ASA’s 2025 Advisory: Perioperative Anesthesia Care for Older adults

Today, we spotlight the 2025 ASA Practice Advisory on Perioperative Care for Older Adults Undergoing Inpatient Surgery—a vital topic as we care for an aging population with unique anesthetic challenges.

Why This Topic Matters to Your Practice

The number of adults aged 65 and older undergoing surgery is rising rapidly, with projections showing this population doubling by 2055. Older adults face heightened risks of postoperative complications, including delirium, cognitive decline, and prolonged recovery, due to age-related changes, frailty, and comorbidities. These challenges necessitate tailored perioperative strategies to preserve functional independence and improve surgical outcomes​.

Key Findings You Should Know

• Preoperative Screening Matters: Comprehensive evaluations for frailty and cognitive impairment reduce postoperative delirium risk. Implementing multidisciplinary care teams, including geriatric specialists, optimizes patient outcomes.
• Anesthetic Choices Are Flexible: Both neuraxial and general anesthesia are acceptable options for older adults, with no clear evidence favoring one over the other for delirium prevention.
• Dexmedetomidine Shows Promise: This agent lowers postoperative delirium risk but carries risks of bradycardia and hypotension, requiring careful consideration.
• Medication Management is Critical: Be cautious with perioperative use of medications with central nervous system effects (e.g., benzodiazepines, antipsychotics), as they may increase delirium risk​.

Breaking Down the Clinical Impact

This advisory reinforces the importance of individualized perioperative care for older adults. While no single anesthetic approach stands out as superior, comprehensive preoperative evaluations and thoughtful pharmacologic choices are key to minimizing cognitive complications. Dexmedetomidine offers a valuable tool for delirium prophylaxis, though its hemodynamic side effects must be managed. Medication selection should be deliberate, balancing benefits and risks in vulnerable older patients.

The Takeaway for Your Daily Practice

ASA’s 2025 advisory provides a clear roadmap for optimizing perioperative care in older adults. Incorporate these strategies to enhance patient safety, reduce complications, and improve recovery outcomes.

Key Takeaways for Clinical Practice

• Screen for frailty and cognitive impairment preoperatively to identify high-risk patients early.
• Engage a multidisciplinary care team when managing older adults undergoing surgery.
• Choose anesthetic techniques based on patient-specific factors—both neuraxial and general anesthesia are acceptable.
• Consider dexmedetomidine for delirium prophylaxis, balancing its benefits with potential cardiovascular risks.
• Review all medications with CNS effects preoperatively to minimize delirium risk when possible.

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Citation: Sieber F, McIsaac DI, Deiner S, et al. 2025 ASA Practice Advisory for Perioperative Care of Older Adults Undergoing Inpatient Surgery. Anesthesiology. 2025;142:22–51.