Older adults benefit most from multicomponent, team-based perioperative care that reduces exposure to delirium triggers and supports brain resilience. Evidence from clinical researchers and specialty societies emphasizes nonpharmacologic prevention, careful medication management, and targeted anesthetic strategies as the core interventions.
Preoperative assessment and medication optimization
Comprehensive risk assessment that includes cognitive screening, frailty and functional status identifies patients at high risk. Edward R. Marcantonio Beth Israel Deaconess Medical Center and Harvard Medical School has documented the strong links between preexisting cognitive impairment, polypharmacy, and postoperative delirium. Preoperative review to stop or reduce high-risk drugs such as anticholinergics and benzodiazepines, and plans to minimize opioids while ensuring analgesia, are foundational. In resource-limited settings or where family caregiving is central, preoperative education that engages caregivers in reorientation and sensory support is particularly important.Intraoperative choices and monitoring
Anesthetic technique matters mainly through avoidance of extremes: avoidance of deep hypnotic states, prevention of intraoperative hypotension, and multimodal analgesia to limit opioid use are associated with lower delirium risk in guideline summaries from the European Society of Anaesthesiology led by Aldecoa and colleagues. Where appropriate, regional anesthesia and nerve blocks can reduce systemic sedative and opioid requirements. Depth-of-anesthesia monitoring and vigilant hemodynamic management support cerebral perfusion; the benefit of specific agents varies and should be individualized for comorbidity and surgical context.Postoperative nonpharmacologic care and targeted pharmacology
Multicomponent nonpharmacologic programs that provide orientation, sleep protection, early mobilization, vision and hearing support, and hydration are effective in preventing delirium. The Hospital Elder Life Program developed by Sharon K. Inouye Hebrew SeniorLife and Harvard Medical School exemplifies this approach and has been associated with reduced delirium incidence in hospitalized older adults. Selective pharmacologic strategies are reserved for specific indications: short-term use of antipsychotics for severe agitation is controversial and should follow institutional protocols and geriatric input; sedative-sparing regimens and careful use of dexmedetomidine in monitored settings have shown promise in some trials but require specialist oversight.Delirium prevention yields meaningful clinical and social benefits: reduced length of stay, lower complication rates, and preservation of independence. Implementation requires interdisciplinary coordination among anesthesiology, surgery, geriatrics, nursing, and allied health, and should adapt to cultural and territorial contexts where family roles, language, and care access shape practical delivery. Sustained improvement depends as much on systems and training as on isolated interventions.