Anesthesia and surgery affect everyone differently, but there is evidence that aging brains are more vulnerable to post-operative cognitive decline (POCD), which may include post-operative cognitive dysfunction, confusion or delirium. Post-operative delirium is the most common surgical complication for older adults, but it's preventable in up to 40% of all patients. Here are 4 tips from the American Society of Anesthesiologists' Brain Health Initiative to screen for and diminish confusion after surgery.

Who's at Risk for Cognitive Decline?

The incidence of post-op delirium ranges from 5 to 15%. However, with certain high-risk groups such as patients with hip fracture, the range can be between 16 to 62%. Can you predict who's at risk for cognitive deficit after surgery? Go to osmag.net/cX5YVe for a list of pre-op screening questions you can ask your elderly patients.

1Screen for cognitive deficit. The goal is to help your geriatric patients return to their pre-op cognitive baseline. Assessing your patients' mental function not only gives you a baseline to compare to after surgery, it also alerts you to patients who may have mild cases of cognitive impairment.

Your cognitive test can be as simple as asking 1 or 2 questions to assess the patient's mental function, or as involved as a neurocognitive test. A negative response to the question "Can you remember things you did 10 years ago?" warrants further cognitive testing. But if your patients are still doing The New York Times crossword in ink, they're probably not experiencing any cognitive impairments.

2Who's the patient's at-home caregiver? The signs of POCD might not emerge until after you've discharged an elderly patient. Confirm that there's a family member or friend observing senior patients after surgery to make sure their cognitive status is improving and they don't try to perform tasks, such as driving, before they're ready. Instruct the caregiver to report anything troubling to the patient's physician. The cognitive tests mentioned above also provide a baseline that your staff and your patient's caregivers should use to assess whether the patient is suffering from memory loss after surgery. It is obvious when someone is having true delirium after surgery, but hypoactive delirium can be more difficult to spot.

3Order post-surgical meds with care. There are clearly drugs that should be avoided if at all possible during the perioperative period. For example, we know that certain drugs, such as benzodiazepines and anticholineregic agents, increase a patient's risk of experiencing delirium after surgery. Here are some medication recommendations:

• Make sure that medications such as Benadryl aren't on your OR's easy-to-order medications list. At the facility where I work, we're working on a protocol that if an older patient screens positive for cognitive impairment, we plan to prompt the provider to consider other options before ordering Benadryl.
• Don't routinely give benzodiazepines as a presedative or sedation to patients 70 years and older. Benzodiazepine use is associated with post-operative delirium.
• Remove meperidine (Demerol) from order sets. Meperidine is a poor drug for control of pain in elderly patients because it is less likely to provide appropriate levels of pain control and because it can lead to delirium or seizures.
• Instruct elderly patients to check with their physician before taking medications after surgery that can affect their nervous system, such as those for anxiety, seizures, muscle spasms or sleep aids.

4Orient your patients. You can't reverse general anesthesia instantly — it leaves a trace after emergence. Remember back to your college days, finally falling asleep after pulling an all nighter. Sometimes you'd wake up in a darkened room and have no idea what time of day it was.

Help orient your patients and reduce confusion after they awake from anesthesia. You could instruct patients to pack familiar items or remind them via text alerts to bring them. Let your patients wear their hearing aids or glasses as soon as possible after the procedure. Tell your patient's at-home caregivers to tune in to the patient's favorite TV shows to orient them to what time of day it is.

Ensure perioperative brain health

Use the tips outlined here and download the "Key Questions to Ask Your Patients" (osmag.net/cX5YVe) to start the conversation about how to help your older patients get back to their cognitive baseline post-op and back to their everyday lives. We use the term "cognitive recovery."

I'm the chairman of the American Society of Anesthesiologists' Brain Health Initiative, which hopes to raise awareness for patients and their families to look for changes they may see after surgical discharge, such as confusion or memory loss. I encourage you to do the same while the patient is under your care. OSM