About

What is Perioperative Brain Health Initiative?

With more than 46 million Americans over the age of 65, postoperative delirium is a major public health issue in this vulnerable population.

In 2015, then ASA President Daniel J. Cole, M.D., proposed a new patient safety initiative — the Brain Health Initiative — to engaged a multidisciplinary group to work with providers, payers and the public to create a low-barrier access program to minimize the impact of pre-existing cognitive deficits, and optimize the cognitive recovery and perioperative experience for adults 65 years and older undergoing surgery.

Facts

  • Postoperative delirium and delayed cognitive recovery are complications of significance to the elderly surgical population.
  • The incidence of postoperative delirium ranges from 5 to 15 percent. However, with certain high-risk groups such as patients with hip fracture, the range can be between 16 to 62 percent.
  • Immediately after surgery, the incidence of delayed cognitive recovery is high with recovery over a period of months.
  • Postoperative delirium is associated with significant postoperative complications.

Our Mission

  • To create a low-barrier access program to minimize the impact of pre-existing cognitive deficits, and optimize the cognitive recovery and perioperative experience for older adults (>65 years) undergoing surgery.
  • To make available a three-year comprehensive plan that anesthesiology departments can follow to become centers of excellence.
  • To create a campaign through which all anesthesiologists have greater awareness of the importance of preoperative screening for cognitive deficit and of appropriate protective measures to minimize impact on cognitive function during the perioperative period.
  • To provide a stepped implementation program supported by tools. Some departments may choose to implement years one to three at an accelerated pace, including consideration of intraoperative monitoring of the brain. However, the intention of this campaign is to ensure widespread early adoption of the simplest evidence-based methods of cognitive protection.

Tools for Providers

  • Simple preoperative screening for cognitive impairment and risk factors including prior history of confusion or disorientation
  • Talk with patients about delirium through the provision of checklists covering risk factors and the promotion of orientation through hearing aids, glasses, importance of family/ friends’ bedside presence and reassurance.
  • Anesthetic sedative and analgesic drug choices, including medications to be avoided.
  • Medication recommendations might include:
    • Do not routinely give benzodiazepines as a presedative or sedation to patients 70 years and older; the impact can be very long lasting. If these drugs are given, document justification.
    • Use dexmedetomidine instead of opioids, benzodiazepines, and propofol in the ICU for sedation. Benzodiazepines should never be used for infusion.
    • Do not give diphenhydramine for sedation or sleep.
    • Remove meperidine from order sets.
    • Low-dose first- or second-generation antipsychotics (haloperidol or risperidone/olanzapine) only for delirium (not for prevention); never as a standing order and for agitated delirium only.
    • Distinguish agitation from pain or anxiety. If patient is delirious look for underlying causes, reorient, utilize family; use medication and restraint as a last resort.
  • Provide orientation program to include environmental cues (white boards) and support of sleep/wake cycles (timing of vital signs, blood draws, ear plugs, eye shades).

Background

In 2015, the American Society of Anesthesiologists (ASA) held the Brain Health Summit on Capitol Hill in Washington, D.C. The summit brought together medical experts, government agencies and other interested nonprofit groups to discuss delayed cognitive recovery and postoperative delirium in elderly patients after surgery and anesthesia.

The Brain Health Summit:

  • Explored the assessment and identification of at-risk patients.
  • Evaluated the need for educational materials for patients and their health care providers to increase patient safety.
  • Promoted advocacy efforts to fund research regarding these complications.

The ASA Ad Hoc Committee on Brain Health Initiative:

Lee A. Fleisher, M.D., Chair
Stacie G. Deiner, M.D., Vice Chair for Clinical Activities
Roderic G. Eckenhoff, M.D., Vice Chair for Scientific Activities
Carol J. Peden, M.B., Ch.B., M.D., M.P.H., Vice Chair for Performance Improvement
Alexander A. Hannenberg, M.D., ASA Interim Chief Quality Officer
Daniel J. Cole, M.D., FASA, Member
James C. Eisenach, M.D., Member
Hugh C. Hemmings M.D., Ph.D., Member
Keith A. Jones, M.D., Member
Evan D. Kharasch, M.D., Ph.D., Member
Jeffrey R. Kirsch, M.D., FASA, Member
Aman Mahajan, M.D., Ph.D., Member
Jeanine P. Wiener-Kronish, M.D., Member

How ASA Can Help

Access ASA tools and resources to learn more about what you can do NOW to make sure your practice is doing all it can to prevent postoperative delirium.

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