attention to blood pressure, since cerebral autoregulation is blunted in elderly patients and those with vascular disease. Once the blood pressure drops, cerebral perfusion pressure decreases, especially when the mean arterial pressure or MAP falls below the lower autoregulatory limits of 50 to 60 millimeters of mercury. And when the blood pressure remains this low, sustained cerebral hypoperfusion can lead to neuronal dysfunction, blood-brain barrier breakdown, and neuroinflammation. And this sets the stage for the pathophysiology of delirium. So it starts with hypotension, leading to decreased cerebral blood flow and oxygen delivery, which may cause brain tissue injury, which may lead to the development of postoperative delirium. Now check out table one in the article for a review of seven studies that looked at the relationship between interoperative hypotension and postoperative delirium. As you can see, the evidence is mixed. Several retrospective studies found an association between interoperative hypotension and post-op delirium, but a prospective, randomized trial, a systemic review, and a meta-analysis and other retrospective studies did not. The authors report that the evidence more strongly suggests that interoperative hypotension may not be a primary cause of postoperative delirium. Keep in mind that this does not mean we don't need to remain vigilant when it comes to interoperative blood pressure monitoring with the goal to prevent hypotension. Limitations from these studies include variability and definitions of absolute and relative hypotension, as well as different patient populations. In addition, interoperative hypotension is a modifiable factor and thus it remains a reasonable prevention target. The ASA Practice Advisory for Perioperative Care of Older Adults Scheduled for Inpatient Surgery suggests that individualized hemodynamic goals with rapid correction of any hypotension. The APSF Brain Health Group agrees with this and recommends the following: maintain optimal interoperative blood pressure with proactive and individualized management strategies to minimize the occurrence, severity, and duration of hypotension and its associated complications in older adults. Going forward, we hope to see high-quality trials tackle this question of the impact of strict blood pressure control or autoregulation guided management on the development of postoperative delirium. Next, let's look at preoperative benzodiazepine use, starting with a review of the BIERS criteria. Have you heard of this? The BIERS criteria were first used to inform clinicians about medications to use with caution in nursing home residents. In 1997, it was expanded to include all older adults. There have been some important changes over time. In 2012, the American Geriatric Society became responsible to the BERS criteria and implemented evidence-based approaches to medications. The recommendations were updated in 2023 and continue to list benzodiazepines as potentially inappropriate for adults over the age of 65. This seems appropriate when it comes to neuroanesthesia and cognitive preservation. At many institutions, benzodiazepine administration preoperatively is avoided for this reason. We are going one step further in our discussion today. There is a limited scope for the BIERS criteria, since a lot of the evidence used groups all benzodiazepines together, including short and long-acting agents, outpatient and inpatient medicine, and a one-time dose versus chronic use. Plus, there are recent trials and new practice advisories. Let's return to the ASA Practice Advisory for Perioperative Care of Older Adults. The advisory discusses the impact of perioperative medications with central nervous system effects on postoperative cognitive dysfunction and outcomes, with the recommendation to weigh the risks and benefits of using these medications given the possible increased risk for postoperative delirium. There is no recommendation to avoid using short-acting benzodiazepines for older adults since newer data did not reveal a consistent link between midazolam and remimasolam and cognitive dysfunction or delirium. There is a recent prospective multi-center cohort study of over 5,600 patients, 65 years of age and older, who underwent non-cardiac surgery in China. There was no increased risk of postoperative delirium in patients who received midazolum compared to those who did not. There was no population in the study where midazolum use led to an increased risk for delirium based on subgroup analysis based on age, sex, ASA class, and comorbidities. There were lower rates of preoperative anxiety for patients who received midazolim, so that is something to keep in mind. Another study evaluated perioperative benzodiazepine use and delirium at 20 North American cardiac surgery centers. The study design was multi-period double-blinded cluster randomized crossover trial with almost 10,000 patients in each group, restricted or liberal benzodiazepine use periods. The results included delirium occurred in 14% of patients during the restricted periods and 14.9% of patients during the liberal periods. Thus, restricting benzodiazepine use during cardiac surgery did not decrease the incidence of delirium. I will include these citations in the show notes as well so you can check out these studies. Here are the summary