Perioperative management of the older patient

With an ageing population, anaesthetists have increasing importance in taking care of the elderly undergoing surgery. Physiological changes, comorbidities, frailty and cognitive dysfunction conduce to adverse outcomes, institutionalization and mortality. This article looks into the physiological changes and anaesthetic considerations in the older patients. Preoperative assessment including use of the Comprehensive Geriatric Assessment, frailty, nutritional and cognitive assessments will be discussed. Prehabilitation can potentially modify frailty, improve outcome and reduce length of hospitalization. Preoperative nutritional therapy, where indicated, can improve nutritional status and reduce complications.Two important complications to avoid in the elderly are perioperative neurocognitive disorder (PND) and postoperative acute kidney injury (PO-AKI). PND is a predictor of poor outcome including mortality. Intraoperative electroencephalogram monitoring may help to decrease the incidence of delirium. PO-AKI is a common morbidity in elderly and its incidence can be reduced by appropriate fluid therapy and drug choice.     

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.     

Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery—2018

Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions.Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that ‘perioperative neurocognitive disorders’ be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).     

Peri-operative optimisation of elderly and frail patients: a narrative review

With increasing life expectancy and technological advancement, provision of anaesthesia for elderly patients has become a significant part of the overall case-load. These patients are unique, not only because they are older with more propensity for comorbidity but a decline in physiological reserve and cognitive function invariably accompanies ageing; this can substantially impact peri-operative outcome and quality of recovery. Furthermore, it is not only morbidity and mortality that matters; quality of life is also especially relevant in this vulnerable population. Comprehensive geriatric assessment is a patient-centred and multidisciplinary approach to peri-operative care. The assessment of frailty has a central role in the pre-operative evaluation of the elderly. Other essential domains include optimisation of nutritional status, assessment of baseline cognitive function and proper approach to patient counselling and the decision-making process. Anaesthetists should be proactive in multidisciplinary care to achieve better outcomes; they are integral to the process.     

Effects of surgery and general anaesthesia on sleep–wake timing: CLOCKS observational study

Surgery and general anaesthesia have the potential to disturb the body’s circadian timing system, which may affect postoperative outcomes. Animal studies suggest that anaesthesia could induce diurnal phase shifts, but clinical research is scarce. We hypothesised that surgery and general anaesthesia would result in peri-operative changes in diurnal sleep–wake patterns in patients. In this single-centre prospective cohort study, we recruited patients aged ≥18 years scheduled for elective surgery receiving ≥30 min of general anaesthesia. The Munich Chronotype Questionnaire and Pittsburgh Sleep Quality Index were used to determine baseline chronotype, sleep characteristics and sleep quality. Peri-operative sleeping patterns were logged. Ninety-four patients with a mean (SD) age of 52 (17) years were included; 56 (60%) were female. The midpoint of sleep (SD) three nights before surgery was 03.33 (55 min) and showed a phase advance of 40 minutes to 02.53 (67 min) the night after surgery (p < 0.001). This correlated with the midpoint of sleep three nights before surgery and was not associated with age, sex, duration of general anaesthesia or intra-operative dexamethasone use. Peri-operatively, patients had lower subjective sleep quality and worse sleep efficiency. Disruption started from one night before surgery and did not normalise until 6 days after surgery. We conclude that there is a peri-operative phase advance in midpoint of sleep, confirming our hypothesis that surgery and general anaesthesia disturb the circadian timing system. Patients had decreased subjective sleep quality, worse sleep efficiency and increased daytime fatigue.     

Anaesthesia for major orthopaedic surgery in the elderly

This article addresses three specific issues related to major hip and knee surgery in the elderly. Firstly, the importance of thorough pre-operative evaluation is discussed. Secondly, the pros and cons in the immediate peri-operative period of major regional (spinal or epidural) anaesthesia versus general anaesthesia are reviewed with respect to blood loss, cardiovascular and respiratory function and immunological and metabolic responses to surgery. Finally, the evidence for an anaesthetic technique effect on outcome parameters, especially thromboembolism, cognitive function and mortality, is presented. Regional anaesthesia is the method of choice for most patients undergoing elective hip surgery since it results in reduced blood loss and transfusion needs, modification of the neuro-endocrine stress response, improved early postoperative oxygenation, and a reduced incidence of deep vein thrombosis (DVT) postoperatively. In the surgery of fractures of the neck of femur, outcome with regional anaesthesia is at least comparable to that with general anaesthesia, but with improved early postoperative oxygenation and a smoother emergence from anaesthesia making initial nursing management easier. Comparative data in other forms of orthopaedic surgery in the elderly are few, but also support the use of regional techniques.     

