Episode #298 New APSF Brain Health Guidance For Older Adults

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.

1. It is important to maintain optimal intraoperative blood pressure, with proactive and individualized management strategies to minimize the occurrence, severity, and duration of hypotension and its associated complications in older adults
2. 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.
3. Intraoperative EEG monitoring is a useful adjunct to tailor anesthetic depth and support precision anesthesia by individualizing care, where it may help minimize drug exposure.
4. Selection of anesthesia techniques (GA or RA) 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, Alli Bechtel. When I’m not podcasting about patient safety, I provide patient care as an anaesthesiologist. 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 today, 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. 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%. Postop 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 have talked about it before on this podcast. If you get a chance, check out episodes #164 and #165 where we talked about the 2023 ASPF 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, intraoperative dexmedetomidine use, and providing delirium education for health care professionals. Have you implemented these strategies at your hospital?

Today, we are going to switch our focus to the impact of intraoperative anaesthetic 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 MAP falls below the lower autoregulatory limits of 50-60mmHg. 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. Check out Table 1 in the article for a review of 7 studies that looked at the relationship between intraoperative hypotension and postoperative delirium. As you can see, the evidence is mixed. Several retrospective studies found an association between intraoperative hypotension and postop delirium, but a prospective randomized trial, a systemic review and meta-analysis and other retrospective studies did not. The authors reports that the evidence more strongly suggests that intraoperative hypotension may NOT be a primary cause of postoperative delirium.

Keep in mind that this does mean that we don’t need to remain vigilant when it comes to intraoperative blood pressure monitoring with the goal to prevent hypotension. Limitations from these studies include variability in definitions of absolute and relative hypotension as well as different patient populations. In addition, intraoperative 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 intraoperative 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 questions 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 Beers Criteria. Have you heard of this? The Beers 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 Geriatrics Society became responsible to the Beer Criteria and implemented evidenced-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 neuro-anesthesia 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 Beer Criteria since a lot of the evidenced used groups all benzodiazepines together including short and long acting agents, outpatient and inpatient medicine, and one time dose versus chronic use. Plus, there are recent trials and new practice advisories.

Let’s return to the ASA Practice Advisory for Periop 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 Remimazolam and cognitive dysfunction or delirium. There is a recent prospective, multicentre 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 midazolam compared to those that did not. There was no population in this study where Midazolam 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 Midazolam, 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 multiperiod, 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 deprescribe when appropriate to help reduce the risk of postoperative delirium.
• Preoperative doses of midazolam or remimazolam need not be avoided if specifically trying to minimize postoperative delirium.
• 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 the 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 sub-study of the BALANCED trial, there were lower rates of delirium with lighter anesthesia which was a BIS of 50 compared to a BIS of 35. In the full BALANCED trial there was no overall benefit for light compared to deep anesthesia. If we look closer at the sub-study, 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 Miyasaka 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 sevoflurane group. These findings may not translate into older adult populations. Going forward, we likely need more clinical trials to evaluate the use of raw EEG-guided intraoperative anesthetic titration compared to processed EEG values to detect and prevent burst suppression and evaluate the impact on postoperative delirium. For now, the APSF Brain Health Group agrees that for older adults intraoperative EEG morning is a useful adjunct to titrate the depth of anesthesia and help minimize drug exposure, but the evidence is inconclusive when it comes to intraoperative EEG monitoring and prevention of postoperative delirium.

We have time for one more topic today. Does the choice of anaesthetic technique have an impact on postop 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 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 postop 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 patients safe. At this time, there are no significant differences in the incidence of postop 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 intraoperative blood pressure to minimize complications, you don’t need to avoid midazolam to help reduce the risk for delirium, EEG-monitoring may be useful, 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 will 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 [email protected]. 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 APSF.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 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.

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