recommendations from the APSF Brain Health Group for older adults. Review home medications regularly and desprescribe when appropriate to help reduce the risk of postoperative delirium. Preoperative doses of midazlam or remimaslam need not be avoided for the purpose of trying to minimize postoperative delirium, and cognitive screening should still be considered during the preoperative evaluation. Let's turn our attention to maintenance of anesthesia and impact of anesthetic depth and monitoring. Check out Table 2 in the article for a review of the literature. The Engages trial found that EEG guidance reduced EEG burst suppression but did not reduce the rate of delirium. The Engages Canada trial reported the incidence of delirium of 18.15% in the EEG guided group compared to 18.1% in the usual care group. And in a substudy of the balanced trial, there were lower rates of delirium with lighter anesthesia, which was abyss of 50, compared to abyss of 35. In the full balanced trial, there was no overall benefit for light compared to deep anesthesia. If we look closer at the substudy, these results may be due to patients with high frailty and preoperative risk factors for delirium and highlight the need for a population-based approach to anesthetic delivery. There may be benefits for EEG monitoring in the pediatric population. A 2025 randomized clinical trial of 177 patients published in JAMA Pediatrics by Mayasaka and colleagues reported lower incidence of emergence delirium, faster emergence, and shorter PACU stays in the EEG guided group compared to the standard 1 MAC of sevofluorine group. These findings may not translate into older adult populations, though. Going forward, we likely need more clinical trials to evaluate the use of raw EEG guided interoperative anesthetic titration compared to processed EEG values to detect and prevent birth suppression and evaluate the impact of postoperative delirium. For now, the APSF Brain Health Group agrees that for older adults, interoperative EEG monitoring is a useful adjunct to titrate the depth of anesthesia and help minimize drug exposure. But the evidence is inconclusive when it comes to interoperative EEG monitoring and prevention of postoperative delirium. We have time for one more topic today. So, does the choice of anesthetic technique have an impact on postoperative delirium? This question of general compared to regional anesthesia has been debated. There is a recent meta-analysis of 21 trials and almost 2 million patients that did not find a significant difference in delirium between general anesthesia and regional anesthesia groups once confounders were controlled. Interestingly, the RAGA trial of 950 patients found similar rates of delirium in patients who received general anesthesia compared to patients who received regional anesthesia without sedation. Plus, there is another meta-analysis of 10 randomized controlled trials with about 4,000 elderly patients undergoing hip fracture surgery, and there was no difference in post-op delirium rates between the general anesthesia groups compared to the neuraxial anesthesia groups. There is one small study of 114 elderly patients undergoing hip fracture surgery under spinal that showed decreased incidence of delirium in the light propofol sedation group compared to deep sedation. So it may be important to avoid excessive sedation. More work is needed in this area so that we can develop personalized plans for anesthesia care to help keep elderly patients safe. At this time, there are no significant differences in the incidence of post-op delirium or other delirium-related outcomes between regional anesthesia and general anesthesia groups. The APSF Brain Health Group agrees that for older adults, the anesthetic technique does not significantly affect the incidence of postoperative delirium. We hope that you will check out Table 3 in the article for all of the APSF Brain Health Group recommendations that we talked about on the show today. And I will include it in the show notes as well. We hope that you can use these recommendations the next time you provide anesthesia care for older adults. Remember, it is important to maintain optimal interoperative blood pressure to minimize complications. You don't need to avoid midazlium to help reduce the risk for delirium. EEG monitoring may be helpful, but the evidence is inconclusive. And your choice of general or regional anesthetic technique does not impact the incidence of postoperative delirium. Going forward, we are likely to see more research in this area and we'll need to update our recommendations so that we can continue to keep older adults safe during anesthesia care. If you have any questions or comments from today's show, please email us at podcast atapsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apf.org for detailed information and check out the show notes for links to all the topics we discussed today. That's it for today's episode. If this conversation sparked a thought or gave you something to take back to your practice, make sure you're subscribed so that you don't miss future episodes. You can listen wherever you get your podcasts, and sharing the show with a colleague really helps spread the word about improving patient safety in anesthesia. Thanks for listening. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.