Predicting severe pain after major surgery: a secondary analysis of the Peri-operative Quality Improvement Programme (PQIP) dataset

Acute postoperative pain is common, distressing and associated with increased morbidity. Targeted interventions can prevent its development. We aimed to develop and internally validate a predictive tool to pre-emptively identify patients at risk of severe pain following major surgery. We analysed data from the UK Peri-operative Quality Improvement Programme to develop and validate a logistic regression model to predict severe pain on the first postoperative day using pre-operative variables. Secondary analyses included the use of peri-operative variables. Data from 17,079 patients undergoing major surgery were included. Severe pain was reported by 3140 (18.4%) patients; this was more prevalent in females, patients with cancer or insulin-dependent diabetes, current smokers and in those taking baseline opioids. Our final model included 25 pre-operative predictors with an optimism-corrected c-statistic of 0.66 and good calibration (mean absolute error 0.005, p = 0.35). Decision-curve analysis suggested an optimal cut-off value of 20–30% predicted risk to identify high-risk individuals. Potentially modifiable risk factors included smoking status and patient-reported measures of psychological well-being. Non-modifiable factors included demographic and surgical factors. Discrimination was improved by the addition of intra-operative variables (likelihood ratio χ² 496.5, p < 0.001) but not by the addition of baseline opioid data. On internal validation, our pre-operative prediction model was well calibrated but discrimination was moderate. Performance was improved with the inclusion of peri-operative covariates suggesting pre-operative variables alone are not sufficient to adequately predict postoperative pain.     

Prospective comparison of three methods for detecting peri-operative neurocognitive disorders in older adults undergoing cardiac and non-cardiac surgery

Postoperative neurocognitive disorders occur frequently in older adult patients. Neuropsychological assessment is the gold standard for diagnosis, but the resources required for routine use are significant. Instead, it is common for simplified and unvalidated tests to be used for trials and in clinical practice. We undertook a single-centre prospective observational study in elective surgical patients aged ≥ 65 years recruited between September 2019 and January 2021. Patients underwent neuropsychological assessment, the Modified Telephone Interview for Cognitive Status and Montreal Cognitive Assessment before surgery. Tests were repeated at approximately four to eight postoperative weeks. We included 105 patients and 28 (27%) were lost to follow-up. Pre-operative Modified Telephone Interview for Cognitive Status and cognitive domain scores were very weakly to moderately correlated (r = 0.09–0.41). Pre-operative Montreal Cognitive Assessment and cognitive domain scores were very weakly to weakly correlated (r = 0.17–0.37) Postoperative Modified Telephone Interview for Cognitive Status and cognitive domain scores were very weakly to weakly correlated (r = 0.09–0.36). Postoperative Montreal Cognitive Assessment score and cognitive domain scores were very weakly to weakly correlated (r = 0.07–0.36). Overall, there was limited agreement between tests. We conclude that the Modified Telephone Interview for Cognitive Status and Montreal Cognitive Assessment should not be used in isolation to diagnose postoperative neurocognitive disorders. There seems to be little to no pre-operative, postoperative or pre- to postoperative correlation between these tests and the neuropsychological assessment in older adults without pre-operative cognitive impairment.     

老年择期关节置换术患者术后谵妄的认知和功能预测因子及其后遗症

背景术后谵妄（postoperativedelirium，POD）在老年患者中很常见，且与不良预后相关。在行择期手术的患者中，POD的认知和功能性后遗症尚且未知。我们试图研究：①在老年手术患者中，敏感性神经认知测试的较低评分能否作为POD的独立风险因子；@POD能否预测手术3个月后的认知和功能下降。方法我们对年龄I〉65岁的全髋关节或全膝关节置换术患者进行了一项前瞻性队列研究。参与者接受术前的神经认知和功能测试。使用混乱评估法诊断POD。出现POD的患者组与对照组在手术后3个月接受重复的神经认知和功能测试。结果418例患者符合入选标准，有42例出现POD。各组之间在基础细微精神状态检查评分、酗酒、抑郁和语言智力等方面没有差别。POD的独立预测因子包括年龄、精神疾病史、功能状态的下降和语言记忆的下降。对于所有测试，POD患者组和匹配的对照组之／＇~-J在术前和术后3个月的变化相似。结论术前神经认知和功能状态的轻微下降可以预测POD。然而在出现POD的小群体中，没有手术后3个月出现认知和功能下降的证据。POD与术前认知功能的降低有关，但在择期手术的老年患者中，可能不存在手术后3个月有害的认知或功能后遗症。     

Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta‐analysis

Background

Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD).

Methods

Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non‐cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses.

Results

Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD).

Conclusion

The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well‐designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.

     

The effect of peri-operative dexmedetomidine on the incidence of postoperative delirium in cardiac and non-cardiac surgical patients: a randomised,double-blind placebo-controlled trial

Delirium occurs commonly following major non-cardiac and cardiac surgery and is associated with: postoperative mortality; postoperative neurocognitive dysfunction; increased length of hospital stay; and major postoperative complications and morbidity. The aim of this study was to investigate the effect of peri-operative administration of dexmedetomidine on the incidence of postoperative delirium in non-cardiac and cardiac surgical patients. In this randomised, double-blind placebo-controlled trial we included 63 patients aged ≥ 60 years undergoing major open abdominal surgery or coronary artery bypass graft surgery with cardiopulmonary bypass. The primary outcome was the incidence of postoperative delirium, as screened for with the Confusion Assessment Method. Delirium assessment was performed twice daily until postoperative day 5, at the time of discharge from hospital or until postoperative day 14. We found that dexmedetomidine was associated with a reduced incidence of postoperative delirium within the first 5 postoperative days, 43.8% vs. 17.9%, p = 0.038. Severity of delirium, screened with the Intensive Care Delirium Screening Checklist, was comparable in both groups, with a mean maximum score of 1.54 vs. 1.68, p = 0.767. No patients in the dexmedetomidine group died while five (15.6%) patients in the placebo group died, p = 0.029. For patients aged ≥ 60 years undergoing major cardiac or non-cardiac surgery, we conclude that the peri-operative administration of dexmedetomidine is associated with a lower incidence of postoperative delirium.     

The impact of the type of anaesthesia on cognitive status and delirium during the first postoperative days in elderly patients

BACKGROUND AND OBJECTIVES: Postoperative confusion and delirium is a common complication in the elderly with a poorly understood pathophysiology. The aim of this study was to examine whether the type of anaesthesia (general or regional) plays a role in the development of cognitive impairment in elderly patients during the immediate postoperative period. METHODS: Forty-seven patients > 60 yr of age and undergoing major surgery were randomly allocated to receive either regional or general anaesthesia. The mental status of the patients was assessed preoperatively and during the first three postoperative days with the Mini Mental State Examination. The incidence of delirium was also examined during the same period with the use of DSM III criteria. RESULTS: Overall, during the first three postoperative days, the mean Mini Mental State Examination score decreased significantly (P < 0.001). However, this decline was very significant only in patients assigned to receive general anaesthesia (P < 0.001) compared to regional anaesthesia. Nine patients developed delirium but the type of anaesthesia did not affect its incidence. The only important factor for the development of delirium was preexisting cardiovascular disease irrespective of anaesthesia type (P < 0.025). CONCLUSIONS: Elderly patients subjected to general anaesthesia displayed more frequent cognitive impairment during the immediate postoperative period in comparison to those who received a regional technique.     

Modified Frailty Index Independently Predicts Postoperative Delirium and Delayed Neurocognitive Recovery After Elective Total Joint Arthroplasty

BackgroundPostoperative delirium (POD) and delayed neurocognitive recovery are 2 common subtypes of postoperative neurocognitive disorders that occur after total joint arthroplasty (TJA), associated with inferior surgical outcomes. The modified frailty index (mFI) reflects the status of physiologic decline and predicts adverse outcomes in various surgical patient cohorts. This study aims at examining the discriminatory value of the mFI to predict POD and delayed neurocognitive recovery after TJA.MethodsThe study includes 383 participants admitted for primary elective TJA under general anesthesia combined with inhalation agents over the period from January 2018 to December 2019. POD and delayed neurocognitive recovery, based on the criteria provided by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), were assessed for each enrolled patient. A multivariate logistic regression analysis was performed to screen potential risk factors for POD and delayed neurocognitive recovery.ResultsThe total incidence of POD and the delayed neurocognitive recovery of this cohort were 17.2% (66/383) and 24.8% (95/383), respectively. Our data from the multivariate logistic regression analysis indicated that a higher age (≥72 years) and a higher mFI level (≥0.18) were 2 independent risk factors for both POD and delayed neurocognitive recovery in elderly subjects after TJA.ConclusionThe mFI may be a promising predictor for both POD and delayed neurocognitive recovery in elderly subjects following TJA. Preoperative mFI evaluation can be used for risk stratification and offers significant potential in clinical application.     

Delirium in vascular surgery.

Delirium is common in many surgical settings. Patients undergoing elective vascular surgery may be at particular risk of developing delirium, and may have modifiable aetiological factors that can be addressed by pre-operative interventions. We decided to review the literature regarding the incidence and aetiology of delirium in elective vascular surgical patients. METHODS: We searched medical databases, journals and bibliographies to identify relevant studies. We used predetermined quality criteria for appraisal of the quality of incidence and aetiological studies. RESULTS: Four studies were identified as relevant to the review. The incidence of delirium ranged from 29.1% to 39.2%. The significant aetiological factors identified were age, pre-operative cognitive impairment, depressive symptoms, inter-operative blood transfusion and previous amputation. CONCLUSIONS: Delirium is common in people undergoing elective vascular surgery. Further research is required to examine the effect on outcome of delirium, and the effect of psychiatric and geriatric medicine interventions in this setting.     

Routine pre-operative blood testing: is it necessary?

In order to determine the value of routine pre-operative screening investigations, the medical notes of 100 patients undergoing elective surgical procedures under general anaesthesia were subject to prospective audit. Pre-operative screening investigations (full blood count, urea and electrolytes and random glucose) were analysed in terms of frequency of abnormalities and whether or not the peri-operative management was changed when the result was abnormal. The frequency of results being present in the note at the time of operation and the costing of the tests was also examined. A total of 773 tests was performed of which 70 (9.1%) were abnormal. Peri-operative management was altered as a result of only two abnormal results (0.2%). Eight complications arose, none of which could have been predicted by the pre-operative screening tests. In only 57% of cases were the results present in the medical notes at the time of surgery. It is conservatively estimated that a saving of pound 50 000 per year could be made in our hospital alone by selective ordering of tests.     

衰弱对老年患者手术后认知功能影响的研究进展

衰弱是身体机能、认知、心理衰退的一种多维综合征。衰弱可增加机体对应激的易损性,并导致患者术后并发症增加、住院时间延长、甚至死亡率上升。随着人口老龄化进程不断加快,越来越多的老年患者需接受手术治疗,而该类患者手术后容易发生认知功能障碍。衰弱是老年患者常见的合并状态,但衰弱对老年患者手术后认知功能的影响尚未完全明确。本文就衰弱与老年患者术后谵妄、术后认知功能障碍及术后认知功能改善相关研究做出综述,为临床开展衰弱与术后认知研究提供参考。     

Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study

Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound results, patients were classified as low risk (empty, gastric fluid volume ≤ 1.5 ml.kg^-1 body weight) or high risk (solid, mixed or gastric fluid volume > 1.5 ml.kg^-1 body weight) of aspiration. After sonography, examiners were asked to indicate changes in aspiration risk management (none; more conservative; more liberal) to their pre-defined anaesthetic plan and to adapt it if patient safety was at risk. We included 2003 patients, 1246 (62%) of which underwent elective and 757 (38%) emergency surgery. Among patients who underwent elective surgery, 1046/1246 (84%) had a low-risk and 178/1246 (14%) a high-risk stomach, with this being 587/757 (78%) vs. 158/757 (21%) among patients undergoing emergency surgery, respectively. Routine pre-operative gastric sonography enabled changes in anaesthetic management in 379/2003 (19%) of patients, with these being a more liberal approach in 303/2003 (15%). In patients undergoing elective surgery, pre-operative gastric sonography would have allowed a more liberal approach in 170/1246 (14%) and made a more conservative approach indicated in 52/1246 (4%), whereas in patients undergoing emergency surgery, 133/757 (18%) would have been managed more liberally and 24/757 (3%) more conservatively. We showed that pre-operative gastric ultrasound helps to identify high- and low-risk situations in patients at risk of aspiration and adds useful information to peri-operative management. Our data suggest that routine use of pre-operative gastric ultrasound may improve individualised care and potentially impact patient safety.     

Postoperative pulmonary complications in older patients undergoing elective surgery with a supraglottic airway device or tracheal intubation

The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing elective non-cardiothoracic surgery under general anaesthesia with positive pressure ventilation, we hypothesised that a composite measure of in-hospital postoperative pulmonary complications would be less frequent when a supraglottic airway device was used compared with a tracheal tube. We studied patients aged ≥ 70 years in 17 clinical centres. Patients were allocated randomly to airway management with a supraglottic airway device or a tracheal tube. Between August 2016 and April 2020, 2900 patients were studied, of whom 2751 were included in the primary analysis (1387 with supraglottic airway device and 1364 with a tracheal tube). Pre-operatively, 2431 (88.4%) patients were estimated to have a postoperative pulmonary complication risk index of 1–2. Postoperative pulmonary complications, mostly coughing, occurred in 270 of 1387 patients (19.5%) allocated to a supraglottic airway device and 342 of 1364 patients (25.1%) assigned to a tracheal tube (absolute difference −5.6% (95%CI −8.7 to −2.5), risk ratio 0.78 (95%CI 0.67–0.89); p < 0.001). Among otherwise healthy older patients undergoing elective surgery under general anaesthesia with intra-operative positive pressure ventilation of their lungs, there were fewer postoperative pulmonary complications when the airway was managed with a supraglottic airway device compared with a tracheal tube.     

术后谵妄：具有远期作用的急性改变

谵妄是一种认知力和注意力的急性改变,包括意识改变和思维涣散。尽管谵妄可以出现于任何年龄组的患者,但是最常见于老年患者,尤其是那些已存在认知功能障碍的老年患者。术后谵妄的患者较无谵妄的患者恢复慢,因此增加了住院时间和医疗费用。术后谵妄的发生率与手术类型、手术紧迫性和谵妄评估方法的类型及敏感性有关。尽管谵妄通常被认为是一种短期病变,其实它可以持续数月并且与术后中期认知功能不良有关。本文中,我们给出了指南对谵妄这一常见的病理状态风险进行术前评估及预防、诊断和治疗。提高诊疗水平,例如术前明确谵妄发生的风险;训练外科医生、麻醉医生和护士诊断谵妄的能力;实行谵妄预防计划以及制定谵妄治疗的标准流程可能有助于减少谵妄及其相关发病率。     

Review articles: postoperative delirium: acute change with long-term implications

Delirium is an acute change in cognition and attention, which may include alterations in consciousness and disorganized thinking. Although delirium may affect any age group, it is most common in older patients, especially those with preexisting cognitive impairment. Patients with delirium after surgery recover more slowly than those without delirium and, as a result, have increased length of stay and hospital costs. The measured incidence of postoperative delirium varies with the type of surgery, the urgency of surgery, and the type and sensitivity of the delirium assessment. Although generally considered a short-term condition, delirium can persist for months and is associated with poor cognitive and functional outcomes beyond the immediate postoperative period. In this article, we provide a guide to assess delirium risk preoperatively and to prevent, diagnose, and treat this common and morbid condition. Care improvements such as identifying delirium risk preoperatively; training surgeons, anesthesiologists, and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols may reduce the risk of delirium and its associated morbidity.